Impact of COVID-19 ­ experiences of 5th year medical students at the university of KwaZulu-natal

Background: The global pandemic associated with coronavirus disease 2019 (COVID-19) had a considerable effect on higher education in South Africa, with online instruction replacing traditional lectures for many students. Medical students were required to vacate their residences in March 2020 but returned to campus in July 2020 to enable them to continue with clinical teaching and learning. The aim of this study was to understand the learning experiences of 5th year medical students at the University of KwaZulu-Natal (UKZN) during 2020. Methods: This was a qualitative study conducted via Zoom in December 2020 with 18 students in four focus group discussions and four semi-structured interviews. These were all facilitated by an independent researcher with experience in qualitative research. All the interviews were recorded, transcribed verbatim and analysed qualitatively through the identification of codes, categories and themes. Results: The following major themes emerged: A stressful and at times an overwhelming year, mental health issues, developing strategies to cope, and issues that related to teaching and learning. Conclusion: The disruptions caused by COVID-19, the lockdown, a condensed academic programme and uncertainty about their competency resulted in high levels of anxiety and stress among medical students. Participants highlighted strategies that had helped them to cope with the isolation and academic pressures. Given the large volume of work, careful thought needs to be given to what should be taught and how it should be taught to ensure that graduates have the competencies they need to practise.

Mastering your fellowship: Part 3, 2022

The series, 'Mastering your Fellowship', provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP SA) examination. The series is aimed at helping family medicine registrars (and their supervisors) prepare for this examination.Keywords: family physicians; FCFP (SA) examination; family medicine registrars; postgraduate training; national exit examination; infectious diseases.

Mastering Your Fellowship: Part 4, 2022

The 'Mastering Your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa examination. The series is aimed at helping family medicine registrars prepare for this examination.

Conceptualising social accountability as an attribute of medical education

Background: Health professionals need to be both person- and community oriented to improve population health. For educators to create socially accountable physicians, they must move learners from understanding social accountability as an expectation to embracing and incorporating it as an aspect of professional identity that informs medical practice. Aim: The aim of this article was to assess the degree to which medical students, preceptors and community mentors understand the concept of social accountability. Setting: The setting is the KwaZulu-Natal Province in Durban, South Africa. Methods: Using an observational design, we surveyed 332 participants, including the first- and sixth-year medical students, physician preceptors and community mentors. Results: Whilst most respondents understood social accountability as requiring an action or set of actions, it was defined by some as simply the awareness one must have about the needs of their patients, community or society at large. Some respondents defined social accountability as multi-dimensional, but these definitions were the exception, not the rule. Finally, most respondents did not identify to whom the accountable party should answer. Conclusion: Whilst the development of professional identity is seen as a process of 'becoming', the ability to define and understand what it means to be socially accountable is not a linear process. Assessment of this progress may start with comprehending how social accountability is understood by students when they begin their education and when they are graduating, as well as in knowing how their educators, both clinical and community, define it

Contribution of the Nelson R. Mandela School of Medicine to a socially accoun table health workforce

Background: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. 'Fit-for-purpose' can be assessed by monitoring graduate practice attributes. Aim: The aim of this article was to identify whether graduates of 'fit-for-purpose' programmes are socially accountable. Setting: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. Methods: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors' characteristics and reasons for leaving or staying at district hospitals. Results: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors.Conclusion: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs

The socioeconomic impact of rural-origin graduates working as healthcare professionals in South Africa

Background: Studies documenting the socioeconomic impact of education leading to employment of rural youth, specifically in the healthcare professions, are lacking. The Umthombo Youth Development Foundation (UYDF) is an NGO that provides financial support for rural students to train as healthcare professionals (HCPs) as a way of addressing staff shortages at rural hospitals. The aim of this study was to understand the social and economic impact on individuals and their families of qualifying as an HCP and being employed at a rural district hospital. Methodology: A mixed methodology was used to collect data from 40 graduates at eight district hospitals in rural KwaZulu-Natal province. The research tools had qualitative and quantitative questions, with additional data being extracted from the UYDF database. The qualitative data were analysed thematically, with STATA software being used for the quantitative analysis. Results: The findings indicate that graduate household assets increased significantly, as did their socioeconomic circumstances, compared with before they qualified as HCPs. Graduates attached high value to education that led to their employment, which provided them with money to afford assets. Having a permanent job and regular income also transformed their families' lives, as they were able to care for their siblings and extended family members. Conclusions: Training rural youth for employment in scarce skills that leads to employment, such as a career in the health sciences, boosts their socioeconomic circumstances and that of their families. This contributes to the staffing of rural hospitals, job creation and the economic development of the country

Staffing levels at KwaZulu-Natal district hospitals: is the University of KwaZulu-Natal training for the needs of the province?

Background: Universities have a social responsibility to ensure that they select and train healthcare professionals (HCPs) who can meet the healthcare needs of local communities. The aim of this study was to assess the extent to which the University of KwaZulu-Natal (UKZN) contributes to the training of HCPs working in district hospitals (DHs) in KwaZulu-Natal Province, and the impact that the funding source for their training has on DH staffing.Methods: This was an observational descriptive study, with all doctors, dentists, dental therapists, pharmacists, physiotherapists and radiographers working at DHs in KZN in November 2016 being invited to participate. Data were collected through a validated questionnaire.Results: A total of 514 HCPs working in 29 DHs participated in the study; over half (57%) of the South African medical graduates had trained at UKZN, as had 62% of pharmacists, 64% of physiotherapists and 92% of dental therapists. Some 87% of the HCPs had worked in DHs for five years or less, 65% planned to leave in the near future, and 29% planned to leave at the end of 2016.Discussion: UKZN plays a significant role in training for the short-term needs of DHs in KZN. Much of the workforce is young and transient, which has implications for service provision and expanding the teaching platform to DHs. The lack of long-term staff retention suggests that UKZN needs to continually monitor the selection of students, as well as the content and context of the training, if it is to contribute to the province's long-term staffing needs

A review of 'medical' knowledge of epilepsy amongst isiZulu-speaking patients at a regional hospital in KwaZulu-Natal

Background: Epilepsy is a common disorder in South Africa and the literature indicates that many patients do not access treatment. The reasons are complex and include a poor knowledge about causes; symptoms; diagnosis and treatment (medical knowledge). This study aimed to assess the medical knowledge of isiZulu-speaking people with epilepsy (PWE) who attend a combination regional and district hospital in the eThekwini district in KwaZulu-Natal Province.Method: This was a prospective; cross-sectional; descriptive study. Data were collected using a validated data collection tool for assessing the medical knowledge of PWE and analysed descriptively.Results: The questionnaires were completed by 199 PWE; with the general level of schooling being low and half being unemployed. Knowledge around causes; symptoms; diagnosis and treatments was good; but there were significant gaps in knowledge that may affect morbidity and mortality.Discussion: The findings will serve as a useful guide to develop both preventive and educational interventions to enhance knowledge around the causes and treatment of epilepsy in this population. It is important that such interventions also consider family and healthcare providers.Conclusion: There were considerable gaps in the medical knowledge of isiZulu-speaking PWE's; indicating the need for an educational intervention to improve their understanding of epilepsy. Further research is needed-using a range of tools to ensure that the data is reliable and valid-if the results are to be generalisable to the rest of the province and South Africa

African primary care research: reviewing the literature

This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the develop -ment of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study; as well as the use of literature in conceptual frameworks and in the methods. Finally; the article looks at how to keep track of the literature used and to reference it appropriately

Review of Final-Year Medical Students' Rural Attachment at District Hospitals in KwaZulu-Natal: Student Perspectives

Objectives: This study aimed to investigate the views of students involved in rural community-based medical attachments during their final year at medical school. The programme has been in existence for some time; but no formal evaluation thereof has yet taken place. This paper describes the first two phases of what is described as a quality improvement project: namely to describe the problem state and to discuss possible activities to improve the programme.Design; setting and subjects: The study adopted a mixture of quantitative and qualitative type research. Data were collected by means of a self-administered questionnaire which students at Nelson R Mandela Medical School; University of KwaZulu-Natal; completed at the end of their Family Medicine rotation. Consent was obtained from the participants and ethical approval granted by the University of KwaZulu-Natal Humanities and Social Science Ethics Committee.Results: Students were generally positive about their rural attachment experience. The majority (86) believed that their skills adequately prepared them to enter the community. Allocation of a supervisor and rostering were found to be of great importance. Academic activities provided adequate learning opportunities. The majority (76) of students who used hospital accommodation found it to be satisfactory; although it was an area that needed attention. Technological support was lacking. Fewer than 50of students had access to such facilities.Conclusion: Students' responses were generally positive about the rural attachment experience; but logistical and technological support issues; as well as that of accommodation; need to be addressed if the programme is to flourish. Community-based education in a rural district hospital can provide unique learning opportunities for students if the opportunities are identified and the programme is well managed

Lactic Acidosis; Risk Factors and Predictive Laboratory Markers: a Nested Case Control Study in South Africa

Background: The incidence of antiretroviral therapy (ART)-induced lactic acidosis and its associated mortality may be reduced by appropriate dosing; risk stratification and early detection. Objectives: To describe the epidemiology of lactic acidosis; define the risk factors and identify predictive laboratory markers in the context of the roll-out of ART in South Africa. Design: A nested case control study. Risk factor analysis was adjusted for the established risk factors of weight and gender.Setting and subjects: Persons commenced on stavudine-containing therapy between 2004 and 2007 at Port Shepstone Hospital in KwaZulu-Natal were included. Persons with a body weight above 60 kg received Stavudine 40 mg twice daily; and those with a body weight below 60 kg; 30 mg twice daily.Outcome measures: Assessed risk factors included weight; gender; age; alanine transaminase (ALT); urea; creatinine; albumin; cholesterol; triglyceride (TG) levels; CD4 counts and viral loads.Results: Lactic acidosis occurred in 79 (17 per 1 000 person-years) of 1 762 people living with HIV on ART. Significant factors were being female [adjusted odds ratio (AOR) of 5.4] and increased body weight (adjusted OR of 1.1 per kg). The risk of lactic acidosis increased 6.6; 6.9 and 95 times (adjusted ORs) as weight increased from a baseline weight of 60 kg to 60-69 kg; 70-79 kg or 80 kg; respectively. Six months into therapy; predictors of developing lactic acidosis were an ALT 50 IU/l (adjusted OR of 11.1) and a higher TG (adjusted OR of 8.8 per mmol/l). No associations were found with regard to age; CD4 count; viral load; and creatinine or albumin levels.Conclusion: Obese females are at greatest risk of lactic acidosis; with an exponential increase in risk above 80 kg. The 30-mg dose may be preferable; given that a sharp increase in risk occurred at 60 kg; was most likely dose related; and that 30 mg has been shown to provide adequate virological suppression. Additional risk factors for lactic acidosis include a high ALT and TG levels at treatment

Contraceptive Knowledge and Practice among HIV-Positive Women Receiving Antiretroviral Therapy at a District Hospital in KwaZulu-Natal

Objectives: To determine the knowledge and use of contraceptives by HIV-positive women attending an ART clinic. Design: Observational descriptive cross-sectional study. Setting and subjects: Many human immunodeficiency virus (HIV)-positive South African women fall pregnant each year while receiving antiretroviral therapy (ART). In 2010; 2 056 women of childbearing age attended the ART clinic at a district hospital south of Durban. Between October 2010 and June 2011; data were collected using a validated questionnaire from 400 women on their contraceptive knowledge and use. Women over 18 years of age who consented to participate; and who had been receiving ART for more than a month; were eligible for participation in the study. Outcome measures: Contraceptive knowledge and use. Results: All participants had received counselling on male condom use. The majority of HIV-positive women receiving ART preferred the male condom as their contraception of choice. Knowledge of male condoms was excellent; but only 66 of the study group used condoms; and just over 50 used a dual method of contraception (male condoms plus another contraceptive method). While 97 of participants were knowledgeable about injectable contraception; only 40 used the latter as a form of contraception. Ninety-two per cent of the participants reported recent sexual activity; 14 had fallen pregnant while receiving ART; and 64 planned on having a child in the future. Conclusion: The low use of dual contraception was a cause for concern. Recommendations include the integration of family planning services into HIV care at all ART sites. This should promote proper fertility management for women receiving ART

The Prevalence of Erectile Dysfunction at a Primary Healthcare Clinic in Durban; KwaZulu-Natal

Objectives: The objectives of this study were to determine the prevalence of erectile dysfunction (ED) in men attending a primary healthcare (PHC) clinic in Durban; KwaZulu-Natal; and to document any relationship between ED and age; smoking; economic status and co-morbid conditions. Design: An observational; descriptive; cross-sectional study. Setting and subjects: More than 50 of men aged 40-70 years experience some degree of erectile dysfunction. However; no data is available on the prevalence of ED in a primary healthcare (PHC) setting in KwaZulu-Natal. Between February and March 2008; 1 300 questionnaires were distributed to men aged 18 years and older with no exclusion criteria; attending a general PHC clinic. Outcome measures: Responses were captured using a validated structured questionnaire (International Index of Erectile Function-15). Results: Eight hundred and three questionnaires were eligible for analysis. The overall prevalence rate of ED was 64.9 (621); of whom 14.6 (117) had mild ED; 19.9 (160) moderate ED; and 30.4 (244) severe ED. Erectile dysfunction increased with age; and there was a strong association between ED and economic status and co-morbid conditions. Conclusion: The prevalence of ED at this urban PHC clinic was high. Increased awareness by doctors working in the clinic may result in improved assessment and appropriate treatment that will enhance patients' quality of life

Characteristics of Women Having First-Trimester Termination of Pregnancy at a District Hospital in Kwazulu-Natal

Termination of pregnancy (TOP) is requested by some women for a variety of reasons and it is plausible that profiling their characteristics might help to target selected groups for counselling. This study aimed to determine the characteristics of women having a legal first-trimester TOP at a regional hospital in KwaZulu-Natal. The medical records of 254 women were retrospectively sampled and analysed from a total of 758 women who had a first-trimester TOP between January and December 2008. The women were aged 14-45 years (the most common age group was 20-29 years; a mean age of 25.3 years and a standard deviation of 5.9). The majority (75.6) reported that they had at least one child who was alive; 1.6 had previously had a TOP; 93.3 were single and 28.4 resided outside the health district in which the hospital was situated. Eighty-nine per cent had not used contraception before the index pregnancy. Fifty-eight per cent requested a TOP between 9 and 12 weeks of gestation (a mean of 8 weeks). Ninety-six per cent had a TOP because of socio-economic reasons. All of the women received counselling prior to undergoing TOP. In our patient population; women who had a legal TOP in the first trimester were in their twenties; single; parous; sexually active; not on a contraceptive and of poor socio-economic status. Women with these characteristics should be targeted for appropriate counselling on reproductive health matters

Correlation between knowledge of HIV, attitudes and perceptions of HIV and a willingness to test for HIV at a regional hospital in KwaZulu-Natal, South Africa

Background: With millions of South Africans infected with human immunodeficiency virus (HIV) and less than 10of the population aware of their HIV status; HIV counselling and testing (HCT) is the first step in any attempt to reduce the number of new infections. For those who test negative; HCT personalises the risks and reinforces preventative messages whilst for those who are positive; it is the gateway to accessing counselling and care. The Health Belief Model postulates that knowledge and attitude influence behaviour. The aim of this study was to determine whether knowledge of HIV and the attitude of patients referred for HCT correlated with a willingness to test for HIV. Methods: One hundred and seventy two patients referred for HCT were randomly selected over a three month period. Data were collected by a research assistant using the modified standardised World Health Organization (WHO)-Global AIDS Project (GAP) questionnaire.Results: Ninety per cent of the participants demonstrated sound knowledge of HIV; acquired immune deficiency syndrome (AIDS) and HCT. Despite the 90of the participants with sound knowledge only 71.5of the participants tested for HIV. There was no statistically significant difference in knowledge between those who tested and those who did not test for HIV. Twenty five per cent of those who refused to test stated that they had already made up their mind not to test for HIV before the counselling session. Conclusions: Despite excellent knowledge of HIV; a significant number of patients referred for HCT do not test for HIV

Exploration of Pain in Children on Antiretroviral Treatment in a Regional Hospital in South Africa

Background: Patients with human immunodeficiency virus (HIV) disease on antiretroviral therapy (ART) may experience pain for a variety of reasons; including the effects of the virus itself; associated opportunistic infections and the ART. Studies indicate that pain in adults on ART is frequent; can be severe; and is often undertreated. This study sought to explore the experience; and the prevalence of pain in young children aged 3-13 years on ART.Method: Primary caregivers of children aged 3-13 years on ART attending a paediatric ART clinic at a regional hospital in Durban participated in the study. Convenience sampling was used. The Wong-Baker FACEST Pain Rating Scale and a questionnaire adapted from Hirshefeld were used to investigate variables such as age; cluster of differentiation 4 (CD4) count; ART regimen; ART duration; and site; prevalence and impact of pain during activities. Data were analysed using a standard statistical programme.Results: Four hundred and twenty primary caregivers were interviewed. Most were mothers caring for their HIV-positive children; and the majority of the children were aged 3-7 years. Most children were on a first-line ART regimen; and half reported pain. Nociceptive pain (visceral or somatic) was the most common type of pain; and pain interfered with the daily activities of a third of the children. There was a significant association between CD4 count and pain (p-value = 0.040). Paracetamol was the most commonly used analgesic.Conclusion: Pain was a common problem; and generally was undertreated with analgesia. A need to improve pain assessment and management in this population group was identified

Adverse Effects Profile of Multidrug-Resistant Tuberculosis Treatment in a South African Outpatient Clinic

Background: Highly active antiretroviral therapy (HAART) and drugs that are used to treat multidrug-resistant tuberculosis have potentially overlapping adverse effects. Few South African studies have documented adverse effects in the multidrugresistant tuberculosis population. This study examined the adverse effects profile in a sample of the outpatient population at the King George V Hospital Multidrug-Resistant Tuberculosis Clinic in Durban; KwaZulu-Natal.Method: The method was an anonymous; retrospective record review of 350 patients with multidrug-resistant tuberculosis; who were attending the King George V Hospital Multidrug-Resistant Tuberculosis Clinic (2010-2011). Adverse effect profiles in patients with multidrug-resistant tuberculosis only; and those who were co-infected with the human immunodeficiency virus (HIV) who were on and not on HAART; were documented and analysed.Results: Adverse events were recorded for 80.6 of patients. These included hearing loss (28.7); peripheral neuropathy (23.2); diarrhoea; nausea and vomiting (20.5); arthralgia (15.9); rashes and dermatological effects (excluding Stevens-Johnson syndrome) (14); abdominal pain and dyspepsia (10.3); and psychoses and confusion (8.3). In this study population; 72.6 of patients were HIV positive; and 85 were concomitantly on HAART and multidrug-resistant tuberculosis treatment. Adverse events were significantly more common in patients who were HIV positive than in patients who were HIV negative with regard to peripheral neuropathy (p-value 0.001); psychosis and confusion (p-value

Factors that positively influence adherence to antiretroviral therapy by HIV and/or AIDS patients and their caregivers

Background: The importance of dedicated adherence to antiretroviral treatment (ART) in the management of Human Immunodeficiency Virus (HIV) is well documented. Multiple factors may affect adherence and this study explores patients' and their caregivers' perceptions of factors which may positively influence adherence to ART. Method: This study was a descriptive, qualitative study that used both free attitude interviews and focus-group discussions. Nineteen patients attending a busy ART-clinic at a district hospital in KwaZulu-Natal and eight caregivers were purposefully selected. Selection criteria included good adherence to ARTs as evidenced by excellent clinic attendance for more than one year with evidence of clinical, immunological and viral improvement. Interviews were tape recorded, transcribed and thematically analysed. Results: Ten female participants, nine male participants and eight caregivers took part in the study. Participants highlighted three main categories that positively affect their adherence to ART namely: patient, disease and health care provider-related factors. Sub-themes included issues related to acceptance, disclosure to significant others, symptomatic improvement on ARTs and the importance of supportive relationships. Participants greatly valued the health care provider relationship and felt that the main role of the health care provider was to educate and support. Conclusion: This study has shown that the factors which most influenced adherence were patient-related (acceptance, disclosure, determination, and family support), disease-related and treatment-related (symptomatic illness and improvement on ARTs), and healthcare worker-related (relationships, and adherence classes)

Description of Surgical and Anaesthetic Services Provided at Two District Hospitals in KwaZulu-Natal in Relation to the Surgical Norms and Standards Outlined in the Service Package for District Hospitals

Provision of surgical services at district hospitals (DHS) is cost effective and important. The District Hospital Service Package for South Africa (package of services) specifies the services that a district hospital should provide. The aim of this study was to document the surgical services provided at two DHS in KwaZulu-Natal and to compare this with the recommendations in the package of services. Methods: In a retrospective quantitative study; data from 2008 were collected from the theatre register at two DHS. Data were analysed and results compared with the norms and standards in the package of services. Results were presented to staff at the hospitals; who then commented on the challenges of providing surgical services at DHS. Results: Only 60 and 30 respectively of procedures listed in the package of services were being carried out at the two hospitals. In total; 3 900 procedures were carried out over the year. Dundee Hospital offered a broader range of surgical procedures and anaesthetics than the Church of Scotland Hospital (COSH). COSH has a large obstetric burden; with 3 666 deliveries each year. A large number of procedures were being carried out by a single operator. Conclusions: Many surgical procedures are being carried out even though neither hospital provides the full complement of surgical services as specified in the package of services. The wide variation between the surgical services offered reflects the surgical and anaesthetic skills at the respective hospitals. Potential medico-legal hazards that require urgent attention were identified. A review of the package of services is essential to identify core procedures that must be provided at DHS