Current practice of family planning among teachers in public secondary school in Enugu East Senatorial District, Nigeria

Background: The aim of this study is to determine the current practice level of family planning and the associated factors among public secondary school teachers in Enugu East Senatorial District. Method: A cross-sectional study was carried out among public secondary school teachers, aged 18 - 60 years, in Enugu East Senatorial District, using probability proportional to size sampling and systematic random sampling to select 1000 participants. Binary and multiple logistic regression analyses were used to determine association. An odds ratio with a 95% confidence interval (CI) was computed to determine the level of significance. Results: The current practice level of family planning is 26.5%. Respondents with bachelor's in education were 2 times more likely to be a current user of family planning (AOR=2.39; 95% CI: 1.25-4.55). However, respondents in age group 38 years and above were less likely to be a current user of family planning (AOR=0.64; 95% CI: 0.43-0.95), likewise female respondents (AOR=0.66; 95% CI: 0.44-0.98). Additionally, respondents who mentioned radio (AOR=0.64; 95%CI: 0.44-0.93), social media (AOR=0.73; 95% CI: 0.53-0.99) and healthcare (AOR=0.61; 95%CI: 0.43-0.88) as source of information were less likely to be current user of family planning. Whereas partner who encouraged the use of family planning (AOR=2.54; 95% CI: 1.71-3.78) span style="font-family: 'Times New Roman'; font-weight: bold">, partner who allow each other to decide on family planning methods (AOR=4.47; 95% CI: 2.67-7.48) and those who had good knowledge of family planning (AOR=1.96; 95% CI: 1.40- 2.67) were more likely to be current user of family planning. Conclusion: The level of current practice of family planning is low and a significant number of factors predict the current practice of family planning. A family planning educational workshop among teachers is needed to improve teacher's knowledge on family planning to address the issue of adolescent sexual reproduction as teachers are vessels of knowledge impartation to students

Assessment of knowledge, attitude and practice on family planning among women of reproductive age at hospitals and clinic centers in the rural Western Sierra Leone

Informed decisions about one's sexual and reproductive health can be made through family planning. Women of reproductive age in rural Sierra Leone's Western area were asked to participate in a survey to determine their attitudes and knowledge toward family planning and the use of contraceptives. A descriptive cross-sectional study survey was conducted in the Western Area Rural of Sierra Leone. Females in the range of 15 to 49 years old were included in the study. The research was conducted from November 2021 to December 2021. Using a pre-designed and pretested questionnaire, 180 women were assessed for their knowledge, attitudes, and practices regarding family planning. According to the study, all participants knew about family planning, but only 68.3% had used contraceptives. There were more than half who learned about it from the media. The study found that 95% of participants had a positive attitude towards contraceptives. Most commonly, contraceptives used were oral pills (31.6), injections (21.1%), implants (19.1%), lactational amenorrhea (13.8%), condoms (8.8%), and intrauterine devices (5%). In our study, the most common reasons given by participants for not using contraceptives were; not willing to disclose 52.6%, a desire for a child 19.2%, fear of side effects 15.7%, currently pregnant 8.7%, and against religious beliefs 3.5%. The study shows that even if people are aware and educated about contraceptives, they may not use them. Educating and motivating people and improving access to family planning services are still necessary to improve the effectiveness and appropriateness of contraceptive use and halt the population growth trend. (Afr J Reprod Health 2022; 26 [6]:15-21).

Parenting practices and family relationships during the COVID-19 lockdown in Ghana

The effects of the COVID-19 pandemic have been far reaching across almost every sphere of life. Families, which are the basic units of society, have not been spared the ravages of the pandemic. Changes in family daily routines as a result of COVID-19 can affect spousal relationships, parenting and childcare practices. However, the extent to which the pandemic has affected parenting practices and family relationships in Ghana is not known. The goal of this study was to assess how parenting practices and family relationships have been influenced during the COVID-19 pandemic in Ghana. Data for this paper was drawn from an online questionnaire response from 463 participants in Ghana as a subset analysis from a multi-country study on personal and family coping system with COVID-19 pandemic in the global south. The mean score for pre-COVID-19 relationship with partner (36.86) was higher (p<0.0001) than the mean score for during COVID-19 relationship with partner (35.32) indicating that COVID-19 has had negative influence on relationships. The mean score for pre-COVID-19 parenting (32.78) was higher (p<0.0001) compared to the mean score for during COVID-19 parenting (31.40) indicating negative influence on parenting. We have predicted that participants whose coping levels were "Well" on the average, are likely to be doing well in relationship with partners and parenting practices during the COVID-19 period The challenging public health containment measures of the COVID-19 pandemic have negatively influenced the relationship between partners and parenting practices in Ghana.

Knowledge and Practice about Glasgow Coma Scale Assessment among Nurses Working in Adult Intensive Care Units of Federal Public Hospitals in Addis Ababa, Ethiopia: A Cross-Sectional Study

The Glasgow Coma Scale is a dependable and objective neurological assessment instrument used for determining and recording a patient's level of consciousness. Therefore, the knowledge, practice, and factors affecting Glasgow coma scale evaluation among nurses working in adult intensive care units of federally administered hospitals in Addis Ababa, Ethiopia, were investigated. METHODS: From April 4 to 24, 2020, 121 Adult Intensive Care Unit nurses at Ethiopian federal hospitals participated in an institutional-based cross-sectional survey with a standardized selfadministered questionnaire. The information was entered into Epidata version 3.1 and then exported to SPSS version 25.0 for analysis. Bivariable and multivariable logistic regressions were used to examine the relationships between independent and dependent variables. RESULT: According to this study, nurses working in the Adult Intensive Care Unit of federal hospitals in Addis Ababa, Ethiopia, had poor knowledge (51.2%) and poor practice (62%) of the Glasgow Coma Scale's basic theoretical notions and competencies. Furthermore, the education and gender of nurses were linked to their level of knowledge and clinical practice. Being a male and having a master's degree were both significantly linked with knowledge (AOR = 4.13, 95% CI: (1.87­9.1)), (AOR=7.4, 95% CI: (1.4-38)) and practice (AOR = 2.7, 95% CI: (1.2­6)), (AOR = 10.4, 95% CI: (2.0­53)) respectively. CONCLUSION: The findings from this study showed that nurses had poor knowledge and application of practice-related clinical scenarios on the Glasgow Coma Scale

Oral Health-Related Knowledge, Attitude and Practices Among Trainee Community Health Officers in A Nigerian Tertiary Health Institution

To evaluate the oral health-related knowledge and practices of trainee Community Health Officers. A cross-sectional descriptive study conducted using total population purposive sampling method with a self-administered questionnaire on 70 community health officer's trainees at the centre for training community health officers. Sixty-two trainees (response rate of 88.6%) participated made up of year one (45.2%) and year two 54.8%. %). Mean age of 33.5 years (SD=8.65). By gender, females 90.3% were more than males 9.7% while privately sponsored (53.2%) were more than government-sponsored 38.7% A majority had knowledge of Caries (98.4%), Periodontal disease (93.5%) and Oral cancer (96.8%). Year two trainees had more knowledge about periodontal diseases 54.8% compared to year one 38.5% (p<0.05). Most respondents (91.1%) reported dental visit to be important with 87.1% of the opinion that the visit should not be for pain only; 38.7% felt that dental treatment was expensive. More privately sponsored (51.5%) compared to government-sponsored (20.8%) felt that dental treatment was expensive (p<0.05). only 11.3% had visited the dentist in the past six months with dental experience gum bleeding (8.1%), dental caries (8.1%), and tooth sensitivity (21%). A majority (85.5%) rated their oral health to be good. The study showed that community health officer trainees have a good knowledge of oral diseases with the year two trainees demonstrating a better knowledge of caries, periodontal disease and oral cancer and self-rated oral health. Their role in oral health promotion programs at the Primary Health Care level should be encouraged to reduce the burden of oral health diseases in the community.

Sensitivity and specificity of malaria rapid diagnostic test (mRDT CareStatTM) compared with microscopy amongst under five children attending a primary care clinic in southern Nigeria

Background: Malaria diagnosis using microscopy is currently the gold standard. However, malaria rapid diagnostic tests (mRDTs) were developed to simplify the diagnosis in regions without access to functional microscopy. Aim: The objective of this study was to compare the diagnostic accuracy of mRDT CareStatTM with microscopy. Setting: This study was conducted in the paediatric primary care clinic of the Federal Medical Centre, Asaba, Nigeria. Methods: A cross-sectional study for diagnostic accuracy was conducted from May 2016 to October 2016. Ninety-eight participants were involved to obtain a precision of 5%, sensitivity of mRDT CareStatTM of 95% from published work and 95% level of confidence after adjusting for 20% non-response rate or missing data. Consecutive participants were tested using both microscopy and mRDT. The results were analysed using EPI Info Version 7. Results: A total of 98 children aged 3­59 months were enrolled. Malaria prevalence was found to be 53% (95% confidence interval [CI] = 46% ­ 60%), whilst sensitivity and specificity were 29% (95% CI = 20% ­ 38%) and 89% (95% CI = 83% ­ 95%), respectively. The positive and negative predictive values were 75% (95% CI = 66.4% ­ 83.6%) and 53% (95% CI = 46% ­ 60%), respectively. Conclusion: Agreement between malaria parasitaemia using microscopy and mRDT positivity increased with increase in the parasite density. The mRDT might be negative when malaria parasite density using microscopy is low

Patient satisfaction with peri-partum care at Bertha Gxowa district hospital, South Africa

Background: Patient satisfaction is one of the key outcome measures of healthcare services. Aim and Setting: To explore factors that influence women's satisfaction with peri-partum care at Bertha Gxowa district hospital, South African primary care. Methods: A cross-sectional study involving 260 women was conducted. A structured questionnaire collected information from participants on pain relief, health education provided by healthcare providers, privacy, cleanliness of the ward and their participation in decision-making about care received in the peri-partum period. Results: Most respondents were co-habiting with their partners (100, 38%) and had completed only secondary school education (119, 46%). The average participant age was 27 years, with an average parity of two children. Most participants were satisfied with the privacy (218, 84%) and the general cleanliness of the wards (233, 90%). However, large proportions of women were dissatisfied with the information given to them by doctors (104, 55%) and nurses (89, 37%), and the rest were unsure. About 189 (73%) participants were dissatisfied with the extent of their participation in decision-making about their own care. The study had a caesarean rate of 53 (20%). Compared to normal vaginal delivery, participants who had caesarean section were significantly more likely to report being satisfied with pain relief during labour (p < 0.001). Conclusion: The study findings showed varying levels of satisfaction with different aspects of peri-partum care and suggested the need for better pain relief during vaginal delivery, information sharing by doctors and patient emancipation for decision-making about their own care

Mixed-methods evaluation of family medicine research training and peer mentorship in Lesotho

Background: Strengthening primary care research capacity is a priority globally. Family medicine training programmes in sub-Saharan Africa represent an important opportunity to build primary care research; however, they are often limited by insufficient research training and mentorship. Peers can be used to extend research mentorship capacity, but have not been evaluated in this context. Aim: The aim of this study was to evaluate one family medicine training programme's research capacity building efforts through a blended research curriculum and peer mentorship. Setting: Lesotho is a landlocked country within South Africa of approximately two million people. The Family Medicine Specialty Training Programme (FMSTP) is the only accredited postgraduate medical education programme in Lesotho. Methods: This two-year mixed-methods evaluation used: (1) Likert-scale surveys measuring trainee research confidence, (2) written evaluations by trainees, peers, programme faculty and administrators and (3) in-depth, semi-structured interviews. Survey data were analysed using Friedman and sign tests. Interview and written data were analysed thematically via a mixed inductive-deductive approach using Cooke's framework. Results: Family Medicine Specialty Training Programme trainees (n = 8) experienced moderate increases in research confidence that were statistically significant. Skill-building occurred primarily via experiential learning. Research was grounded in trainees' clinical practice and locally relevant. A positive research culture was created, promising for sustainability. We identified infrastructure gaps, including funding and protected time. Peer research mentorship supported trainees' motivation and provided a safe space for questions. Conclusion: The FMSTP research curriculum and peer mentorship programme were successful in positively impacting a number of Cooke's research capacity domains. This evaluation identified improvements that are now being implemented

Training family physicians: A qualitative exploration of experiences of registrars in a family medicine training programme in Cape Town, South Africa

Background: The MMed in Family Medicine is a professional Master's qualification spanning 4 years of training. The outcomes were predetermined by national consensus. While these outcomes are measured in the form of a national exit examination, there has been no exploration of the experiences of registrars (residents) in this relatively new programme. To evaluate the experiences of registrars in one of the nine training programmes in South Africa and to identify areas for improvement. Methods: This study used purposive sampling to recruit registrar (n = 9) and supervisor (n = 8) participants into respective groups. Data were collected via semi-structured interviews and analysed thematically, and consensus was built using the nominal group technique. Results: Supervisors identified the strengths and weaknesses of the programme which will impact on further strategic planning. Data from registrar interviews yielded two themes: affirmation, referring to the positive social engagement and facilitation of professional identity formation; and frustrations, referring to structural aspects of the programme which hindered academic progress. Conclusion: Qualitative programme evaluation is a useful tool in understanding the learning environment. The student perspective helped to identify the unintended consequences of the programme. It was also shown that the nominal group consensus building technique worked well in a resource-constrained environment

Lifestyle, cardiovascular risk knowledge and patient counselling among selected sub-Saharan African family physicians and trainees

Background: Cardiovascular disease (CVD)-related deaths in sub-Saharan Africa (SSA) are on the rise, and primary care physicians could facilitate the reversal of this trend through treatment and prevention strategies. Aim: The aim of this study was to determine the relationship between physician lifestyle practices, CVD prevention knowledge and patient CVD counselling practices among family physicians (FPs) and family medicine (FM) trainees affiliated to FM colleges and organisations in SSA. Setting: FPs and FM trainees affiliated to FM colleges and organisations in Anglophone SSA. Methods: A web-based cross-sectional analytical study was conducted using validated, self-administered questionnaires. Following collation of responses, the relationship between the participants' CVD prevention knowledge, lifestyle practices and CVD counselling rates was assessed. Results: Of the 174 participants (53% response rate), 83% were married, 51% were females and the mean age was 39.2 (standard deviation [SD] 7.6) years. Most of the participants responded accurately to the CVD prevention knowledge items, but few had accurate responses on prioritising care by 10-year risk. Most participants had less than optimal lifestyle practices except for smoking, vegetable or fruit ingestion and sleep habits. Most participants (65%) usually counselled patients on nutrition, but less frequently on weight management, exercise, smoking and alcohol. The region of practice and physicians with poor lifestyle were predictive of patient counselling rates. Conclusion: Training on patient counselling and self-awareness for CVD prevention may influence patient counselling practice. Promoting quality training on patient counselling among FPs as well as a healthy self-awareness for CVD prevention is thus needed. The complex relationship between physician lifestyle and patient counselling warrants further study

Knowledge of final-year medical students at the University of KwaZulu-Natal about family medicine, and long-term career choices

Background: While international experience suggests that well-trained primary care physicians improve the quality and cost effectiveness of health care, family medicine (FM) as the discipline of the specialist primary care physician appears to not be an attractive career for medical graduates in South Africa (SA). The aim of this study was to establish final-year medical students' knowledge about FM and its relevance to the healthcare system, explore their perceptions of the discipline's relevance, and identify their specialty preference.Methods: This was a descriptive study conducted amongst final-year medical students at the University of KwaZulu-Natal (UKZN) in 2017 attheconclusion of their seven-week FM module. Data were collected using a self-administered questionnaire and results were analysed descriptively.Results: The response rate of completed questionnaires was 80.2% (157/196). Students reported limited exposure to FM in their early undergraduate years and low levels of awareness about essential public health programmes. Students showed good awareness of the six roles of family physicians (FPs), but FM was only the sixth most popular choice for specialisation. Conclusions: In general, students had favourable views concerning FM and its role in the future of healthcare delivery in SA,although their knowledge of essential health programmes was poor. The majority of students had limited interest in pursuing a career in FM. A key recommendation to address these issues is to introduce FM into the curriculum earlier, to cover the key roles of the FP, and provide teaching that highlights the relevance of FM to health system programmes

Knowledge and perception of family medicine among medical students at University of Ibadan, Nigeria

Background: Postgraduate training in Family Medicine in Nigeria began over three decades ago, but it was not until recently that the National University Commission (NUC) made it a policy for all Nigerian universities to include undergraduate Family Medicine training in their curriculum. This study aimed to assess the awareness and perception of Family Medicine among medical students at the University College Hospital (UCH), Ibadan. Method: A descriptive cross-sectional study was conducted over a period of four weeks (June 11­July 6, 2018) among 131 fourth-year, 118 fifth-year and 163 sixth-year medical students at UCH, Ibadan. Data were obtained using a self-administered questionnaire. Results: Data were collected from 309 (75% of the target population). The mean age of the respondents was 22.3 ± 2.3 years. The majority (74.4%) did not have a family member who was a doctor and only 2.3% had a family member who was specialising in Family Medicine. Most of the participants (68.9%) had good knowledge of Family Medicine, while 57.3% had good perception of Family Medicine as a specialty. Importantly, an increase in year of clerkship was associated with an increase in the knowledge of Family Medicine among the respondents. Conclusion: It was observed that with increase in length of exposure to Family Medicine as a specialty, knowledge and perception of the specialty improved among the medical students. It is imperative that all the medical schools in Nigeria implement the NUC directive and start undergraduate Family Medicine training

Mastering your Fellowship

The series, "Mastering your Fellowship", provides examples of the question format encountered in the FCFP(SA) examination. The series aims to help family medicine registrars and their supervisors prepare for this examination. Model answers are available online

Conference report: undergraduate family medicine and primary care training in Sub-Saharan Africa: reflections of the PRIMAFAMED network

Internationally, there is a move towards strengthening primary healthcare systems and encouraging community-based and socially responsible education. The development of doctors with an interest in primary healthcare and family medicine in the African region should begin during undergraduate training. Over the last few years, attention has been given to the development of postgraduate training in family medicine in the African region, but little attention has been given to undergraduate training. This article reports on the 8th PRIMAFAMED (Primary Care and Family Medicine Education) network meeting held in Nairobi from 21 to 24 May 2016. At this meeting the delegates spent time presenting and discussing the current state of undergraduate training at 18 universities in the region and shared lessons on how to successfully implement undergraduate training. This article reports on the rationale for, information presented, process followed and conclusions reached at the conference

Personality Profile and Coping Resources of Family Medicine Vocational Trainees at the University of Limpopo; South Africa

Background: Doctors are exposed to various stress factors in their personal and family lives; as well as in the workplace. Stress inherent to the responsibilities and challenges of the medical field may become a health hazard and threaten the well-being of the medical practitioner. Methods: The aim of this study was to investigate the personality traits and coping resources that contribute to the wellbeing of medical practitioners. A cross-sectional study of 44 out of 45 (98response rate) family medicine vocational trainees at the Medical University of Southern Africa (now known as the University of Limpopo) was conducted. A biographic questionnaire was utilised to obtain specific information regarding the participants. The principal researcher used the Coping Resources Inventory (CRI) questionnaire to assess coping resources; and the 16PF personality analysis (16PF) to establish a personality profile of the participants. Results: The majority of participants (81.8) indicated that they mainly experienced work-related stress. Thirty-two participants (72.72) self-medicated. Fourteen participants (31.81) claimed to experience burn-out and twenty (45.45) reported fatigue. In terms of their coping resources; 24 male participants (54.54) did not cope socially (p . 0.008) and eight (18.18) also did not cope physically (p . 0.024). Conclusions: The medical practitioners had a universal personality profile. They lacked insight regarding the symptoms they were experiencing that warranted management; e.g. depression and anxiety. The medical practitioners in this study did not utilise their social and physical coping resources optimally and reported poor help-seeking behaviour

Prevalence of chronic kidney disease in a Nigerian family practice population

Background: Chronic kidney disease (CKD) is a global public health problem, with a greater burden and prohibitive cost of care particularly in developing countries. This study determined the prevalence of chronic kidney disease and identified its associated risk factors in patients attending the Family Practice Clinic, Wesley Guild Hospital, Ilesa, Nigeria. Method: Consecutive newly-registered patients who attended the Family Practice Clinic of Wesley Guild Hospital, Ilesa from August 2005 to January 2006 were recruited and studied. Relevant data were collected by using an interviewer-administered questionnaire, and determining the spot urinary ACR (albumin-creatinine ratio) of the subjects by using Microalbustix™ reagent strips and using their serum creatinine concentration. The glomerular filtration rate (GFR) of each subject was estimated using the Modification of Diet in Renal Disease (MDRD) formula. A repeat urine test was done three months after the initial screening to identify subjects with persistent microalbuminuria. Results: The age of the study subjects ranged from 20 to 74 years, with a mean age of 50.52 + 13.03 years. There were 68 males and 182 females in the sample population, showing a male to female ratio of 1:2.7. One hundred and thirteen of the 250 subjects (45.2%) were found to have pathologic albuminuria at the initial screening, while 31 (12.4%) had persistent albuminuria three months later. Also, 51 subjects (20.4%) had estimated low GFR at the initial screening and 26 (10.4%) had persistent low GFR three months later. Significant risk factors for CKD in the study subjects were increasing age, elevated blood pressure, history of diabetes mellitus (DM), habitual intake of analgesics and herbs, and an abnormal waist to hip ratio(p < 0.05). The association between persistent abnormal ACR and low GFR did not reach statistical significance (p = 0.053). Habitual analgesic intake (p = 0.002) and age group (p = 0.0027) were true predictors of CKD among the study subjects. Conclusions: The prevalence of CKD in the study population was high and its association with modifiable risk factors was demonstrated. Family physicians have a unique opportunity to identify and address these factors in their patients. Routine screening for CKD in family practice clinics is indicated to reduce the burden of renal disease in the population

Family Practitioners Perception of; Knowledge about and use of Peak Flow Meters in Lenasia; Lenasia South; and Soweto Community Health Clinics

Background : The purpose of this paper was to determine the availability of peak flow meters; perceptions about their usefulness and the perceptions of clinical indications for their use. Methods : A questionnaire was administered to private and public sector practitioners (n=72) working in three urban areas of greater Johannesburg. Data were collected concerning practice profiles; the characteristics of the practitioners; the extent of and indications for use; and the reasons for failure to use these meters. Results : The results showed that only 21 (29) of the practitioners advised their asthma patients to use peak flow meters for home monitoring. A scoring system (summary score); which was developed to summarise knowledge of both the indications for the use of the meters and the method of peak flow measurement; showed that only 33.3of the practitioners attained maximum or close to maximum scores (6 to 8 of an 8-point scale). Conclusion : Peak flow meters were underutilised by family practitioners. The cost of the peak flow meter was an important reported cause of underutilisation. It is recommended that the importance of the peak flow meter in the management of asthma be emphasised at the undergraduate and continuing medical education level. The findings of this study could also be used to guide the national campaign coordinators in South Africa in their strategy to improve asthma care among family practitioners. Since asthma may be under-diagnosed in the community; further research is needed to assess the effects of education in assisting people to recognise asthma. Early recognition and diagnosis of asthma; together with appropriate asthma education; may significantly reduce morbidity. The role of illiteracy and cost in limiting the use of peak flow meters warrants investigation; as does the possibility of developing suitable meters for populations with limited formal education. Doctors need to make more conscientious; concerted and informed efforts to monitor their asthma patients and to collaborate; where appropriate; with health educators to optimise the management of asthma. This could include workshops within the community and with fellow healthcare workers (doctors; primary healthcare sisters) on various aspects of asthma care; which will incorporate inhaler techniques and peak flow meter use

Building Consensus on Clinical Procedural Skills for South African Family Medicine Training Using the Delphi Technique

Background: The development of registrar training as part of the newly created speciality. Methods: This study utilized a Delphi technique to establish a national consensus between 35 experts from training institutions; those already in family practice and managers who might be employing family physicians in both private and public sector contexts of family medicine in South Africa requires the development of a national consensus on the clinical procedural skills outcomes that should be expected of training programmes.Results: Consensus was reached on 214 core skills at different levels of desired competency and 23 elective skills. The core skills were divided into 58 that should be taught by family physicians; 101 that should be performed independently and 55 that should be performed during training under supervision. The panel were unable to reach consensus on a further 21 skills.Conclusion: This is the first study that has proposed a set of essential clinical procedural skills for the training of family physicians in South Africa. The findings will act as a benchmark for programmes in South Africa and through the new initiative of 'FaMEC in Africa' may influence curriculum development in other African countries. They may be used as a guide for curriculum planning; as a way of monitoring skills development and as an indication to registrars of the skills they need to achieve for assessment purposes. The findings may also inform the planning of training programmes for the proposed mid-level health worker (clinical associate) in South Africa as their skills will be a sub-set of these skills and will be taught by family physicians within district hospitals. Training programmes for undergraduates and interns in family medicine may also want to position themselves as stepping stones in line with these final outcomes of postgraduate training