Comparative Evaluation of Pharmacy Students' Knowledge and Skills in Maternal and Child Health: Traditional versus Integrated Curriculum.

Reducing maternal and child mortality is a health priority in South Africa. Therefore, health professional education should produce graduates that can meet these needs. This study compared the maternal and child health (MCH) knowledge and skills of cohorts of final-year students exposed to a traditional (in 2017 and 2018) and integrated (2019) curriculum using a 34-item questionnaire. Between the 2019 and 2017 cohorts, ANOVA and post hoc analysis showed significant differences in the reproductive and sexual health component which was dispersed in the second and final years of study (p = 0.007, Mean Difference (MD) = 8.3) andneonatal and child care (p = 0.000, MD = 15). while it was only in maternal and antenatal care (p = 0.009, MD = 10.0) for the 2019 and 2018 cohorts. Significant differences were observed in participants' average mean scores (p = 0.000 for 2018 and 2017). The highest mean scores were recorded by the 2019 cohort in the three assessments. A one-sample t-test showed the highest mean differences in the reproductive and sexual health components (p = 0.000; MD 2017 = 12.4, MD 2018 = 14.8, MD 2019 = 20.7). Overall, the integrated MCH curriculum and the longitudinal dispersion of content enhanced students' knowledge and skills.

Development and Implementation of an Integrated Framework for Undergraduate Pharmacy Training in Maternal and Child Health at a South African University.

The South African Pharmacy Council (SAPC) regulates undergraduate pharmacy education and pharmacy practice. The SAPC Good Pharmacy Practice manual describes the role of pharmacists in maternal and child health (MCH) in line with the recommendation of international health regulatory bodies. However, baseline study findings in 2017 supported literature from around the world that indicated a need for curriculum review and integration to address the knowledge and skills gap in pharmacists' MCH training. This paper describes the development and implementation of an integrated framework for MCH training across the four years of a Bachelor of Pharmacy program. The intervention included didactic lectures, skills practical on infant growth assessment, and an experiential learning component at primary health care clinics and pharmacies. Knowledge and skills assessment on contraception, maternal and antenatal care, and neonatal and child care were carried out pre, eight weeks post, and two years post intervention using the same questionnaire. ANOVA and post hoc analyses showed that participants' knowledge and skills increased post intervention but decreased significantly two years later except in contraception where students experienced longitudinal integration of the MCH component. Generally, participants performed above the university average except in maternal and antenatal care.

The effectiveness of using text and pictograms on oral rehydration, dry-mixture sachet labels.

BACKGROUND: Medication labels are often the only information available to patients after obtaining medication from a healthcare practitioner. Pictograms are graphic symbols that have shown to increase understanding of medicine use instructions. AIM: To compare the accuracy of the interpretation of medicine use instructions from two different oral rehydration (OR) dry-mixture sachet labels - the control 'routine textonly' label and an experimental label with 'text-and-pictograms'. SETTING: Participants were recruited from waiting rooms in public primary health care (PHC) facilities in Cape Town. METHOD: Each participant was required to answer six questions about OR preparation. Response accuracy was determined by comparing the participant's answer to the actual information written on the relevant label. Afterwards, participants could offer their opinion about the label and ways to improve their understanding. RESULTS: Of the 132 participants who were recruited, 67 were allocated to the experimental group and 65 to the control group. Only the significant difference between the experimental and control groups for the six questions regarding the label, was recorded for the answer that could be read from a single pictogram (p = 0.00) on the experimental group's label. When asked about this question, more control participants (15/65) found the dosing instruction difficult to understand when compared to the experimental group (1/67). A third of the control participants (22/65) indicated that they could not see or locate instructions on the label. CONCLUSION: Text and pictograms on written medicine labels may be an effective tool to aid understanding of medicine use instructions amongst patients attending PHC facilities.

Access to chronic medicines: patients' preferences for a last kilometre medicine delivery service in Cape Town, South Africa.

BACKGROUND: Chronic patients are required to access their chronic medicines on a regular basis, often only to refill their repeat prescriptions. Adherence to chronic medicines is challenging and has stimulated health care providers to devise differentiated service delivery models of care to decentralise chronic medicine distribution to decrease the frequency of medicine collection at health care facilities. One such option includes a last kilometre medicine delivery service. This study investigated chronic patients' preferences for a last kilometre medicine delivery service model. METHODS: An exploratory non-randomised quantitative study was conducted over 4 weeks at four public sector primary health care facilities in Cape Town, South Africa. Data was collected on a structured questionnaire from chronic patients queuing to receive medication at each facility's pharmacy waiting area. Patient demographics were noted to align with preferences for chronic medicine service delivery characteristics including; mobile ordering, fee for service and location for delivery. Chi-square test and frequencies were employed to analyse data using SPSS version 23. RESULTS: A total of 116 patients participated in this study. Most were interested in a medicine delivery service (80.2%) and were willing to use a mobile application to order their medicines (84.5%). Almost all patients (96.8%) preferred that their medicines be delivered to their home. More than three quarters of participants were willing to pay for the service (77.6%). Chi-square test showed that gender, age group, employment status, distance to the health facility and /or average waiting time at the clinic significantly influenced the preference for certain characteristics of the medicine delivery service (p < 0.05). CONCLUSION: Most participants were interested in a last kilometre medicine delivery service, especially those older than 45 years, waiting for more than 6 h at the facility, and staying within one kilometre radius of the clinic. More studies are needed to establish the influence of patients' employment status and the distance to health facility on interest in the medicine delivery service.

Evaluating pharmacy students' knowledge and skills in reproductive, maternal, new-born and child health care at a South African university.

BACKGROUND: Maternal and child mortality is a global concern and one of South Africa's quadruple burdens of disease. As easily accessible frontline healthcare workers, pharmacists play an important role in the continuum of maternal and child health (MCH) care according to recommendations by international health regulatory bodies. Pharmacy schools are obliged to train pharmacy students to meet the priority health needs of the population so that graduates are 'fit for purpose'. The baseline study aimed to evaluate the knowledge and skills of 2017 final year pharmacy students who were exposed to a fragmented MCH care curriculum at a university in South Africa to inform curriculum review. METHODS: A descriptive, quantitative, non-randomized study was conducted among final year pharmacy students using a self-administered structured questionnaire. The questionnaire was designed in sections to assess participants' knowledge of reproductive and sexual health (RSH), maternal and antenatal care (MAC), neonatal and child care (NCC) and skills related to infant growth assessment procedures. Data was analysed descriptively using frequencies and percentages. A score of 50% in each section of the questionnaire indicated a pass. Participants assessed their exposure to MCH topics in the curriculum. RESULTS: Of the 89 available students, 61% consented to participate in the study. The average scores attained for each section were; 62.4% for RSH, 54.5% for MAC, 50.4% for NCC and 25.3% for infant growth assessment. The pass rate was 78% for RSH, 56% for MAC, 57% for NCC, and 19% for infant growth assessment. About 13% of the participants passed all the knowledge and the skills sections. Age, gender, being a parent or doing locums did not have any influence on participants' performance. Participants reported that they had more on-campus curriculum content exposure to RSH compared to other MCH care topics. CONCLUSION: Final year pharmacy students showed adequate knowledge of RSH with adequate curriculum exposure. Average knowledge of MAC, NCC and poor skills in infant growth assessment which corresponded to curriculum exposure was observed. The results suggest the need for improvement in the current curriculum in the affected areas to adequately equip students to render desirable services.

Continuous Professional Development for Public Sector Pharmacists in South Africa: A Case Study of Mapping Competencies in a Pharmacists' Preceptor Programme.

Lifelong learning among healthcare practitioners is crucial to keep abreast of advances in therapeutic and service delivery approaches. In South Africa, continuous professional development (CPD) was mandated (2019) for re-registration of pharmacists to illustrate their learning according to the South African Pharmacy Council's (SAPC) competency standards. This paper uses a preceptor programme linked to the University of the Western Cape School of Pharmacy's service learning programme to map the competencies employed by pharmacist preceptors in primary care public healthcare facilities in Cape Town in an attempt to encourage completion of their annual CPDs and strengthening the academic-service partnership. Competencies identified were divided into input competencies related to the preceptor's role in designing and implementing the educational programme in their facilities and assisting students to complete their prescribed learning activities, and output/outcome competencies that emerged from preceptors identifying the facility needs and employing their input competencies. Input competencies pertained to education, leadership, patient counselling, collaborative practice and human resources management. Output competencies related to pharmaceutical infrastructure, quality assurance, professional and health advocacy, primary healthcare, self-management and patient-centred care. The preceptor programme enabled pharmacist preceptors to employ several competencies that are aligned with the SAPC's competency framework.

Exploring the Implications of a Needs-Based Pharmacy Education Framework Modelled on Population Health: Perspective from a Developing Country.

Globally, health education reform is directing efforts to strengthen the health system through collaboration between health education and health services. However, collaborative efforts vary between developed and developing countries as the health needs, economic constraints, and resource availability differs. In developing countries, resource allocation is weighed in favor of interventions that will benefit the majority of the population. The question that emerges is: How could health education, service, and research activities be (re-)aligned to optimize return on investment for the health system and society at large? This paper proposes a needs-based pharmacy educational approach by centralizing population health for a developing country like South Africa. Literature on systems-based approaches to health professional education reform and the global pharmacy education framework was reviewed. A needs-based pharmacy educational approach, the population health model which underpins health outcome measurements to gauge an educational institution's effectiveness, was contextualized. An evaluation framework to determine the pharmacy school's effectiveness in strengthening the health system could be applied. A needs-based pharmacy educational approach modeled on population health could: Integrate resources from education, service, and research activities; follow a monitoring and evaluation framework that tracks educational outcomes; and engage with external stakeholders in curricular development and assessment.

Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial.

OBJECTIVE: To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV/AIDS. DESIGN: Cluster randomised trial. SETTING: Public primary care clinics offering HIV/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South Africa. PARTICIPANTS: Fifteen clinics all implementing decentralisation and task shifting were randomised. The clinics cared for 400,000 general primary care patients and 10,136 patients in an HIV/AIDS/ART programme. There were 150 nurses. INTERVENTION: On-site outreach education in eight clinics; no such education in seven (control). MAIN OUTCOME MEASURES: Provision of co-trimoxazole prophylaxis among patients referred to the HIV/AIDS/ART programme, and detection of cases of tuberculosis among those in the programme. Proportion of patients in the programme enrolled through general primary care consultations. RESULTS: Patients referred to the HIV/AIDS programme through general primary care at intervention clinics were more likely than those at control clinics to receive co-trimoxazole prophylaxis (41%, (2253/5523) v 32% (1340/4210); odds ratio 1.95, 95% confidence interval 1.11 to 3.40), and tuberculosis was more likely to be diagnosed among patients with HIV/AIDS/ART (7% (417/5793) v 6% (245/4343); 1.25, 1.01 to 1.55). Enrolment in the HIV/AIDS and ART programme through HIV testing in general primary care was not significantly increased (53% v 50%; 1.19, 0.51 to 2.77). Secondary outcomes were similar, except for weight gain, which was higher in the intervention group (2.3 kg v 1.9 kg, P<0.001). CONCLUSION: Though outreach education is an effective and feasible strategy for improving comprehensiveness of care and wellbeing of patients with HIV/AIDS, there is no evidence that it increases access to the ART programme. It is now being widely implemented in South Africa. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 24820584.

Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial.

OBJECTIVE: To evaluate the cost-effectiveness of an educational outreach intervention to improve primary respiratory care by South African nurses. METHODS: Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial, with individual patient data. The intervention, the Practical Approach to Lung Health in South Africa (PALSA), comprised educational outreach based on syndromic clinical practice guidelines for tuberculosis, asthma, chronic obstructive pulmonary disease, pneumonia and other respiratory diseases. The study included 1999 patients aged 15 or over with cough or difficult breathing, attending 40 primary care clinics staffed by nurses in the Free State province. They were interviewed at first presentation, and 1856 (93%) were interviewed 3 months later. RESULTS: The intervention increased the tuberculosis case detection rate by 2.2% and increased the proportion of patients appropriately managed (that is, diagnosed with tuberculosis or prescribed an inhaled corticosteroid for asthma or referred with indicators of severe disease) by 10%. It costs the health service $68 more for each extra patient diagnosed with tuberculosis and $15 more for every extra patient appropriately managed. Analyses were most sensitive to assumptions about how long training was effective for and to inclusion of household and tuberculosis treatment costs. CONCLUSION: This educational outreach method was more effective and more costly than usual training in improving tuberculosis, asthma and urgent respiratory care. The extra cost of increasing tuberculosis case detection was comparable to current costs of passive case detection. The syndromic approach increased cost-effectiveness by also improving care of other conditions. This educational intervention was sustainable, reaching thousands of health workers and hundreds of clinics since the trial.

Quality of asthma care: Western Cape province, South Africa.

BACKGROUND: Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. The Asthma Guidelines Implementation Project (AGIP) was established to improve the impact of the South African guidelines for chronic asthma in adults and adolescents in the Western Cape. One strategy was an audit tool to assist with assessing and improving the quality of care. METHODS: The audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape province. The usual steps in the quality improvement cycle were followed. RESULTS: Data were obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% were given a self-management plan; 81% of medication was in stock, and the controller/reliever dispensing ratio was 0.6. Only 31.5% of patients were well controlled, 16.3% of all visits were for exacerbations, and 17.6% of all patients had been hospitalised in the previous year. CONCLUSION: The availability of medication and prescription of inhaled steroids is reasonable, yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique, and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.

Development of a South African integrated syndromic respiratory disease guideline for primary care.

AIMS: The Practical Approach to Lung Health in South Africa (PALSA) initiative aimed to develop an integrated symptom- and sign-based (syndromic) respiratory disease guideline for nurse care practitioners working in primary care in a developing country. METHODS: A multidisciplinary team developed the guideline after reviewing local barriers to respiratory health care provision, relevant health care policies, existing respiratory guidelines, and literature. Guideline drafts were evaluated by means of focus group discussions. Existing evidence-based guideline development methodologies were tailored for development of the guideline. RESULTS: A locally-applicable guideline based on syndromic diagnostic algorithms was developed for the management of patients 15 years and older who presented to primary care facilities with cough or difficulty breathing. CONCLUSIONS: PALSA has developed a guideline that integrates and presents diagnostic and management recommendations for priority respiratory diseases in adults using a symptom- and sign-based algorithmic guideline for nurses in developing countries.

Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial.

BACKGROUND: Childhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners. Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to general practitioners on asthma symptoms of children in their practice. METHODS: This is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain (population 300,000), a dormitory town near Cape Town. Solo general practitioners, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending general practitioners in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices. Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year post-intervention. RESULTS: Symptom scores declined an additional 0.84 points in the intervention vs. control group (on a nine-point scale. p = 0.03). For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms. CONCLUSION: Educational outreach was accepted by general practitioners and was effective. It could be applied to other health care quality problems in this setting.

Diagnostic accuracy of an integrated respiratory guideline in identifying patients with respiratory symptoms requiring screening for pulmonary tuberculosis: a cross-sectional study.

BACKGROUND: To evaluate the diagnostic accuracy of the integrated Practical Approach to Lung Health in South Africa (PALSA) guideline in identifying patients requiring bacteriological screening for tuberculosis (TB), and to determine which clinical features best predict suspected and bacteriologically-confirmed tuberculosis among patients with respiratory symptoms. METHODS: A prospective, cross-sectional study in which 1392 adult patients with cough and/or difficult breathing, attending a primary care facility in Cape Town, South Africa, were evaluated by a nurse using the guideline. The accuracy of a nurse using the guideline to identify TB suspects was compared to that of primary care physicians' diagnoses of (1) suspected TB, and (2) proven TB supported by clinical information and chest radiographs. RESULTS: The nurse using the guideline identified 516 patients as TB suspects compared with 365 by the primary care physicians, representing a sensitivity of 76% (95% confidence interval (CI) 71%-79%), specificity of 77% (95% CI 74%-79%), positive predictive value of 53% (95% CI 49%-58%), negative predictive value of 90% (95% CI 88%-92%), and area under the receiver operating characteristic curve (ARUC) of 0.76 (95% CI 0.74-0.79). Sputum results were obtained in 320 of the 365 primary care physicians TB suspects (88%); 40 (13%) of these were positive for TB. Only 4 cases were not identified by the nurse using the guideline. The primary care physicians diagnostic accuracy in diagnosing bacteriologically-confirmed TB (n = 320) was as follows: sensitivity 90% (95% CI 76%-97%), specificity 65% (95% CI 63%-68%), negative predictive value 7% (95% CI 5%-10%), positive predictive value 99.5% (95% CI 98.8%-99.8%), and ARUC 0.78 (95% CI 0.73-0.82). Weight loss, pleuritic pain, and night sweats were independently associated with the diagnosis of bacteriologically-confirmed tuberculosis (positive likelihood ratio if all three present = 16.7, 95% CI 5.9-29.4). CONCLUSION: The PALSA guideline is an effective screening tool for identifying patients requiring bacteriological screening for pulmonary tuberculosis in this primary care setting. This supports the randomized trial finding that use of the guideline increased TB case detection.

Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial.

OBJECTIVES: To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics. DESIGN: Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation. SETTING: 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa. PARTICIPANTS: 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics). INTERVENTION: Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials. MAIN OUTCOME MEASURES: Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections. RESULTS: All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38). CONCLUSIONS: Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings. TRIAL REGISTRATION: Current controlled trials ISRCTN13438073.