Electronic distance based clinical skills training development in family medicine in Namibia.

Workplace-based evaluation is one of the most important, but challenging aspects of medical education. The aim was to improve the assessment of the rural community-based clinical training for undergraduate 3rd and 4th year family medicine students at the University of Namibia (UNAM) and implement a paperless process. An online module was developed on the Moodle platform to include a study guide, an electronic portfolio, and electronic resources (e-books and apps) to replace the current paper version of the logbook. We explored local resources by engaging with students and clinical trainers on how to best conduct the initial implementation. Engagement also entailed motivating students to actively participate in the implementation process. All 3rd and 4th year community-based education end service (COBES) students are now submitting proof of clinical learning electronically with the use of their phones in their online portfolio and using online resources. In addition, students in the practical family medicine module that has been introduced in the 6th year since 2023 are now also using an electronic portfolio and these assessment tools.Contribution: Overall feedback from students and supervisors indicates a positive atmosphere of learning and constructive feedback on performance from all team members, hopefully improving work-based assessments and ultimately patient care. More members of the primary health care team were involved and the carbon footprint has also been decreased.

The psychometric properties of a tool to assess brief behaviour change counselling in South Africa.

BACKGROUND: Primary care providers should be competent in brief behaviour change counselling (BBCC). A new model of BBCC was developed in South Africa. Tools are needed for training and research to evaluate BBCC. AIM: To evaluate the validity and reliability of a tool to assess BBCC. SETTING: Primary care providers in Western Cape, South Africa. METHODS: Exploratory sequential mixed methods included initial qualitative feedback from an expert panel to assess validity, followed by quantitative analysis of internal consistency, inter- and intra-rater reliability. Six raters assessed 33 randomly selected audiotapes from a repository of 123 tapes of BBCC at baseline and 1 month later. RESULTS: Changes to the existing tool involved item changes, added items and grammatical as well as layout changes. The 'Assessment of Brief Behavioural Change Counselling' tool (ABC tool) had good overall internal consistency (Cronbach's alpha 0.955), inter-rater (intra-class correlation coefficient [ICC] 0.813 at follow-up) and intra-rater reliability (Pearson's correlation 0.899 and p 0.001). Sub-scores for the Assist (ICC 0.784) and Arrange (ICC 0.704) stages had lower inter-rater reliability than the sub-scores for Ask (ICC 0.920), Alert (ICC 0.925) and Assess (ICC 0.931) stages. CONCLUSION: The ABC tool is sufficiently reliable for the assessment of BBCC. Minor revisions may further improve the reliability of the tool, particularly for the sub-scores measuring Assist and Arrange. The ABC tool can be used in clinical training or research studies to assess fidelity to this model of BBCC.

The state of family medicine training programmes within the Primary Care and Family Medicine Education network.

The 2019 Primary Care and Family Medicine Education network (Primafamed) meeting in Kampala, Uganda, included a workshop that aimed to assess the state of postgraduate family medicine training programmes in the Primafamed network. Forty-six people from 14 African and five other countries were present. The evaluation of programmes or countries according to the stages of change model was compared to a previous assessment made 5 years ago. Most countries have remained at the same stage of change. Two countries appeared to have reversed their readiness to change as Rwanda moved from relapse to pre-contemplation and Mozambique moved from action to contemplation. Malawi, Zambia and Zimbabwe increased their readiness to change and moved from contemplation to action. Countries in the region remain quite diverse in terms of their commitment to family medicine training. Within Primafamed, it is possible for countries with a more advanced stage of change to assist countries with an earlier stage. Primafamed is also supported by a variety of partners outside of Africa. Five years after the previous country-level assessment, family medicine in Africa continues to span across all levels of the stages of change model. Stage-matched interventions aligned with the needs of individual countries should follow. Consequently, this workshop report will serve as a mandate and compass for Primafamed's actions over the next few years, aimed at designing and delivering these interventions. As reiterated in the 2019 Kampala commitment, we should continue developing the discipline of family medicine (the medical 'specialty' of primary care), through alignment of our training programmes to the health needs in the African region.

Improving the quality of care for female rape survivors at Scottish Livingstone Hospital, Molepolole, Botswana: A quality improvement cycle.

BACKGROUND: Rape is prevalent in Botswana, but there has been limited research undertaken to improve the quality of healthcare for female rape survivors in this clinical setting. Research can not only influence the health outcomes of victims but also has the potential to inform policy. AIM: The aim of this study was to improve the quality of care for female rape survivors in Scottish Livingstone Hospital, Molepolole, Botswana. SETTING: The setting is Scottish Livingstone Hospital, Molepolole, Botswana. METHODS: This study was a qualitative cycle, using the normal steps of performing a baseline audit of clinical practice, planning and implementing changes and re-audit. RESULTS: A total of 124 patient records were audited, comprising 62 patient records at baseline and re-audit. The mean age of victims was 23 years and the age category with the highest incidence of rape ranged between 12 and 20 years, constituting 47% of patients' records. During the baseline audit, only one out of 10 structural standards was met, while at re-audit eight structural standards were fully met. Although none of the process standards were met during both audits, statistically significant improvements in performance (p 0.05) were shown in six out of 10 criteria at re-audit. CONCLUSION: The quality of care for female rape survivors is suboptimal in our setting. However, simple interventions to improve the structure in place for patients and upskilling the entire practice team to align care to current international standards can improve the overall quality of healthcare.

Improving the quality of care for female rape survivors at Scottish Livingstone Hospital, Molepolole, Botswana: a quality improvement cycle

Background: Rape is prevalent in Botswana, but there has been limited research undertaken to improve the quality of healthcare for female rape survivors in this clinical setting. Research can not only influence the health outcomes of victims but also has the potential to inform policy. Aim: The aim of this study was to improve the quality of care for female rape survivors in Scottish Livingstone Hospital, Molepolole, Botswana. Setting: The setting is Scottish Livingstone Hospital, Molepolole, Botswana. Methods: This study was a qualitative cycle, using the normal steps of performing a baseline audit of clinical practice, planning and implementing changes and re-audit. Results: A total of 124 patient records were audited, comprising 62 patient records at baseline and re-audit. The mean age of victims was 23 years and the age category with the highest incidence of rape ranged between 12 and 20 years, constituting 47% of patients' records. During the baseline audit, only one out of 10 structural standards was met, while at re-audit eight structural standards were fully met. Although none of the process standards were met during both audits, statistically significant improvements in performance (p < 0.05) were shown in six out of 10 criteria at re-audit. Conclusion: The quality of care for female rape survivors is suboptimal in our setting. However, simple interventions to improve the structure in place for patients and upskilling the entire practice team to align care to current international standards can improve the overall quality of healthcare

Perceptions about family-centred care among adult patients with chronic diseases at a general outpatient clinic in Nigeria.

BACKGROUND:  Few studies in Africa have described patients' perceptions about family-centred care (FCC). AIM:  The aim of this study was to explore perceptions of FCC among patients with chronic diseases. SETTING:  The study was conducted at a general outpatient clinic (GOPC) in Jos, north-central Nigeria. METHODS:  We used a mixed-methods phenomenological study design and conducted structured and semi-structured interviews with 21 adult patients with chronic diseases at a general outpatient clinic in north-central Nigeria. RESULTS:  Patients described FCC using progressive levels of family engagement including the doctor inquiring about history of similar disease in the family, information sharing with family members and fostering of family ties. They described current family involvement in their care as either inquiring about their health, accompanying them to the clinic or offering material or social support and health advice. Also, patients considered the value of FCC based on how it meets information needs of the family, influences individual health behaviour and addresses family dynamics. Those who were literate and older than 50 years of age favoured FCC during history taking. Those who were literate, aged lesser than 50 years and had poor disease control showed preference for FCC during treatment decision-making. CONCLUSION:  The acceptability of FCC is a complex synthesis of age, socio-economic status, literacy and disease outcomes. Patients older than 50 years, with good treatment outcomes, and those without formal education may need further education and counselling on this approach to care.

Reliability measurement and ICD-10 validation of ICPC-2 for coding/classification of diagnoses/health problems in an African primary care setting.

Background: The routine application of a primary care classification system to patients' medical records in general practice/primary care is rare in the African region. Reliable data are crucial to understanding the domain of primary care in Nigeria, and this may be actualized through the use of a locally validated primary care classification system such as the International Classification of Primary Care, 2nd edition (ICPC-2). Although a few studies from Europe and Australia have reported that ICPC is a reliable and feasible tool for classifying data in primary care, the reliability and validity of the revised version (ICPC-2) is yet to be objectively determined particularly in Africa. Objectives: (i) To determine the convergent validity of ICPC-2 diagnoses codes when correlated with International Statistical Classification of Diseases (ICD)-10 codes, (ii) to determine the inter-coder reliability among local and foreign ICPC-2 experts and (iii) to ascertain the level of accuracy when ICPC-2 is engaged by coders without previous training. Methods: Psychometric analysis was carried out on ICPC-2 and ICD-10 coded data that were generated from physicians' diagnoses, which were randomly selected from general outpatients' clinic attendance registers, using a systematic sampling technique. Participants comprised two groups of coders (ICPC-2 coders and ICD-10 coders) who coded independently a total of 220 diagnoses/health problems with ICPC-2 and/or ICD-10, respectively. Results: Two hundred and twenty diagnoses/health problems were considered and were found to cut across all 17 chapters of the ICPC-2. The dataset revealed a strong positive correlation between selected ICPC-2 codes and ICD-10 codes (r ≈ 0.7) at a sensitivity of 86.8%. Mean percentage agreement among the ICPC-2 coders was 97.9% at the chapter level and 95.6% at the rubric level. Similarly, Cohen's kappa coefficients were very good (κ > 0.81) and were higher at chapter level (0.94-0.97) than rubric level (0.90-0.93) between sets of pairs of ICPC-2 coders. An accuracy of 74.5% was achieved by ICD-10 coders who had no previous experience or prior training on ICPC-2 usage. Conclusion: Findings support the utility of ICPC-2 as a valid and reliable coding tool that may be adopted for routine data collection in the African primary care context. The level of accuracy achieved without training lends credence to the proposition that it is a simple-to-use classification and may be a useful starting point in a setting devoid of any primary care classification system for morbidity and mortality registration at such a critical level of public health importance.

Evaluation of a training programme for primary care providers to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa.

OBJECTIVE: To evaluate the effect on clinical practice of training primary care providers (PCPs) in an approach to brief behaviour change counselling (BBCC), integrating the 5As (ask, alert, assess, assist, arrange) with a guiding style derived from motivational interviewing in the South African context. BBCC was focused on the four risky behaviours (unhealthy eating, tobacco smoking, physical inactivity, harmful alcohol use) for non-communicable diseases. METHODS: It was a before-and-after design, recording BBCC skills at baseline, directly after training and 6-weeks later. We evaluated each recording for adherence to the guiding style and delivery of the 5As using the Motivational Interviewing Treatment Integrity 3.1.1. tool, and a tool based on the 5As training design. RESULTS: 123 recordings were collected from 41 PCPs. Results showed a significant improvement in adoption of the guiding style (e.g. global score at baseline 2.0 (2.0-2.6) and in clinical practice 3.0 (2.7-3.3) p<0.001) and completion of the 5A steps (e.g. assist score at baseline 1.26 (1.12-1.4) and in clinical practice 1.75 (1.61-1.89) p<0.001). CONCLUSION: Training PCPs in this approach to BBCC is effective at changing their clinical practice in the short term. PRACTICE IMPLICATIONS: The training programme should be integrated into the curricula of PCPs, and used in continuing professional development.

A situational analysis of training for behaviour change counselling for primary care providers, South Africa.

BACKGROUND: Non-communicable diseases and associated risk factors (smoking, alcohol abuse, physical inactivity and unhealthy diet) are a major contributor to primary care morbidity and the burden of disease. The need for healthcare-provider training in evidence-based lifestyle interventions has been acknowledged by the National Department of Health. However, local studies suggest that counselling on lifestyle modification from healthcare providers is inadequate and this may, in part, be attributable to a lack of training. AIM: This study aimed to assess the current training courses for primary healthcare providers in the Western Cape. SETTING: Stellenbosch University and University of Cape Town. METHODS: Qualitative interviews were conducted with six key informants (trainers of primary care nurses and registrars in family medicine) and two focus groups (nine nurses and eight doctors) from both Stellenbosch University and the University of Cape Town. RESULTS: Trainers lack confidence in the effectiveness of behaviour change counselling and in current approaches to training. Current training is limited by time constraints and is not integrated throughout the curriculum--there is a focus on theory rather than modelling and practice, as well as a lack of both formative and summative assessment. Implementation of training is limited by a lack of patient education materials, poor continuity of care and record keeping, conflicting lifestyle messages and an unsupportive organisational culture. CONCLUSION: Revising the approach to current training is necessary in order to improve primary care providers' behaviour change counselling skills. Primary care facilities need to create a more conducive environment that is supportive of behaviour change counselling.

Development of a training programme for primary care providers to counsel patients with risky lifestyle behaviours in South Africa.

BACKGROUND: We are facing a global epidemic of non-communicable disease (NCDs), which has been linked with four risky lifestyle behaviours. It is recommended that primary care providers (PCPs) provide individual brief behaviour change counselling (BBCC) as part of everyday primary care, however currently training is required to build capacity. Local training programmes are not sufficient to achieve competence. AIM: This study aimed to redesign the current training for PCPs in South Africa, around a new model for BBCC that would offer a standardised approach to addressing patients' risky lifestyle behaviours. SETTING: The study population included clinical nurse practitioners and primary care doctors in the Western Cape Province. METHODS: The analyse, design, develop, implement and evaluate (ADDIE) model provided a systematic approach to the analysis of learning needs, the design and development of the training programme, its implementation and initial evaluation. RESULTS: This study designed a new training programme for PCPs in BBCC, which was based on a conceptual model that combined the 5As (ask, alert, assess, assist and arrange) with a guiding style derived from motivational interviewing. The programme was developed as an eight-hour training programme that combined theory, modelling and simulated practice with feedback, for either clinical nurse practitioners or primary care doctors. CONCLUSION: This was the first attempt at developing and implementing a best practice BBCC training programme in our context, targeting a variety of PCPs, and addressing different risk factors.

Qualitative evaluation of primary care providers experiences of a training programme to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa.

BACKGROUND: The global epidemic of non-communicable disease (NCDs) has been linked with four modifiable risky lifestyle behaviours, namely smoking, unhealthy diet, physical inactivity and alcohol abuse. Primary care providers (PCPs) can play an important role in changing patient's risky behaviours. It is recommended that PCPs provide individual brief behaviour change counselling (BBCC) as part of everyday primary care. This study is part of a larger project that re-designed the current training for PCPs in South Africa, to offer a standardized approach to BBCC based on the 5 As and a guiding style. This article reports on a qualitative sub-study, which explored whether the training intervention changed PCPs perception of their confidence in their ability to offer BBCC, whether they believed that the new approach could overcome the barriers to implementation in clinical practice and be sustained, and their recommendations on future training and integration of BBCC into curricula and clinical practice. METHODS: This was a qualitative study that used verbal feedback from participants at the beginning and end of the training course, and twelve individual in-depth interviews with participants once they had returned to their clinical practice. RESULTS: Although PCP's confidence in their ability to counselling improved, and some thought that time constraints could be overcome, they still reported that understaffing, lack of support from within the facility and poor continuity of care were barriers to counselling. However, the current organisational culture was not congruent with the patient-centred guiding style of BBCC. Training should be incorporated into undergraduate curricula of PCPs for both nurses and doctors, to ensure that counselling skills are embedded from the start. Existing PCPs should be offered training as part of continued professional development programmes. CONCLUSIONS: This study showed that although training changed PCPs perception of their ability to offer BBCC, and increased their confidence to overcome certain barriers to implementation, significant barriers remained. It is clear that to incorporate BBCC into everyday care, not only training, but also a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels.