Education médicale et amélioration de sa qualité: une étude de cas au Mpumalanga, Afrique du Sud.

BACKGROUND : The short timeframe of medical students’ rotations is not always conducive to successful, in-depth quality-improvement projects requiring a more longitudinal approach. AIM : To describe the process of inducting students into a longitudinal quality-improvement project, using the topic of the Mother- and Baby-Friendly Initiative as a case study; and to explore the possible contribution of a quality-improvement project to the development of student competencies. SETTING : Mpumalanga clinical learning centres, where University of Pretoria medical students did their district health rotations. METHOD : Consecutive student groups had to engage with a hospital’s compliance with specific steps of the Ten Steps to Successful Breastfeeding that form the standards for the Mother- and Baby-Friendly Initiative. Primary data sources included an on-site PowerPoint group presentation (n = 42), a written group report (n = 42) and notes of individual interviews in an end-of-rotation objectively structured clinical examination station (n = 139). RESULTS : Activities in each rotation varied according to the needs identified through the application of the quality-improvement cycle in consultation with the local health team. The development of student competencies is described according to the roles of a medical expert in the CanMEDS framework: collaborator, health advocate, scholar, communicator, manager and professional. The exposure to the real-life situation in South African public hospitals had a great influence on many students, who also acted as catalysts for transforming practice. CONCLUSION : Service learning and quality-improvement projects can be successfully integrated in one rotation and can contribute to the development of the different roles of a medical expert. More studies could provide insight into the potential of this approach in transforming institutions and student learning.CONTEXTE: La courte durée des roulements des étudiants médicaux ne favorise pas la réussite des projets approfondis d’amélioration de la qualité qui nécessitent une approche plus longitudinale. OBJECTIF : Décrire le processus d’intronisation des étudiants dans un projet longitudinal d’amélioration de la qualité, au moyen du thème de l’Initiative des Hôpitaux amis de la Mère et des Bébés comme étude de cas; et examiner la contribution possible d’un projet d’amélioration de la qualité au développement des compétences des étudiants. LIEU : Les centres de formation clinique du Mpumalanga où les étudiants médicaux de l’Université de Pretoria ont fait leurs roulements dans les districts sanitaires. METHODE : Des groupes consécutifs d’étudiants ont dû, avec l’autorisation de l’hôpital, s’engager à suivre les mesures spécifiques des Dix Conditions pour le Succès de l’Allaitement maternel qui est la norme de l’Initiative des Hôpitaux amis de la Mère et des Bébés. Les sources de données primaires comprenaient une présentation PowerPoint du groupe sur le terrain (n = 42), un rapport écrit du groupe (n = 42) et les notes des entrevues individuelles dans une station d’examen Clinique structuré objectivement à la fin du roulement (n = 139). RESULTATS : Les activités de chaque roulement changeaient selon les besoins identifiés par l’application du cycle d’amélioration de la qualité en consultation avec l’équipe de santé locale. Le développement des compétences des étudiants est décrit selon les rôles d’un expert médical dans le cadre du CanMEDS: collaborateur, promoteur de la santé, érudit, communicateur, gérant et professionnel. L’exposition à la situation réelle dans les hôpitaux publics sud-africains a eu une grande influence sur beaucoup d’étudiants, qui ont aussi été les catalyseurs du changement de pratique. CONCLUSION : L’apprentissage par le service et les projets d’amélioration de la qualité peuvent être intégrés avec succès dans un roulement et peuvent contribuer au développement des différents rôles d’un expert médical. Un plus grand nombre d’études pourra donner un aperçu des possibilités de cette approche et transformer les institutions et l’apprentissage des étudiants.http://www.phcfm.org/am201

Development of a measure of the patient-provider relationship in antenatal care and its importance in PMTCT

The prevention of mother-to-child HIV transmission (PMTCT) is a complex challenge in heavily affected and resource-limited settings such as South Africa. Management of PMTCT requires a cascade of interventions that need to be addressed to effectively decrease the risk of HIV transmission to infants. This PMTCT cascade includes incremental components that can be shaped and influenced by the patient provider relationship. The relationship that a pregnant woman has with her care providers may possibly affect decisions that she makes concerning her antenatal care and may, in turn, influence the quality of the care provided. A patient provider relationship scale (PPRS) was developed in Pretoria, South Africa with two aims: first, to quantify the patient provider relationship in an antenatal population in a resource-limited setting and provide preliminary evidence of its reliability and validity; and second, to determine whether the patient provider relationship has an effect on PMTCT. The instrument was administrated in a cross-sectional pilot study to a group of women at discharge after delivery (n 192) at two major hospitals in South West Tshwane. Statistical analysis of the instrument showed high reliability (a 0.91) and preliminary evidence of its validity including significant associations with participants’ attitudes regarding the functioning of the clinics and a single statement (the clinic staff ‘‘know me as a person,’’ R 0.47, pB0.001) that has been shown previously to have a significant association with adherence to antiretroviral treatment. For HIV-positive participants, the PPRS was significantly associated with statements related to important components of the PMTCT cascade. In addition, those with substantially inadequate antenatal care (52 visits) and those who did not initiate highly active antiretroviral therapy, although eligible, had significantly poorer PPRS scores. The PPRS is a potentially useful, context-appropriate instrument that could have an important role in future research focused on improving PMTCT and decreasing the risk of HIV infection in children.The Wilbur G. Downs International Health Student Travel Fellowship and Yale School of Medicine Office of Student Research grants.http://www.tandfonline.com/loi/caic2

'I thought they were going to handle me like a queen but they didn't': A qualitative study exploring the quality of care provided to women at the time of birth.

OBJECTIVE:To explore experiences of care during labour and birth from the perspectives of both the healthcare provider and women receiving care, to inform recommendations for how the quality of care can be improved and monitored, and, to identify the main aspects of care that are important to women. DESIGN:A descriptive phenomenological approach. 53 interviews and 10KII as per table 1 took place including in-depth interviews (IDI), focus group discussions (FGD) and key informant interviews (KII) conducted with women, healthcare providers, managers and policy makers. Following verbatim transcription thematic framework analysis was used to describe the lived experience of those interviewed. SETTING:11 public healthcare facilities providing maternity care in urban Tshwane District, Gauteng Province (n = 4) and rural Waterberg District, Limpopo Province (n = 7), South Africa. PARTICIPANTS:Women who had given birth in the preceding 12 weeks (49 women, 7 FGD and 23 IDI); healthcare providers working in the labour wards (33 healthcare providers; nurses, midwives, medical staff, 5 FGD, 18 IDI; managers and policy makers (10 KII). FINDINGS:Both women and healthcare providers largely feel alone and unsupported. There is mutual distrust between women and healthcare providers exacerbated by word of mouth and the media. A lack of belief in women's ability to make appropriate choices negates principles of choice and consent. Procedure- rather than patient-centred care is prioritised by healthcare providers. Although healthcare providers know the principles of good quality care, this was not reflected in the care women described as having received. Beliefs and attitudes as well as structural and organisational problems make it difficult to provide good quality care. Caring behaviour and environment as well as companionship are the most important needs highlighted by women. Professional hierarchy is rarely seen as supportive by healthcare providers but when present, good leadership changes the culture and experience of women and care providers. The use of mobile phones to provide feedback regarding care was positively viewed by women. CONCLUSION:Clarity regarding what a healthcare facility can (or cannot provide) is important in order to separate practice issues from structural and organisational constraints. Improvements in quality that focus on caring as well as competence should be prioritised. Increased dialogue between healthcare providers and users should be encouraged and prioritised. IMPLICATIONS FOR PRACTICE:A renewed focus is needed to ensure companionship during labour and birth is facilitated. Training in respectful maternity care needs to prioritise caring behaviour and supportive leadership