Approaches to learning and the influence of raising metacognitive awareness of deep learning among undergraduate pharmacy students at a public university in Zambia.

PhD thesisThis study investigated the approaches to learning and influence of a metacognitive educational intervention on deep learning among undergraduate pharmacy students. The study was necessitated by contextually relevant recurring concerns about attrition rates due to poor academic performance that remained relatively high over the years among the preclinical (Year 1 and 2) undergraduate pharmacy students at the University of Zambia (UNZA). This study utilised a sequential multiple mixed-methods design. Firstly, a descriptive cross-sectional survey was conducted to determine the predominant approach to learning among the 2017 to 2018 undergraduate pharmacy students at UNZA. A modified Approaches and Study Skills Inventory for Students (ASSIST) questionnaire was employed to determine approaches to learning and teaching style preference. Secondly, qualitative focus groups were utilised to explore contextual factors affecting preclinical pharmacy students’ learning efficacy. Lastly, a quasi-experiment was conducted to assess effects of a novel metacognitive educational intervention - a five-day elective module dubbed ‘Orientation and Approaches to Deep Learning and Study Skills (OADLSS)’ on preclinical pharmacy students’ approaches to learning and academic performance. A modified short-version of the ASSIST was used to measure approaches to learning before and 4-weeks after the OADLSS intervention compared to a control group. Descriptive and inferential statistical methods were used to analyse quantitative data whereas deductive thematic analysis was used for qualitative data. A strategic approach to learning was predominant among the majority (67%) of the undergraduate pharmacy students surveyed (n = 147). Only 25% adopted a deep approach to their learning whereas 7% were surface learners. Learning approach was statistically significantly associated with course load (p = 0.028) and programme stage (p = 0.010). Compared to pharmacy students in Year 1 level of study, those in Year 4 were 90% less likely to adopt strategic approach to learning (AOR = 0.1, 95% CI: 0.01 – 0.7, p = 0.023) on the B. Pharm. programme at UNZA. The majority (67%) of participants preferred teaching styles that transmitted information. Thematic analysis of qualitative focus groups yielded 4 themes, 8 subthemes and 22 categories. Managing notional time, the high course load, methods of teaching and assessment modalities, achievement motive, and the learning environment were among key contextual factors that affected pharmacy students’ learning efficacy at UNZA. All the participants (100%, n = 25) exposed to the OADLSS elective module found it relevant and useful for enhancing their learning. Although there was not a corresponding significant increase in their deep learning scores, mean scores for strategic learning significantly reduced after the OADLSS intervention compared to the control group. When academic performance in summative assessments was compared, the Grade Point Average (GPA) scores were not significantly different between participants exposed to the OADLSS (2.51 ± 0.53, 95% CI: 2.29 – 2.74) versus controls (2.47 ± 0.39, 95% CI: 2.28 – 2.66; p = 0.771). The predominance of a strategic approach to learning was largely influenced by the inadvertently high educational demands placed on undergraduate pharmacy students. The learning environment, educational strategies, and student-related factors were affecting learning efficacy at the university. Immediate influence of a metacognitive intervention aimed at promoting deep learning in pharmacy education was minimal. Educators and institutional policymakers can enhance interventions further by accompanying changes to the learning environment, educational strategies, and assessment methods employed in pharmacy education. Remodelling these aspects in future research can potentially improve the quality of pharmacy education outcomes at UNZA. Key words: Approaches to Learning, Deep learning, Educational intervention, Metacognitive awareness, Pharmacy students, University of Zambi

Addressing Radiography Workforce Competence Gaps in Zambia: Insights into the Radiography Diploma Training Programme Using a Curriculum Mapping Approach

In Zambia, the radiography diploma programme has been offered since 1970 and has undergone only five reviews against an estimated ten [10] over 40 years. Such a situation can call into question the quality of radiography training. Curriculum evaluation is a key factor in ensuring quality standards of an educational training programme. The timely review ensures that curricula are in keeping with contemporary practice requirements. We analysed the 2014 radiography curriculum using a curriculum mapping approach to evaluate the stated objectives and their alignment to the educational domains and contemporary radiography practice requirements. Method: A case study design was used to explore the 2014 TEVETA radiography curriculum. Content analysis was used to identify curriculum learning objectives. A framework based on Harden’s curriculum mapping approach was developed. The first phase involved analysis of the curriculum content against the educational domains [i.e. cognitive, psychomotor, and affective domains, respectively]. The second phase involved comparing the stated learning outcomes with contemporary radiography practices. Results: A total of 90 learning outcomes were identified. The analysis revealed that 80% [N=72] of all the stated objectives were cognitive, while only 13% and 7% were psychomotor and affective, respectively. Furthermore, over 70% were pitched at the lower-order skills level of Dave’s taxonomy. In terms of radiographer competence, 55% [N=40] were attributed to technical skills. However, more than 90% of the technical competences were knowledge components and 10% actual psychomotor skills. Conclusion: A curriculum mapping approach was useful in analysing the current Zambian radiography diploma curriculum. The overemphasis on lower-order cognitive and psychomotor competence in the curriculum calls into question the technical readiness of new graduates to effectively perform at the expected level of proficiency in the workplace. Findings of this study provide valuable information that can be used for reviewing the curriculum to make the training more responsive to contemporary radiography practice demands

A Comparison of the Arbitrary Set Fifty Percent Pass Mark Standard and Grade Point Average Attainment for Pharmacy Students at the University of Zambia: Implications for High-stakes decisions in Assessments

In many higher learning institutions and Health Professions Education (HPE) programmes in particular, there exists varying standard setting methods for assessment, certification and graduation of students’ academic performance. In Zambia, the historic arbitrary set 50% pass-fail standard is predominant in most health professions’ training programmes. Scientific validation of this practice, however, remains scarce. The aim of this study was to compare the academic performance on the historic arbitrary set 50% pass-fail standard to the Grade Point Average (GPA) score attainment for pharmacy students examined between 2013 and 2017 at the University of Zambia. A cross-sectional study was conducted with a total of 445 randomly selected final examination results for undergraduate pharmacy students examined between 2013 and 2017 at the University of Zambia. The data was analysed using Stata 13 and GraphPad Prism 5.  For all the statistical tests conducted, normality of the data was checked using the Shapiro-Wilk test. There was statistically significant difference between the historic arbitrary set 50% pass-fail standard and the course-specific examination composite score attainment in all the courses (P<0.0001). Additionally, there was a statistically significant difference between the examinees’ GPA score attained and the acceptable GPA score of 3.0 (Median GPA 1.75; IQR: 0.75-2.25 and 1.67; IQR: 1.0-2.0) for the fourth and fifth-year examinees respectively). The comparison of the academic performance on the arbitrary 50% pass-fail standard and GPA score attainment for pharmacy students revealed that despite students demonstrating ability to attain high course-specific composite scores using the arbitrary set 50% pass-fail standard, the attained median GPA score was statistically significantly less than the minimum acceptable GPA score of 3.0. While the 50% pass-fail standards’ precision to detect academic performance maybe questioned, the findings suggests that the incorporation of a credit point and GPA system for making assessment decisions to rate students, certification and graduation requirements in Health Professions Education may offer better precision and prediction to detect academic performance and competency attainment

Training of pharmacists in Zambia: developments, curriculum structure and future perspectives

In Zambia, local training of pharmacists commenced in 2001. Development of pharmaceutical education in Zambia has been largely influenced by the national need for pharmacists in the healthcare sector. Training institutions offer the Bachelor of Pharmacy (B.Pharm.) degree programme which follows a four-year curriculum structure. The B.Pharm. programme aims to produce pharmacists with requisite competences to practise pharmaceutical care and sustain the development of pharmacy in Zambia. Seventeen years down the line, Zambia continues to advance local pharmaceutical education programmes. Over 700 pharmacists have graduated from the national training programmes in Zambia which continue to address the pharmaceutical workforce needs. Pharmaceutical education in Zambia offers a number of career prospects in hospital, community, pharmaceutical manufacturing, medicine regulation, public health administration, and progression to academia. Positive transitions made to advance pharmacists’ training in Zambia give a positive outlook for the future

Antimicrobial stewardship knowledge and perception among physicians and pharmacists at leading tertiary teaching hospitals in Zambia: implications for future policy and practice

Antimicrobial stewardship (AMS) is a key strategy promoting rational antimicrobial use. In Zambia, information on health professionals’ knowledge, attitude, and practice of AMS is limited. This study was undertaken to address this at Zambia’s leading specialized teaching hospitals. Descriptive, cross-sectional study involved 137 physicians and 61 pharmacists. AMS knowledge was relatively low among physicians (51%) and pharmacists (39%). Few physicians (9%) and pharmacists (20%) demonstrated sufficient knowledge of the basic principles of AMS. Physicians’ and pharmacists’ knowledge levels were significantly associated with years of practice, job position or practice rank, and previous AMS training. The majority (95%) perceived AMR as a current problem in their practise. Most physicians (92%) and pharmacists (86%) had not undertaken AMS training before. All indicated the need for context-specific educational interventions to promote AMS in Zambia. Despite positive perceptions, basic knowledge of AMS was relatively low. Context-specific educational interventions and capacity building are needed to address AMS gaps

Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems

BACKGROUND: Substandard and falsified (SF) medical products are removed from circulation through a process called 'product recall' by medicines regulatory agencies. In Zambia, the Zambia Medicines Regulatory Authority (ZAMRA) is responsible for recalling SF medical products from the Zambian market through passive and active surveillance methods. This study aimed to describe the prevalence of recalls of SF medical products and to analyse the frequently recalled therapeutic categories, dosage forms, categories of defects that led to the recalls and their sources with respect to the country of the marketing authorisation holder (MAH) or manufacturer. METHODS: We conducted a descriptive cross-sectional review of the product recalls issued by ZAMRA between January 2018 and December 2021. A search for all medical product alerts and recalls issued by ZAMRA was carried out by reviewing the internal post-marketing surveillance database kept at ZAMRA headquarters. Data were extracted using a structured Excel database and analysed using Microsoft Excel. RESULTS: A total of 119 alerts were received during the review period, of which 83 (69.7%) were product recalls. Oral solid dosage forms were the most recalled dosage form (53%). Furthermore, the number of recalls increased in 2020 (44.6%) and 2021 (22.9%), with the majority (20.5%) of the recalled products being substandard products classified as antiseptics and disinfectants and were attributed to the high demand during the COVID-19 pandemic. Manufacturing laboratory control issues were the reason for product recall in almost half (47.4%) of the cases. Most of the products recalled originated from India (38.6%), followed by Zambia (25.3%). Only one suspected falsified product was recalled between 2018 and 2021. A total of 66 recalls of the 83 products were initiated by ZAMRA, with only 17 voluntarily by foreign MAHs. No product recall was initiated by the local representatives of foreign manufacturers or MAH. CONCLUSION: The majority of the pharmaceutical product recalls in Zambia were substandard products. Manufacturing laboratory control issues lead to most recalls and require investigation of the root causes, preventive action, and strict compliance with the good manufacturing practices guidelines by manufacturers

Is timing and extended prophylaxis with antibiotics to prevent surgical-site infections still a concern across Africa? Findings and implications

Background and Objectives: Increasing inappropriate prescribing of antimicrobials increases antimicrobial resistance (AMR) - a growing concern across sub-Saharan Africa (SSA). A key area is healthcare-associated infections (HAIs) with their subsequent impact on morbidity, mortality and costs. Major issues include the timing and extended use of antibiotics to prevent surgical site infections (SSIs), with studies across SSA documenting concerns with these two issues, increasing adverse drug reactions, AMR and costs. Successful initiatives can improve future antibiotic use in low- and middle-income countries (LMICs), particularly in SSA. Consequently, a need to document the timing and duration of surgical antibiotic prophylaxis (SAP) among SSA countries together with potential ways forward. Methods: A narrative review of submitted and published studies among SSA countries coupled with studies across LMICs documenting successful approaches to improve SAP. Results: Inappropriate prescribing of antibiotics for SAP is common in SSA. In Botswana, a study showed only 15% of surgical patients received antibiotics pre-operatively, 58.3% post-surgery, and 26.8% were not prescribed any antibiotic. In Ethiopia, 62.2% of patients received SAP longer than one hour pre-operatively, and in Nigeria, between 57.6% and 83.5% of patients were not administered their first antibiotic dose within the 60-minute window. In Nigeria, 98.7% of patients in one study and all patients in another were given prophylaxis for more than one day with a mean of 8.7 days, and in Botswana extended prophylaxis was common in one study with a mean (SD) of 5 (2.6) days. In a point prevalence survey (PPS) in Botswana, extended prophylaxis was also common, i.e. 100% of tertiary- and primary hospitals, with similar high rates in Ethiopia (88.9%), Ghana (69% to 77%), Kenya (100% in neurotrauma patients) and Rwanda (92%). In recent PPS studies in Nigeria and South Africa, 76.2% and 73.2% patients respectively received SAP for longer than 24 hours. Multiple approaches have been used across LMICs to improve SAP, including educational initiatives and audits. Studies have shown such initiatives improve the timing and duration of antibiotic use and reduce costs. In one study, timing and appropriateness of antibiotics improved from 30.1% to 91.4%, prolonged duration reduced from 92.1% to 5.7% and mean antibiotic costs decreased eleven-fold. Other studies have also shown appreciable improvements. Conclusion: There are considerable concerns with the timing and duration of SAP across Africa. Multiple interventions, including effective guidelines, education and audit, can reverse this and provide future direction to reduce AMR and costs

Evidence on the cost-effectiveness of lifelong antiretroviral therapy for prevention of mother-to-child transmission of HIV : implications for resource-limited countries in sub-Saharan Africa

Introduction: The 2016 World Health Organization (WHO) consolidated guideline recommends lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and breastfeeding women for preventing mother-to-child HIV transmission (PMTCT). Ambiguity remains about the cost-effectiveness of this strategy in resource-limited developing countries. Areas Covered: We reviewed model-based studies on the cost-effectiveness of lifelong ART (formerly Option B+) relative to previous WHO guidelines for PMTCT. Our search using PubMed, Medline and Google Scholar for articles on Option B+ resulted in the final inclusion of seven studies published between 2012 and 2016. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to assess the quality of reporting. Outcomes of interest, which included infant infections averted, maternal quality and length of life, and the Incremental Cost Effectiveness Ratio (ICER), were used in comparing cost-effectiveness. Expert Commentary: Despite most model-based studies favouring lifelong ART (Option B+) in terms of cost-effectiveness in comparison to Options A and B, inclusiveness of the evidence remains weak for generalization largely because setting specificity for providing lifelong ART to all pregnant and breastfeeding women may differ significantly in each setting. Therefore, future cost-effectiveness studies should be robust, setting-specific, and endeavor to assess the willingness and ability to pay of each setting

Current challenges with tackling antimicrobial resistance across sub-Saharan Africa and the implications

Background: Antimicrobial resistance (AMR) is a growing concern increasing morbidity, mortality and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR has resulted in Pan-African and country activities including national action plans (NAPs); however, there is variable implementation with key challenges remaining. Objective: Document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. Methodology: Mixed methods approach including a comprehensive literature review combined with input from senior-level personnel from thirteen African countries with respect to five agreed specific questions regarding the current status of their NAPs as well as ongoing barriers and challenges. Results: All the surveyed 13 sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Namibia and Botswana are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with the instigation of its NAP than these countries; however, there are ongoing concerns with implementation. Overall, South Africa appears to have made the greatest strides among the surveyed African countries with implementing its NAP, which incorporates regular monitoring of activities. These include the instigation of antimicrobial stewardship programmes. Key challenges still remain across Africa. These include necessary personnel, expertise, capacity and resources to undertake agreed NAP activities as well as a lack of focal points and personnel to drive NAPs. In addition, competing priorities and demands including among donors. Conclusion: Challenges with implementing NAPs are starting to be addressed. Further co-ordinated efforts are needed to reduce AMR across Africa

Indigenous Knowledge Systems for the Treatment of Hypertension in Lusaka, Zambia: Perceptions, Knowledge and Practice.

Indigenous knowledge systems and traditional technologies have made and can continue to make a significant contribution to modern medicines with discovery of novel molecules in the treatment of various conditions. The traditional knowledge in our communities is passed on from generation to generation. Scientific evaluation of these compounds from traditional medicines can lead to discovery drugs with better efficacy and novel mechanism. The study aimed at determining the indigenous knowledge based preparations used for hypertension in Lusaka, Zambia. The specific objectives were: a). To determine the knowledge and practice of Traditional Health Practitioners in the management of HTN, b). To identify the parts of the plants utilized in the preparation of the IKS-based preparation used in the management of hypertension. c). To determine the procedure employed in preparing the IKS-based preparations used in the management of hypertension. d). To recommend for further elucidation of the possible active compounds in the indigenous based preparations and postulate possible pharmacological mechanisms of actions. The study adopted structured interviews complemented by non-participatory observations. Samples used by traditional healers were collected for identification and characterization A total of twelve (12) traditional healers registered with Traditional Health Practitioners of Zambia who manage hypertension were interviewed. The traditional healers interviewed had knowledge of causes of hypertension, only three (3) indicated bewitchment as one of the causes. spiritual method constituted an important method of diagnosis. The beliefs of Traditional Healers with regard to hypertension indicates their alignment to agreeing the scientific understanding of hypertension in terms of its causes, risk factors and complications. Traditional Healers in Zambia believe hypertension can be managed by some mode of action of the herbs. Common themes that emerged to determine the effectiveness of the herbs used included; patient feedback, physical appearance, confirmation at local clinic and increased urine output. Majority (5/12) felt that there herbs take atleast 7-14 before the effects are seen. All the traditional healers indicated using atleast two (2) types of herbal preparations to manage hypertension. Of the preparations mentioned three (3) were not of plant origin. These include; crocodile fat, pebble and honey. This study observed that the traditional healers of Zambia knowledge of causes and complications of hypertension are alligned to the scientific knowledge. Divination is however still the most important (50%) method used for diagnosis and witchcraft/ spiritual method forms an important method for some for diagnosis of hypertension. It is noteworthy that traditional healers in Zambia believe hypertension can be managed by some mode of action of the herbs a belief shared by the conventional management.National Science and Technology Council (NSTC