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

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

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

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

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

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

Availability and use of long-acting insulin analogues across Africa including biosimilars; current situation and implications

Background: Prevalence rates of diabetes mellitus are growing, and likely reach 34.2 million people in sub-Saharan Africa by 2040. This has significant implications on morbidity, mortality, and costs exacerbated by complications. Complications in patients requiring insulins enhanced by hypoglycaemia. Long-acting insulin analogues can reduce hypoglycaemia and improve patient compliance. However, typically appreciably more expensive than other insulins, limiting their listing on national essential medicine lists (EMLs). Biosimilars may help reduce prices and enhance listing. Objectives: Assess current listing and funding for insulins including long-acting insulin analogues across Africa. Methods: Mixed methods approach including documentation of utilisation patterns and prices nationally as well as from hospitals, ambulatory care, wholesalers and pharmacies among a range of African countries. Input from senior level government, academic, and healthcare professionals on the current situation with long-acting insulin analogues and potential changes needed to enhance future funding of biosimilar long-acting insulins. Results: Variable listing of long-acting insulin analogues on national EMLs across Africa due to high prices and issues of affordability. Even when listed in EMLs, utilisation in public healthcare systems is limited due to similar issues including affordability. Appreciably lowering the prices of long-acting insulin analogues via biosimilars should enhance future listing on EMLs and use accompanied by educational and other initiatives. However to date, limited price reductions for biosimilars versus originators across Europe and Asia. Conclusion: There are concerns with funding long-acting insulin analogues across Africa including biosimilars. A number of activities have been identified to improve future listing on EMLs and subsequent us

Awareness and acceptance of COVID-19 vaccines and associated factors among pharmacy students in Zambia

Background: Several vaccines have been developed and administered since coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020. In April 2021, the authorities in Zambia administered the first doses of the Oxford-AstraZeneca® COVID-19 vaccine. Objective: To assess the awareness and acceptance of COVID-19 vaccines and associated factors among pharmacy students in Zambia. Methods: A cross-sectional study among 326 undergraduate pharmacy students in Lusaka, Zambia, from February through to 25 April 2021. Data were analysed using Stata version 16.1. Multivariable logistic regression was used to determine factors influencing vaccine acceptance. Results: Of the 326 participants, 98.8% were aware of the COVID-19 vaccines, but only 24.5% would accept vaccination. Being of Christian faith was associated with reduced odds of awareness of the COVID-19 vaccine (aOR=0.01; 95% CI: 0.01-0.20). Compared to females, male respondents were 86% more likely to accept the vaccine if it was made available (aOR=1.86; 95% CI: 1.10-3.14). Unmarried compared to married respondents were 2.65 times as likely to accept vaccination (aOR=2.65; 95% CI: 1.06-6.63) whilst unemployed respondents were less likely to accept vaccination (aOR=0.32; 95% CI: 0.16-0.46). Barriers to the acceptability of the vaccine were possible side effects (78.5%) and scepticism about its effectiveness to prevent COVID-19 (10.2%). Conclusion: There was significant vaccine hesitancy toward COVID-19 vaccines among Zambian pharmacy students despite their awareness of the vaccines. Health authorities must work collaboratively with training institutions to mitigate vaccine hesitancy, especially with healthcare students being a key part of the future healthcare workforce overseeing disease prevention strategies

Practical Pharmacist-Led Interventions to Improve Antimicrobial Stewardship in Ghana, Tanzania, Uganda and Zambia.

The World Health Organisation (WHO) and others have identified, as a priority, the need to improve antimicrobial stewardship (AMS) interventions as part of the effort to tackle antimicrobial resistance (AMR). An international health partnership model, the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme, was established between selected countries in Africa (Ghana, Tanzania, Zambia and Uganda) and the UK to support AMS. This was funded by UK aid under the Fleming Fund and managed by the Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET). The primary aims were to develop local AMS teams and generate antimicrobial consumption surveillance data, quality improvement initiatives, infection prevention and control (IPC) and education/training to reduce AMR. Education and training were key components in achieving this, with pharmacists taking a lead role in developing and leading AMS interventions. Pharmacist-led interventions in Ghana improved access to national antimicrobial prescribing guidelines via the CwPAMS mobile app and improved compliance with policy from 18% to 70% initially for patients with pneumonia in one outpatient clinic. Capacity development on AMS and IPC were achieved in both Tanzania and Zambia, and a train-the-trainer model on the local production of alcohol hand rub in Uganda and Zambia. The model of pharmacy health partnerships has been identified as a model with great potential to be used in other low and middle income countries (LMICs) to support tackling AMR