Preparing medical graduates to care for older adults.

Doctoral Degree. University of KwaZulu-Natal, Durban.Background: Social accountability in medical training requires medical schools in South Africa to respond to the health needs of the country’s rapidly increasing number of older adults. Reports, however, indicate that elderly patients in South Africa receive poor quality of care from health professionals. Reports also indicate that students’ empathy towards older adults declines as they progress through their studies. These disparities necessitate greater awareness of the health needs and expectations of older adults and an inquiry into the geriatric care training of medical professionals. Aim: This 360-degree study investigated the geriatric medical curriculum at one institution from the perspectives of geriatric patients, learners and health professions educators to make recommendations for improvement, and to develop policy guidelines for the enhancement of undergraduate medical education in geriatric care. Methodology: A sequential mixed methods approach was adopted for this study. Four focus group discussions were conducted with patients aged 60 years and older from primary care facilities served by graduates of the medical institution (n=28). Data that emerged from this phase regarding patients’ expectations of quality geriatric healthcare were triangulated with a review of curriculum documents, semistructured interviews with health professions educators (n=5) and an evaluation of the levels of knowledge and attitudes of final year medical students regarding the care of older adults. Results: The key principles for quality healthcare of older adults that were elicited from patients were respectful communication, compassion, appropriate prescribing, patient-centredness and coordinated care. However, professional attributes such as compassion and patient-centered care that were valued by geriatric patients are not explicitly taught or assessed in the curriculum. The current curriculum includes a wide variety of topics relevant to the care of older adults. Teaching and assessment relevant to geriatric care were further integrated into other modules, but no minimum standards are applied in assessment of the geriatric component. Students lacked exposure to older adults in ambulatory settings and received little teaching on health promotion or rehabilitative services relevant to the care of older adults. Despite the opportunities afforded by the problem-based learning approach in the curriculum for team-based learning and collaboration, interprofessional education was absent in teaching and learning relevant to older adults. Overall, final year medical students possessed minimal levels of geriatric knowledge despite their perceptions of having had adequate exposure to geriatrics in the current curriculum. The majority of students had positive attitudes towards working with elderly patients. In particular, older students and those with a prior higher education qualification had significantly higher levels of knowledge and attitudes towards caring for older adults. Of note, there was no association between geriatric knowledge and attitudes. Medical students also reported challenges in communicating with older adults and believed that their training had not prepared them adequately for this aspect. Conclusion: The findings of the study affirmed the need to enhance the geriatric curriculum for undergraduate medical students, and to develop and implement minimum core competencies in geriatric care. Curriculum planners should consider greater attention to patient-centred care, communication skills training with older adults and interprofessional education, as well as broader community engagement. Policy guidelines based on the findings of this study were developed and recommended to the Undergraduate Committee for Teaching and Learning to improve the preparedness of medical graduates to care for older adults

Enhancing sexual health in primary care: Guidance for practitioners

Sexual health is an integral aspect of overall health and well-being and is fundamental to the sustainable development of societies worldwide. The World Health Organization (WHO) defines sexual health as ‘a state of physical, emotional, mental, and social well-being in relation to sexuality’. However, addressing sexual health has been afforded low priority in primary healthcare systems. Primary care practitioners (PCPs), who play a crucial role in providing comprehensive care to communities, receive little training on screening and managing individuals with sexual health problems. The scope of services ranges from education, prevention and screening, to management of sexual health matters. Patients with noncommunicable diseases (NCDs), such as stroke, cancer, heart disease and diabetes, are at increased risk for sexual dysfunction, possibly because of common pathogenetic mechanisms, such as inflammation. This is of considerable importance in the sub-Saharan African context where there is a rapidly increasing prevalence of NCDs, as well as a high burden of HIV. Strategies to improve the quality of sexual health services in primary care include creating a safe and non-judgemental practice environment for history-taking among gender-diverse populations, utilising effective screening tools aligned with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for sexual dysfunctions. In particular, the International Consultation on Sexual Medicine (ICSM -5) diagnostic and treatment algorithm can empower primary care providers to effectively address sexual dysfunctions among patients and improve the quality of care provided to communities regarding sexual and reproductive health

Knowledge, attitudes and perceptions of nursing students regarding vaccines

Background: Final-year nursing students are actively involved in the delivery of public immunisation programmes as part of workplace-based learning, and require adequate knowledge, clinical skills, and attitudes regarding vaccines. This study investigated the knowledge, attitudes and perceptions regarding vaccines of final year nursing students at a South African University. Methods: This cross-sectional study, through the use of an online survey questionnaire, assessed the knowledge, attitudes and perceptions regarding vaccines and the Expanded Programme of Immunization of final-year nursing students registered at a South African University during the 2021–2022 academic year. Results: There were 68 participants enrolled in the study (85% response rate). Participants displayed good knowledge regarding vaccines (average score of 52.54/70 ± 5.01 standard deviation [s.d.]), and overall positive perceptions of their training on vaccines and its safety. Knowledge gaps were identified in the mechanisms through which vaccines confer immunity in the human body and the cold chain requirements for the storage of vaccines. Of concern was the prevalent misconception among 78% of participants that vaccines are not effective. Conclusion: The findings of this study indicate that final year nursing students at the University of KwaZulu-Natal, South Africa have good knowledge regarding vaccines. However, an improved understanding of the mechanism of vaccines will aid nursing students to confront and address misperceptions by clients thereby reducing improving vaccine uptake. Curriculum planners should also consider the inclusion of communication strategies to address vaccine hesitancy. Contribution: The study contributes to data on nurse education regarding vaccines in the African context, and identifies areas to improve vaccine uptake

Integrated care for people with multi-morbidities: A scoping review of integrated chronic disease management systems in sub-Saharan Africa

Many studies indicate that people living with HIV (PLWH) are at increased risk for chronic diseases such as hypertension and diabetes. Stand-alone antiretroviral therapy services introduced in sub-Saharan Africa (SSA) have been very effective in improving the morbidity and mortality from HIV-related disease but have failed to address the increasing co-existence of non-communicable diseases in the HIV-positive population. Therefore there is need for more integration of care in provision of health care services

Preparing medical graduates to care for geriatric patients: A case study of the undergraduate medical curriculum at a South African university

Background: Medical schools in South Africa must be responsive to the health needs of the rapidly ageing population. Reports of the poor quality of care received by elderly patients raises concerns about the training of medical students. A review of the curriculum can help to assess current geriatric care training and identify the areas in need of improvement. This study was conducted to describe the nature and scope of undergraduate medical education in geriatric care at a South African university.Methods: An exploratory, descriptive case study was conducted to analyse the learning objectives, opportunities and outcomes of the 6-year undergraduate medical program. Data included an electronic curriculum supported by student and teacher guides. Semi-structured interviews were conducted with health professions educators.Results: The curriculum covered key geriatric competencies that included addressing geriatric syndromes and conducting a comprehensive geriatric assessment. Teaching on geriatric competencies occurred mainly in the clinical years, was integrated and no sub-minima was applied in its assessment. Teaching occurred in disciplinary silos with little involvement of the multidisciplinary team. Learning objectives and assessments focussed on geriatric knowledge and skills.Conclusion: The curriculum targets the development of student geriatric knowledge and skills, but not student attitudes towards caring for older patients. However, a national curriculum will ensure greater coverage of geriatric care competencies, particularly advocacy and attitudes towards caring for geriatric patients. Greater engagement with stakeholders in geriatric health care will inform suitable educational guidelines for undergraduate medical education in geriatric care at this institution. This may also contribute to a standardised national curriculum

COVID-19 and diabetic ketoacidosis: A case series at an urban district hospital in South Africa

Background: Coronavirus disease 2019 (COVID-19) is associated with an increased prevalence and mortality from diabetic ketoacidosis (DKA) globally. With limited access to specialised care, most patients with DKA in South Africa are managed at district hospital level. This study describes the profile of patients admitted to a district hospital in South Africa with DKA and COVID-19 and examines associated risk factors encountered.Methods: This was a case series of all patients presenting to a district hospital with DKA and COVID-19 infection between July 2020 and July 2021. Data extracted included patients’ demographic profiles, biochemical results, comorbidities and clinical outcomes.Results: The median age of the 10 patients admitted during the study period was 39 years old (±12), six of whom were male. The hemoglobin A1c (HbA1c) values on admission ranged from 9.7 to 13.8. Five of the patients had pre-existing type 2 diabetes mellitus (DM). Four of the known DM patients were on metformin only, and one was on biphasic insulin. Three patients had other pre-existing comorbidities, two patients with hypertension and one with human immunodeficiency virus (HIV). Three patients demised, two of whom were hypoxic on admission.Conclusion: Diabetic ketoacidosis appears more commonly in COVID-19 infected patients with type 2 DM and at a young age. Suboptimal glycaemic control was associated with DKA, and hypoxia was a strong predictor for mortality. Treatment inertia was evident in the known DM group, who were on monotherapy despite persistent hyperglycaemia. Greater vigilance is required to detect ketosis in type 2 DM and intensify therapy to improve glycaemic control

Integrated chronic care models for people with comorbid of HIV and non-communicable diseases in Sub-Saharan Africa: A scoping review.

BackgroundIntegrated health care is an approach characterized by a high degree of collaboration and communication among health professionals. Integration of HIV/NCD is recommended to enhance the quality of healthcare services being provided. Duplication of limited resources is minimized, and a holistic care approach is promoted by shifting from acute and reactive care to care that embraces patient-centredness that includes promotive health and disease surveillance. The high burden of HIV disease in sub-Saharan Africa (SSA) combined with the increasing prevalence of chronic non-communicable diseases (NCDs) necessitates a review of how health systems has been doing to deliver quality integrated care for people living with HIV (PLWH) and comorbid chronic NCDs.MethodsA scoping review was conducted to identify and describe all publications on integrated chronic care management models at the primary care level in the SSA context, particularly those that addressed the care of PLHIV with co-morbid chronic NCDs. The inclusion and exclusion criteria were applied, and duplicates were removed.ResultsA total of twenty-one articles were included in the final review. Integrated healthcare systems were reported in only eight SSA countries-(South Africa, Uganda, Kenya, the United Republic of Tanzania, Zambia, Malawi, Zimbabwe and Swaziland). Integrated care systems adopted one of three health models. These included added-on NCD services to previously dedicated HIV care facilities, expansion of primary care facilities to include HIV care and establishment of integrated care services. Short-term benefits included staff capacitation, improved retention of patients and improved screening and detection of NCDs. However, the expansion of existing services resulted in an increased workload with no additional staff. A significant positive change noted by communities was that there was less or no stigmatisation of people living with HIV when attending dedicated HIV clinics.ConclusionEvidence of integrated healthcare services for PLWH and co-morbid of NCDs in SSA is scanty. Data on some short-term benefits of integrated care was available, but evidence was absent on the long-term outcomes. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care

Knowledge of symptoms and self-management of hypoglycaemia amongst patients attending a diabetic clinic at a regional hospital in KwaZulu-Natal

Background: Diabetic patients on insulin and sulphonylureas are at risk of developing hypoglycaemia. Many patients do not respond appropriately because of poor knowledge and understanding of the symptoms of hypoglycaemia, which if not promptly treated can lead to permanent neurological and renal damage. Hypoglycaemic complications can be avoided if patients have a good knowledge of the early symptoms of hypoglycaemia and know how to respond appropriately. Aim: The aim of this study was to assess the knowledge of adult diabetic patients attending a diabetic clinic about symptoms of hypoglycaemia and how they responded to these symptoms. Setting: A hospital-based diabetic clinic in northern KwaZulu-Natal. Methods: This was a cross-sectional, descriptive study involving 200 diabetic patients. Demographic data and details of current medication, knowledge of hypoglycaemia and how patients responded to the symptoms were collected using a validated questionnaire. Results: The majority of the patients had fair to good knowledge of hypoglycaemia; however, less than 25% knew what action to take when they experienced symptoms suggestive of hypoglycaemia. Conclusion: There is a need to improve the education given to diabetic patients on stepwise measures to take to avoid life-threatening complications associated with hypoglycaemia

Spread of models <i>(own work)</i>.

BackgroundIntegrated health care is an approach characterized by a high degree of collaboration and communication among health professionals. Integration of HIV/NCD is recommended to enhance the quality of healthcare services being provided. Duplication of limited resources is minimized, and a holistic care approach is promoted by shifting from acute and reactive care to care that embraces patient-centredness that includes promotive health and disease surveillance. The high burden of HIV disease in sub-Saharan Africa (SSA) combined with the increasing prevalence of chronic non-communicable diseases (NCDs) necessitates a review of how health systems has been doing to deliver quality integrated care for people living with HIV (PLWH) and comorbid chronic NCDs.MethodsA scoping review was conducted to identify and describe all publications on integrated chronic care management models at the primary care level in the SSA context, particularly those that addressed the care of PLHIV with co-morbid chronic NCDs. The inclusion and exclusion criteria were applied, and duplicates were removed.ResultsA total of twenty-one articles were included in the final review. Integrated healthcare systems were reported in only eight SSA countries–(South Africa, Uganda, Kenya, the United Republic of Tanzania, Zambia, Malawi, Zimbabwe and Swaziland). Integrated care systems adopted one of three health models. These included added-on NCD services to previously dedicated HIV care facilities, expansion of primary care facilities to include HIV care and establishment of integrated care services. Short-term benefits included staff capacitation, improved retention of patients and improved screening and detection of NCDs. However, the expansion of existing services resulted in an increased workload with no additional staff. A significant positive change noted by communities was that there was less or no stigmatisation of people living with HIV when attending dedicated HIV clinics.ConclusionEvidence of integrated healthcare services for PLWH and co-morbid of NCDs in SSA is scanty. Data on some short-term benefits of integrated care was available, but evidence was absent on the long-term outcomes. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care.</div

Summary of studies on model A: NCD services integrated into centres originally providing HIV care.

Summary of studies on model A: NCD services integrated into centres originally providing HIV care.</p