Continuing professional development for medical, nursing, and midwifery cadres in Malawi, Tanzania and South Africa: A qualitative evaluation

<div><p>Background</p><p>As innovations in the prevention and treatment of HIV and TB advance, continuing professional development (CPD) of health care workers (HCWs) remains a high priority, particularly in sub-Saharan Africa where dual TB/HIV epidemics are compounded by severe HCW shortages. There is further need to examine CPD programs to identify challenges and effective solutions to strengthen HIV/TB-related CPD.</p><p>Methods</p><p>Qualitative evaluations in Malawi, Tanzania and South Africa (RSA) were conducted using key informant interviews (KIIs) and focus group discussions (FGDs) in each country to identify barriers and enablers of effective HIV/TB-related CPD. Key stakeholders represented CPD implementers, regulators, and developers. HCWs were purposively sampled from high disease burden districts; each HCW completed brief, semi-structured questionnaires and participated in a FGD. KII and FGD results were combined into key themes spanning across countries using a grounded theory approach.</p><p>Results</p><p>Fifty-two KIIs were conducted: 17 in Malawi, 19 in Tanzania and 16 in RSA. Eighty-nine HCWs (24 from Malawi, 38 from Tanzania and 27 from RSA) completed questionnaires and participated in FGDs. Primarily, lack of sustainable financial resources and limitations in coordination of CPD result in poor accountability for CPD oversight and reduce CPD quality assurance. Healthcare worker shortages limit CPD opportunities, creating disparities in CPD access. CPD irrelevance and imbalance between HCW-identified CPD needs and current programs reduce enthusiasm for CPD. Facility-level constraints, including poor infrastructure and weak supply chains, restrict implementation of CPD skills and knowledge. Challenges are more severe in rural settings.</p><p>Conclusion</p><p>To address identified gaps, sustainable funding, strong leadership and collaboration at every level are needed to strengthen CPD regulation and accreditation systems; increase CPD accessibility in the workplace; and create enabling environments for CPD implementation. Together, these improvements may improve TB/HIV CPD quality and patient outcomes.</p></div

HIV Web Study.

<p>HIV Web Study.</p

Sites and countries by year.

<p>Sites and countries by year.</p

Adobe Connect Lecture Screenshot.

<p>Adobe Connect Lecture Screenshot.</p

Focus group participants, by country.

<p>Focus group participants, by country.</p

Key informant organizations by country.

<p>Key informant organizations by country.</p

Schematic of amplification and ligation in the existing oligonucleotide ligation assay (OLA).

<p>The <i>pol</i> gene of HIV DNA is amplified by nested PCR. Note that the HIV DNA gene map positions are not to scale. A portion of the amplicon is mixed with three oligonucleotide probes: a 5’ fluorescein (F) -conjugated mutant (MUT)-specific HIV probe; a 5’ digoxigenin (D) -conjugated wild-type (WT)-specific probe; and a 5’ phosphorylated, 3’ biotin (B) -conjugated common probe. When specific probes are complementary at the mutation site, they are ligated to the common probe to create a DNA strand with labels at both ends. Only ligated products are detected during the CDD procedure (surface <u><b>c</b></u>apture, <u><b>d</b></u>enaturation of oligonucleotide from target DNA, and enzyme-based detection).</p

Plate and paper formats for Capture, Denaturation and Detection (CDD) in the oligonucleotide ligation assay.

<p>(A) Plate CDD procedure. Products from the ligation step (both ligated and non-ligated products) are captured on a streptavidin-coated plate. Non-ligated probes are released during oligonucleotide denaturation, and ligated MUT and WT probes are then detected in sequential enzyme-based immunoassays (labeling by different detection antibodies, alkaline phosphatase yellow substrate development, optical density reading at 405nm, wash steps, tetramethylbenzidine (TMB) development, stop solution, and optical density reading at 450nm). (B) Paper CDD procedure. Similar to the plate CDD procedure, products from the ligation step (both ligated and non-ligated products) are captured. However, here the products are captured on paper strips by immobilized streptavidin. Non-ligated probes are released during oligonucleotide denaturation. Antibodies targeting the end-labels of the mutant (MUT) or wild-type (WT) probes have conjugated horseradish peroxidase (POD) that converts 3,3’ diazoaminobenzidine substrate (DAB) into brown precipitates. Signals were captured by the scanner (600 DPI). Reported signals represent capture spot intensity minus a background region from the strip.</p

Analysis of clinical specimens and plasmid standards by paper capture, denaturation, and detection (CDD) and plate CDD for mutations K103N and Y181C.

<p>Panels A and C show mutant (MUT) detection, and Panels B and D show wild-type (WT) detection. Sample optical density (OD) minus negative control OD (left y axis) for each specimen is shown in white/gray by rank along the x axis, from the lowest MUT OD, followed by the plasmid standards (0%, 5%, 50% MUT) performed in duplicate. Spot intensity minus background intensity (right y axis) for each specimen is shown in blue and green bars followed by the plasmid standards (0%, 5%, 50% MUT) performed in triplicate. Scanned images of the paper CDD detection strip are shown below each specimen’s signal data.</p

Analysis of clinical specimens and plasmid standards by paper capture, denaturation, and detection (CDD) and plate CDD for mutations M184V and G190A.

<p>Panels A and C show mutant (MUT) detection, and Panels B and D show wild-type (WT) detection. Sample optical density (OD) minus negative control OD (left y axis) for each specimen is shown in white/gray by rank along the x axis, from the lowest MUT OD, followed by the plasmid standards (0%, 5%, 50% MUT) performed in duplicate. Spot intensity minus background intensity (right y axis) for each specimen is shown in pink and orange bars followed by the plasmid standards (0%, 5%, 50% MUT) performed in triplicate. Scanned images of the paper CDD detection strip are shown below each specimen’s signal data.</p