Determining the causes for the shortage of human resources for primary health care in Botswana and developing a pilot intervention to address the problem

Thesis (PhD)--Stellenbosch University, 2017.ENGLISH SUMMARY : The global policy on universal health coverage is a commitment to ensuring that all people have access to comprehensive health services without suffering financial hardship. Furthermore, primary healthcare has been recognised as a vehicle to achieving equitable access to comprehensive and cost effective health services. Effective primary healthcare services in many low– and middle-income countries, however, have been hampered by severe shortages and inequitable distribution of the health workforce. Internal migration of health workers from rural to urban areas and from public to private or non-governmental organisations, coupled with regional and international migrations, have exacerbated the shortage and inequity in many of these countries. Multiple strategies have been employed to address the shortage of healthcare workers with varying degrees of success. These include training, fiscal, regulatory and professional or personal support. Thse strategies concur with the World Health Organisation’s policy recommedations for the retention of healthcare workers in rural and remote areas. The causes of shortages in human resources for health are many and complex and effective mitigating strategies should therefore be comprehensive and context-specific and derived from an adequate understanding of the context. Although Botswana is reported to have a shortage of human resources for health, which is worse in rural areas and primary health care, there is a paucity of readily-accessible, integrated and comprehensive information on human resources for health. Moreover, there has not been any research to determine the cause(s) of the shortage which negates evidence based interventions. A situational analysis of the human resources for primary health care in Botswana was conducted using an analysis of the existing databases as well as conducting focus group discussions with health care workers, the community and policy makers in three health districts. The findings of the situational analysis then informed the subsequent intervention: creating more supportive health management for primary healthcare workers using a cooperative inquiry group method. The cooperative inquiry group, based on what they learnt from the inquiry, developed a consensus on the prerequisites for effective supportive supervision. This thesis has quantified the numbers of healthcare workers in the primary and hospital care as well as rural and urban areas. It has elucidated the perceived causes of the shortage of healthcare workers as well as potential solutions. It has also highlighted the need for Botswana to explore how to implement the World Health Organisation’s policy recommendations for retention of healthcare workers which were deemed to be inadequately addressed. This is a thesis by publication. The abstracts of the four articles are given below: Article number 1: Human resources for health in Botswana: the results of in-country database and reports analysis Background: Botswana is a large middle-income country in Southern Africa with a population of just over two million. Shortage of human resources for health is blamed for the inability to provide high quality accessible health services. There is however a lack of integrated, comprehensive and readily-accessible data on the health workforce. Aim: The aim of this study was to analyse the existing databases on health workforce in Botswana in order to quantify the human resources for health. Method: The Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health, Ministry of Education and Skills Development, the Botswana Health Professions Council, the Nursing and Midwifery Council of Botswana and the in-country World Health Organization office provided raw data on human resources for health in Botswana. Results: The densities of doctors and nurses per 10 000 population were four and 42, respectively; three and 26 for rural districts; and nine and 77 for urban districts. The average vacancy rate in 2007/2008 was 5% and 13% in primary and hospital care, respectively, but this is projected to increase to 53% and 43%, respectively, in 2016. Only 21% of the doctors registered with the Botswana Health Professions Council were from Botswana, the rest being mainly from other African countries. Before 2009 doctors were trained at regional and international medical schools. Nonetheless Botswana trained 77% of its health workforce locally. Conclusion: Although the density of health workers is relatively high compared to the region, they are concentrated in urban areas, insufficient to meet the projected requirements and reliant on migrant professionals. Article number 2: Stakeholders’ perceptions on shortage of healthcare workers in primary healthcare in Botswana: focus group discussions Background: An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries, including Botswana, have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana. Method: Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data. Results: There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service. Conclusions: Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. Article number 3: Understanding the organisational culture of district health services: Mahalapye and Ngamiland Health Districts of Botswana Background: Botswana has a shortage of healthcare workers, especially in primary health care. Retention and high performance of employees however is closely linked to job satisfaction and motivation which are both highest where employees’ personal values and goals are realised. Aim: The aim of the study was to evaluate the organisational culture of the district health services as experienced by the primary healthcare workers. Setting: The study was conducted in the Ngamiland and Mahalapye health districts Method: This was a cross-sectional survey. The participants were asked to select ten values that best described their personal, current organisational and desired organisational values from a predetermined list. Results: 60 and 67 healthcare workers completed the survey in Mahalapye and Ngamiland districts, respectively. Eight of the top ten prevalent organisational values were common to both districts: teamwork, blame, patient satisfaction, blame, confusion, job insecurity, not sharing information and manipulation. When all the current values were assessed 32% (Mahalapye) and 36% (Ngamiland) selected by healthcare workers, were potentially limiting organisational effectiveness. The organisational values desired by healthcare workers in both districts were: transparency, professional growth, staff recognition, shared decision-making, accountability, productivity, leadership development and teamwork. Conclusions: The experience of the primary healthcare workers in the two health districts were overwhelmingly negative which is likely to contribute to low levels of motivation, job satisfaction, productivity and high attrition rates. There is an urgent need for organisational transformation with a focus on staff experience and leadership development at all levels of the health system in Botswana. Article number 4: How to create more supportive supervision for primary healthcare: lessons from Ngamiland district of Botswana: Co-operative inquiry group Background: Supportive supervision is a way to foster performance, productivity, motivation and retention of health workforce. Nevertheless there is a dearth of evidence of the impact and acceptability of supportive supervision in low- and middle-income countries. This article describes a participatory process of transforming the supervisory practice of district health managers to create a supportive environment for primary healthcare workers. Objective: The objective of the study was to explore how district health managers can change their practice to create a more supportive environment for primary healthcare providers. Methods: A facilitated cooperative inquiry group was formed with Ngamiland health district managers. Cooperative inquiry group belongs to the participatory action research paradigm and is characterised by a cyclic process of observation, reflection, planning and action. The cooperative inquiry group went through three cycles between March 2013 and March 2014. Results: 12 district health managers participated in the inquiry group. The major insights and learning that emerged from the inquiry process included inadequate supervisory practice, perceptions of healthcare workers’ experiences; change in the managers’ supervision paradigm, recognition of the supervisors’ inadequate supervisory skills and barriers to supportive supervision. Finally, the group developed a 10-point consensus on what they had learnt regarding supportive supervision. Conclusion: Ngamiland health district managers have come to appreciate the value of supportive supervision and changed their management style to be more supportive of their subordinates. They also developed a consensus on supportive supervision that could be adapted for use nationally. Supportive supervision should be prioritised at all levels of the health system and it should be adequately resourced.AFRIKAANSE OPSOMMING : Die wêreldwye beleid oor universele gesondheidsdekking is ’n verbintenis tot die versekering dat alle mense toegang tot omvattende gesondheidsdienste het sonder om finansieël daaronder te ly. Voorts word primêre gesondheidsorg beskou as ’n werktuig om gelyke toegang tot omvattende en kostedoeltreffende gesondheidsdienste te bewerkstellig. Tog word doeltreffende primêre gesondheidsdienste in vele lae- en middelinkomstelande deur ernstige tekorte in, en die ongelyke verspreiding van, die gesondheidswerksmag gekortwiek. Interne migrasie van gesondheidswerkers van landelike na stedelike gebiede en van openbare na privaat of nieregeringsorganisasies, tesame met streeks- en internasionale migrasies, vererger ook die bestaande tekorte en ongelykhede in baie van hierdie lande. In die verlede is verskeie strategiee implementeer om die kwessie van tekorte van gesondheids werkers aan te spreek, met verskillende grade van sukses. Strategiee sluit in opleiding, fiskale, regulatoriese, professionele of persoonlike ondersteuning.Hierdie stratgiee is meestal geskoei op die Wereld Gesondheids Organisasie se beleids voorstelle vir die retensie van gesondheids werkers in landelike en afgelee areas. Die oorsake van die tekort aan menslike hulpbronne op gesondheidsgebied is talryk en kompleks. Daarom sal temperingstrategieë slegs doeltreffend wees indien dit omvattend en konteksspesifiek en op ’n deeglike begrip van die konteks gegrond is. Hoewel Botswana luidens berigte gebuk gaan onder ’n tekort aan menslike hulpbronne op gesondheidsgebied, wat erger is in landelike gebiede en in primêre gesondheidsorg, is daar ’n skaarste aan geredelik toeganklike, geïntegreerde en omvattende inligting daaroor. Daarbenewens is geen navorsing nog gedoen om die oorsake van die tekort te bepaal nie. ’n Omstandigheidsontleding van die menslike hulpbronne in primêre gesondheidsorg in Botswana is derhalwe uitgevoer deur die bestaande databasisse te ondersoek, sowel as deur fokusgroepgesprekke met gesondheidsorgwerkers, die gemeenskap en beleidvormers in drie gesondheidsdistrikte te voer. Die bevindinge van die omstandigheidsontleding het die grondslag uitgemaak vir die daaropvolgende ontwikkeling en beoordeling van ’n intervensie om meer ondersteunende distriksbestuurstoesig oor primêre gesondheidsorgwerkers te skep, deur n kooperatiewe navorsings groep metode te volg. Die kooperatiewe navorsings groep het konsensus bereik oor die voorvereistes vir effektiewe supervisie, gebaseer op die bevindinge van die navorsings proses. Die tesis het die aantal gesondheids werkers in primere sorg en sekondere sorg, in beide landelike en stedelike gebiede gekwantifiseer. Dit spreek die kwessie aan van die moontlike redes vir die tekort van gesondheids werkers sowel as moontlike oplossings daarvan. Die navorsing le ook klem op die nodigheid vir Botswana om meer navorsing te doen wat in lyn is met die Wereld Gesondheids Organisasie se riglyne vir retensie van gesongheids werkers.Hierdie tesis is in publikasievorm en die opsommings van die vier artikels volg hieronder. Artikel 1: Menslike hulpbronne op gesondheidsgebied in Botswana: die resultate van ’n ontleding van die interne nasionale databasisse en verslae Agtergrond: Botswana is ’n groot middelinkomsteland in Suider-Afrika met ’n bevolking van net meer as twee miljoen. Die onvermoë om toeganklike gesondheidsdienste van gehalte te voorsien, word dikwels aan die tekort aan menslike hulpbronne op gesondheidsgebied toegeskryf. Tog is daar ’n gebrek aan geïntegreerde, omvattende en geredelik toeganklike data oor die gesondheidswerksmag. Doel: Die doel van hierdie studie was om die bestaande databasisse oor die gesondheidswerksmag in Botswana te ontleed ten einde die menslike hulpbronne op gesondheidsgebied te kwantifiseer. Metode: Die Departement van Beleid, Beplanning, Monitering en Evaluering in die Ministerie van Gesondheid, die Ministerie van Onderwys en Vaardigheidsontwikkeling, die Gesondheidsberoepsraad van Botswana, die Raad op Verpleeg- en Verloskunde van Botswana en die plaaslike kantoor van die Wêreldgesondheidsorganisasie het onverwerkte data oor menslike hulpbronne op gesondheidsgebied in Botswana voorsien. Resultate: Die gemiddelde verspreiding van dokters en verpleegkundiges per 10 000 lede van die bevolking is vier en 42 onderskeidelik – drie en 26 vir landelike distrikte, en nege en 77 vir stedelike distrikte. Die gemiddelde persentasie vakatures in 2007/8 was 5% en 13% in primêre en hospitaalsorg onderskeidelik, maar sal na verwagting teen 2016 tot 53% en 43% onderskeidelik toeneem. Slegs 21% van die dokters wat by die Gesondheidsberoepsraad van Botswana geregistreer is, is van Botswana, terwyl die res hoofsaaklik van ander Afrikalande afkomstig is. Botswana lei 77% van sy gesondheidswerksmag plaaslik op. Gevolgtrekking: Hoewel die verspreiding van gesondheidswerkers betreklik hoog is vergeleke met die res van die Suider-Afrika-streek, is dié werkers gekonsentreerd in stedelike gebiede, nie genoeg om in die verwagte vraag te voorsien nie, en afhanklik van beroepslui wat van elders migreer. Artikel 2: Belanghebbendes se opvattings oor die tekort aan gesondheidsorgwerkers in primêre gesondheidsorg in Botswana: fokusgroepgesprekke Agtergrond: ’n Toereikende gesondheidswerksmag is noodsaaklik vir universele gesondheidsdekking en positiewe uitkomste in openbare gesondheid. Tog gaan vele Afrikalande, waaronder Botswana, gebuk onder ernstige tekorte aan gesondheidsorgwerkers, wat veral primêre gesondheidsorg raak. Die doel van hierdie studie was om gesondheidsorgwerkers, beleidvormers en die gemeenskap se opvattings oor die tekort aan gesondheidsorgwerkers in Botswana te ondersoek. Metode: Vyftien fokusgroepgesprekke is met drie groepe beleidvormers, ses groepe gesondheidsorgwerkers en ses groepe gemeenskapslede in landelike, stedelike en afgeleë landelike gesondheidsdistrikte van Botswana gevoer. Alle deelnemers was 18 jaar en ouer. Doelbewuste seleksie is toegepas en die raamwerkmetode is gebruik om die data induktief te ontleed. Resultate: Daar bestaan ’n waargenome tekort aan gesondheidsorgwerkers in primêre gesondheidsorg, wat toegeskryf word aan ’n groter vraag na gesondheidsdienste, ongelyke verspreiding van gesondheidsorgwerkers, migrasie en te min werkers wat op hierdie gebied opgelei word. Migrasie vind hoofsaaklik plaas as gevolg van ongunstige persoonlike en familiefaktore, swak en ondoeltreffende gesondheidsorg- en menslikehulpbronbestuur, swak salarisse en onvoldoende aansporings vir dienslewering in landelike en afgeleë gebiede. Gevolgtrekking: Botswana gaan gebuk onder ’n waargenome tekort aan gesondheidsorgwerkers, wat veral primêre gesondheidsorg en landelike gebiede raak en aan etlike komplekse faktore te wyte is. Om dié skaarste die hoof te bied, behoort die land genoeg gesondheidsorgwerkers op te lei en hulle in gelyke mate tussen gesondheidsorgfasiliteite met voldoende hulpbronne te verdeel. Artikel 3: ’n Begrip van die organisatoriese kultuur van twee gesondheidsdistrikte in Botswana: implikasies vir die behoud van primêre gesondheidsorgwerkers Agtergrond: Botswana gaan gebuk onder ’n tekort aan gesondheidsorgwerkers, veral in primêre gesondheidsorg. Die behoud en prestasie van werknemers hou egter sterk verband met werkstevredenheid en motivering, wat albei die hoogste is waar werknemers se persoonlike waardes en doelwitte verwesenlik word. Doel: Die doel van die studie was om die organisatoriese kultuur van die distriksgesondheidsdienste deur die oë van primêre gesondheidsorgwerkers te beoordeel. Omgewing: Die studie is in die gesondheidsdistrikte Ngamiland en Mahalapye uitgevoer. Metode: Die studie is in die vorm van ’n deursnee-opname uitgevoer. Deelnemers is gevra om uit ’n voorafbepaalde lys tien waardes te kies wat hulle persoonlike, huidige organisatoriese en gewenste organisatoriese waardes die beste beskryf. Resultate: Altesaam 60 en 67 gesondheidsorgwerkers het die opname in die Mahalapye- en Ngamiland-distrik onderskeidelik voltooi. Die tien organisatoriese waardes wat die algemeenste in albei distrikte voorkom, is spanwerk, pasiënttevredenheid, skuld, verwarring, werksonsekerheid, versuim om inligting te deel, en manipulasie. ’n Beoordeling van alle huidige waardes dui daarop dat 32% (Mahalapye) en 36% (Ngamiland) van die waardes wat gesondheidsorgwerkers geïdentifiseer het, moontlik organisatoriese doeltreffendheid beperk. Die gewenste organisatoriese waardes van gesondheidswerkers in albei distrikte is deursigtigheid, professionele groei, personeelerkenning, gesamentlike besluitneming, verantwoordbaarheid, produktiwiteit, leierskapsontwikkeling en spanwerk. Gevolgtrekking: Die ervaring van die primêre gesondheidsorgwerkers in die twee gesondheidsdistrikte is oorweldigend negatief, wat heel waarskynlik tot swak motivering, werkstevredenheid en produktiwiteit sowel as hoë uitvloeisyfers bydra. Daar is ’n dringende behoefte aan organisatoriese transformasie met die klem op personeelervaring en leierskapsontwikkeling op alle vlakke van die gesondheidstelsel in Botswana. Artikel 4: Hoe om meer ondersteunende distriksbestuur vir primêre gesondheidsorg in die Ngamiland-distrik van Botswana te skep: samewerkende navorsingsgroep Agtergrond: Ondersteunende toesig word wêreldwyd aangemoedig as ’n manier om prestasie, produktiwiteit, motivering, die behoud van die gesondheidswerksmag en sorg van gehalte teweeg te bring. Nietemin is daar ’n gebrek aan bewyse van die impak en aanvaarbaarheid van ondersteunende toesig in lae- en middelinkomstelande, met die meeste bestaande bewyse wat uit hoëinkomstelande kom. Ondersteunende toesig sal slegs as relevant en geloofwaardig beskou word indien dit op grond van plaaslike bewyse bestudeer en ingestel word. Hierdie artikel beskryf ’n deelnemende proses vir die transformasie van toesigpraktyke onder distriksgesondheidsbestuurders om ’n ondersteunende omgewing vir primêre gesondheidsorgwerkers te skep. Metodes: ’n Gefasiliteerde samewerkende navorsingsgroep is met 12 distriksgesondheidsbestuurders van die Ngamiland-gesondheidsdistrik – vyf lede van die distriksgesondheidsbestuurspan en sewe klusterhoofde van primêre gesondheidsorgklinieke – op die been gebring. ’n Samewerkende navorsingsgroep behels ’n sikliese proses van waarneming, besinning, beplanning en optrede. Die groep het opleiding ontvang oor hoe om oor waarnemings te besin, om terugvoering te bied en te ontvang, en aktief te luister. Die samewerkende navorsingsgroep het tussen Maart 2013 en Maart 2014 drie siklusse van twee tot ses maande elk voltooi. Resultate: Twee van die oorspronklike lede van die groep het gedurende die 12 maande die distrik verlaat. Die temas wat uit die navorsingsproses na vore kom, is onder meer onvoldoende huidige toesigpraktyke, nuwe opvattings oor gesondheidsorgwerkers se ervarings, begrip daarvoor dat bestuurders hulle toesigparadigma moet verander, erkenning van toesighouers se onvoldoende toesigvaardighede, waardering vir die professionele groei wat uit die samewerkende navorsingsgroep gespruit het, en hindernisse vir ondersteunende toesig. Die groep het uiteindelik ’n tienpuntkonsensus ontwikkel oor wat hulle met betrekking tot ondersteunende toesig geleer het. Gevolgtrekking: Bestuurders in die Ngamiland-gesondheidsdistrik het d

Human resources for health in Botswana : the results of in-country database and reports analysis

CITATION: Nkomazana, O., et al. 2014. Human resources for health in Botswana: The results of in-country database and reports analysis. African Journal of Primary Health Care & Family Medicine, 6(1): 1-8, doi: 10.4102/phcfm.v6i1.716.The original publication is available at http://www.phcfm.orgBackground: Botswana is a large middle-income country in Southern Africa with a population of just over two million. Shortage of human resources for health is blamed for the inability to provide high quality accessible health services. There is however a lack of integrated, comprehensive and readily-accessible data on the health workforce. Aim: The aim of this study was to analyse the existing databases on health workforce in Botswana in order to quantify the human resources for health. Method: The Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health, Ministry of Education and Skills Development, the Botswana Health Professions Council, the Nursing and Midwifery Council of Botswana and the in-country World Health Organization office provided raw data on human resources for health in Botswana. Results: The densities of doctors and nurses per 10 000 population were four and 42, respectively; three and 26 for rural districts; and nine and 77 for urban districts. The average vacancy rate in 2007 and 2008 was 5% and 13% in primary and hospital care, respectively, but this is projected to increase to 53% and 43%, respectively, in 2016. Only 21% of the doctors registered with the Botswana Health Professions Council were from Botswana, the rest being mainly from other African countries. Botswana trained 77% of its health workforce locally. Conclusion: Although the density of health workers is relatively high compared to the region, they are concentrated in urban areas, insufficient to meet the projected requirements and reliant on migrant professionals.http://www.phcfm.org/index.php/phcfm/article/view/716Publisher's versio

Survey of Childhood Blindness and Visual Impairment in Botswana

Background/aims In terms of blind-person years, the worldwide burden of childhood blindness is second only to cataracts. In many developing countries, 30–72% of childhood blindness is avoidable. The authors conducted this study to determine the causes of childhood blindness and visual impairment (VI) in Botswana, a middle-income country with limited access to ophthalmic care. Methods This study was conducted over 4 weeks in eight cities and villages in Botswana. Children were recruited through a radio advertisement and local outreach programmes. Those ≤15 years of age with visual acuity \u3c6/18 in either eye were enrolled. The WHO/Prevention of Blindness Eye Examination Record for Children with Blindness and Low Vision was used to record data. Results The authors enrolled 241 children, 79 with unilateral and 162 with bilateral VI. Of unilateral cases, 89% were avoidable: 23% preventable (83% trauma-related) and 66% treatable (40% refractive error and 31% amblyopia). Of bilateral cases, 63% were avoidable: 5% preventable and 58% treatable (33% refractive error and 31% congenital cataracts). Conclusion Refractive error, which is easily correctable with glasses, is the most common cause of bilateral VI, with cataracts a close second. A nationwide intervention is currently being planned to reduce the burden of avoidable childhood VI in Botswana

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BACKGROUND: The World Health Organization defines a "critical shortage" of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. METHODS: This study is a review of published and unpublished "grey" literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. RESULTS: Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. CONCLUSION: There is an "inverse primary health care law" in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa

Sociocultural factors affecting first-year medical students’ adjustment to a PBL program at an African medical school

Background: Besides regulatory learning skills, learning also requires students to relate to their social context and negotiate it as they transition and adjust to medical training. As such, there is a need to consider and explore the role of social and cultural aspects in student learning, particularly in problem-based learning, where the learning paradigm differs from what most students have previously experienced. In this article, we report on the findings of a study exploring first-year medical students’ experiences during the first semester of an undergraduate problem-based learning medical program at an African medical school. Method: We employed a qualitative case study approach using in-depth interviews with 23 first-year medical students. Participants ranged in age from 18 to 25 years. All students were bi/multilingual (some spoke three to five languages), with English as the learning language. We conducted an inductive thematic analysis to systematically identify and analyze patterns in the data using the Braun and Clarke framework. Results: Before medical school, students worked hard to compete for admission to medical school, were primarily taught using a teacher-centered approach, and preferred working alone. At the beginning of medical school, students found it challenging to understand the problem-based learning process, the role of the case, speaking and working effectively in a group, managing a heavy workload, and taking increased responsibility for their learning. By the end of the first semester, most students were handling the workload better, were more comfortable with their peers and facilitators, and appreciated the value of the problem-based learning approach. Conclusions: Our study highlights the importance of interrogating contextual sociocultural factors that could cause tension when implementing problem-based learning in non-western medical schools. Adjustment to problem-based learning requires a conceptual and pedagogic shift towards learner-centered practice, particularly concerning self direction, the role of the case, and collaborative learning. As such, there is a need to develop and implement research informed learning development programs that enable students to reflect on their sociocultural beliefs and practices, and enhance their regulatory learning competence to optimize meaningful and early engagement with the problem based learning process

Protocol for an automated, pragmatic, embedded, adaptive randomised controlled trial: behavioural economics-informed mobile phone-based reminder messages to improve clinic attendance in a Botswanan school-based vision screening programme.

BACKGROUND: Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. METHODS: We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. DISCUSSION: As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. TRIAL REGISTRATION: ISRCTN 96528723 . Registered on 5 January 2022

Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal

Background Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country’s data management legislation and UK law. Discussion This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.</ns3:p

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice

Building Health System Capacity through Medical Education: A Targeted Needs Assessment to Guide Development of a Structured Internal Medicine Curriculum for Medical Interns in Botswana

Background: Medical internship is the final year of training before independent practice for most doctors in Botswana. Internship training in Botswana faces challenges including variability in participants’ level of knowledge and skill related to their completion of medical school in a variety of settings (both foreign and domestic), lack of planned curricular content, and limited time for structured educational activities. Data on trainees’ opinions regarding the content and delivery of graduate medical education in settings like Botswana are limited, which makes it difficult to revise programs in a learner-centered way. Objective: To understand the perceptions and experiences of a group of medical interns in Botswana, in order to inform a large curriculum initiative. Methods: We conducted a targeted needs assessment using structured interviews at one district hospital. The interview script included demographic, quantitative, and free- response questions. Fourteen interns were asked their opinions about the content and format of structured educational activities, and provided feedback on the preferred characteristics of a new curriculum. Descriptive statistics were calculated. Findings: In the current curriculum, training workshops were the highest-scored teaching format, although most interns preferred lectures overall. Specialists were rated as the most useful teachers, and other interns and medical officers were rated as average. Interns felt they had adequate exposure to content such as HIV and tuberculosis, but inadequate exposure to areas including medical emergencies, non-communicable diseases, pain management, procedural skills, X-ray and EKG interpretation, disclosing medical information, and identifying career goals. For the new curriculum, interns preferred a structured case discussion format, and a focus on clinical reasoning and procedural skills. Conclusions: This needs assessment identified several foci for development, including a shift toward interactive sessions focused on skill development, the need to empower interns and medical officers to improve teaching skills, and the value of shifting curricular content to mirror the epidemiologic transition occurring in Botswana. Interns’ input is being used to initiate a large curriculum intervention that will be piloted and scaled nationally over the next several years. Our results underscore the value of seeking the opinion of trainees, both to aid educators in building programs that serve them and in empowering them to direct their education toward their needs and goals