Workshops at the 2011 PHASA conference

Epidemiology of non-communicable diseases for Africa

Facilitators:

Prof. Rodney Ehrlich, School of Public Health and Family Medicine, University of Cape Town
Prof. Debbie Bradshaw, Burden of Disease Research Unit, Medical Research Council of South Africa, Cape Town
Prof. Stephen Tollman, Health and Population Division, School of Public Health, University of the Witwatersrand, Johannesburg 

Key messages:

  1. Since non-communicable diseases (NCDs) contribute heavily to the disease burden in South Africa, and increasingly in Africa, an important public health goal is to reverse the trends in risk factors. There is thus a need not only for conventional (prevalence) surveillance data but also for better data to monitor NCD management and control efforts.
  2. While studies of individual risk factors of NCDs have increased our understanding of risk variability between individuals, there remain many social or contextual factors – employment, housing, social inclusiveness, rural versus urban residence, income inequality – which require research to understand inequities in disease burden between social groups in Africa.
  3. There is much scope to explore the relationship between NCDs and poverty in Africa, including the distribution of risk factors as well as access to care and management. Health and socio-demographic surveillance systems (HDSS) are platforms for supporting descriptive and analytic epidemiology in settings with uncertain or absent vital registration systems. Such sites allow for repeat surveys and cohort studies enabling us to better understand the rising burden of NCDs and respond more effectively to the complex and interacting disease epidemics that are underway.
  4. We need to understand the distinction between individually focused health service action such as treatment or patient behaviour change, on the one hand, and population or upstream (usually policy) interventions, on the other. These two strategies compete for resources and attention and the balance between them needs conscious consideration by researchers and policy makers. Whether individually or population directed, these interventions need to be based on evidence on their effectiveness, much of which is lacking.

Qualitative Data Analysis

Facilitator:

Sara Nieuwoudt, Division of Social and Behaviour Change Communication, School of Public Health, University of the Witwatersrand.

The session included presentations as well as a practical session on coding transcripts using grounded theory.

At the end of the workshop, participants reflected on the following lessons:

  1. Quantitative and qualitative research methods have different objectives, but can complement and enhance eachother.
  2. The qualitative researcher is the research instrument, from data collection through analysis, requiring a high level of reflexivity.
  3. Qualitative data analysis is an iterative multi-step process.
  4. There are systems and processes to ensure high quality analysis of qualitative data, such as inter-coder reliability, enhanced by working in teams.
  5. Qualitative software programmes can facilitate a more nuanced and reliable analytic process, but they cannot analyse the data for you.
  6. Developing skills in qualitative analysis requires time and practice. While participants were able to learn the concepts of coding, further training would be necessary to enhance these skills.

Develop Personal Effectiveness Skills

Facilitators:

Prof. Supa Pengpid and Dr.Linda Skaal

Becoming effective is a continuous process for long-term growth in all professions. The aim of this workshop was to build personal effectiveness skills for post-graduate students and young Public Health professionals. The workshop assisted the participants in discovering essentials elements of life that enable them to be more effective according to their self-identified purpose, value, strength and intention. The workshop activities included lectures, self-analysis and empowerment training activities. Topic and activities that the workshop covered included: paradigm shift, setting-up purpose, goal and values, time management, improvement of academic skills, stress management and highly effective habits. Contents of the workshop were based on Steve Covey’s “8 Effective Habits”.

Meeting Millennium Development Goal 6: Learn how the Cochrane HIV/AIDS Review Group can help you meet this challenge

Facilitator:

Elizabeth D Pienaar, Senior Scientist: South African Cochrane Centre

Millennium Development Goal 6 has as its aim combating HIV/AIDS. Given the serious implications of the unfolding HIV/AIDS pandemic it is essential for healthcare providers to provide care based on the most reliable evidence. To make informed decisions, they need to access, appraise and interpret relevant research evidence. With this in mind the aim of the workshop was to equip participants with the knowledge to:

  1. Understand differences between traditional narrative and systematic reviews (SRs).
  2. Know where to find SRs of HIV/AIDS interventions.
  3. Interpret results of a SR including meta-analyses.

There were lively discussions during all presentations. It is clear that HIV/AIDS and its management remains an important topic for the majority of people involved in healthcare not only in South Africa but on the African continent as a whole. The key messages from the workshop were:

  1. HIV/AIDS remains a very important topic for health care practitioners in South Africa.
  2. Relevant information based on evidence is needed for health care to work.
  3. It is important for stake-holders to know where to find relevant research information.
  4. Consumers need to be able to read and understand research results in order for them to use it.
  5. It is important for collaborations to be formed between institutions and consumers, so that the research that is conducted is properly used.

Can the NHI deliver? PHM's vision of an equitable, quality health system, and the role of the Global Peoples Health Assembly as a platform

Facilitators:

Leslie London, David Sanders and Anneleen de Keukelaere, Peoples Health Movement South Africa

This workshop explored a civil society response to the National Health Insurance process being driven by the South African National Department of Health. It aimed to share the vision of PHM for an equitable, quality health system, and to highlight the potential for the Global Peoples Health Assembly in Cape Town in July 2012 to serve as a platform for promoting this vision.

Key messages to emerge from the workshop:

  1. The NHI is an important policy response to the unsustainable inequities in health in South Africa, and provides an opportunity to strengthen comprehensive Primary Health Care and overcome widening inequity between private and public sectors.
  2. To do this, NHI must avoid focusing only on curative services but must develop ways to incentivise health promotion and prevention, and to promote patient-centeredness. One way to do this might be through adopting an outcomes-based approach in funding.
  3. The NHI is relatively silent on the Human Resources needed to make it work and must, particularly, find effective ways to incentivise the retention of human resources in rural areas. This implies that, as a policy, the NHI must link with policies on Human Resource Development and training to ensure accelerated production of appropriate human resources that builds sustainable rural capacity.
  4. The NHI will also only work if it is able to be located in a truly intersectoral and systems-orientated approach to health. For example, patient transport is critical to access to care in rural areas, and the social determinants of health are largely a function of services outside the health sector.
  5. A number of potential pitfalls remain which have to be addressed as the NHI unfolds: transparency, efficiency, accountability, absence of corruption and the need for a gradual and careful scaling back of medical aid tax subsidies so as not to disadvantage the working poor
  6. The importance of the NHI is that it is a vision for social solidarity and for a social system that cares collectively for all in South Africa. As such, the NHI is about building a national health system rather than just a funding mechanism.

Tobacco Use and Dependence Treatment

Facilitators:

Dr OA Ayo-Yusuf, PhD, University of Pretoria and Regional Director of Global Bridges AFRO region 
Dr Scott Leischow, PhD, University of Arizona, USA
Dr Christoph Bolliger, PhD, University of Stellenbosch, South Africa
Dr Yusuf Saloojee, PhD, National Council Against Smoking, South Africa

Key messages delivered:

  1. Integrated primary health care should include tobacco use and dependence treatment. There is also a need to advocate for health insurance schemes to cover costs for tobacco use treatment.
  2. The burden of tobacco use, including snuff use and cigarette smoking in South Africa has declined due to successes in tobacco control regulations that have been passed. However, there is still a need for strengthening policy implementation such as ensuring tax increases that are commensurable to rate of income increases (i.e. focus on reducing affordability and not just increasing price), ensuring that non-tobacco users are protected from second-hand smoke (100% smoke-free public places) and encouraging all health care providers to offer brief advice to assist users with quitting.
  3. Public awareness campaigns have to be created to increase the knowledge of health risks and thus promote cessation activities and discourage the initiation of tobacco use. Such awareness efforts could include the introduction of pictorial health warning labels on tobacco packs, promotion of cessation services such as the national Quit line and the celebration of the annual World No-Tobacco Day.
  4. The clinical intervention framework presented was the 5 A’s (i.e. Ask and record all patients’ tobacco use status, Advice briefly to quit, Assess willingness to quit, Assist client in quitting [motivate with or without medication], Arrange for follow-up).
  5. There is evidence that nicotine replacement therapy (NRT) can be used to successfully wean tobacco users off cigarettes. NRT formulations readily available as over-the-counter medication (not needing a prescription) in SA include the patch, gum and mouth spray. Also available is Bupropion (Zyban) – an antidepressant. Varenicline (champix) – a newly launched stop-smoking medication, was highlighted as the most effective drug for smoking cessation as evident from a recent multi-country study that included South Africans.
  6. It was however also highlighted that aside the costs, the fact that three-quarters of South Africans typically smoke 5-7 cigarettes per day (CPD) means that the use of pharmacotherapy may not always be necessary as most studies on the effectiveness of these medications were conducted on mainly heavy smokers (i.e. smoke ≥15CPD).
  7. Brief advice and if time allows (10-15min), brief motivational interviewing (MI), which is a strategy applicable to exploring change for several behaviours, should always be used to assist a smoker reach a resolution towards a positive change i.e. to becoming a non-smoker. Because each smoker is unique, the process of MI allows engagement with the client (client-centred approach), such that clients’ own perspectives is what is used in resolving the ambivalence about change.
  8. While there is need for ongoing training of all health providers, all smokers can be referred to the National quit line for addition support (Quit line number is 011 720 3145).

Letsema Circle: Community mobilization for health and wellness

Facilitators:

Dr Mamphela Ramphele, Founder Letsema Circle Trust
Dr Welile Shash, Manager of health systems reform program, Letsema Circle Trust
Mr Sam Chimbuya, Manager of livelihoods program, Letsema Circle Trust

Five messages that came out of the workshop:

  1. South Africans need to collectively envision a better SA and work towards enabling all communities to contribute to the realization of our collective aspirations as a nation.
  2. We need to start by mobilizing the social capital and assets that already exist within communities and enable them to play a role in tackling their own challenges rather than creating dependency on government and other donors.
  3. Universities should be embedded in health systems, rather than just using the community as a learning laboratory. In this way, universities will be able to take part in the shaping of the health care system of the country in partnership with health care institutions, policy makers and the communities in which they are embedded, as a necessary basis for the expression of the universities’ social responsibility.
  4. Community Capacity Enhancement and community dialogues are an important tool to establish a culture of ownership within communities and to build Human Capacity for Response as well as Competent Communities for improved health outcomes.
  5. The KZN “Sukuma Sakhe” flagship project demonstrates that community participation and intersectoral collaboration are very important in ensuring that government programs are successfully implemented.

MBChB Undergraduate Curriculum

Facilitators:

Dr Stephen Knight, Desireé Michaels, Virginia Zweigenthal

The purpose of the workshop was to share the exposures and learning activities for Public health across undergraduate medical curricula.

The universities of Kwa Zulu Natal, Cape Town, Pretoria, Witwatersrand, Stellenbosch and Namibia were represented, and each outlined their curricula, teaching platforms and challenges. Commonly, public health is embedded in all curricula across preclinical and clinical years. Individual patient/family follow-up, health systems, quality improvement, health promotion and epidemiological research projects, are some of the preferred activities for Public Health teaching using community based platforms and rural attachments. Longitudinal student-driven projects with peer support and evaluation are gaining favour. Student activities can contribute positively to health care delivery in South Africa as pointed out by Dr Zameer Brey (SAMA), who remarked that “if all health sciences faculties in the country engaged in Quality Improvement projects (10 students per 10 projects p.a), this can systematically change the way the health system functions.” The challenge of the 21st century is that universities graduate socially accountable professionals who are potentially ‘change agents’.

The need for expansion of appropriate service learning platforms, integration of public health learning into clinical disciplines and increased opportunities for ‘generalist longitudinal clerkships’ during the clinical years were noted as main challenges. The importance of student exposure to a multi-disciplinary and inter-professional team approach was acknowledged.

The need to move from a specialist “silo” approach in our undergraduate education to produce a generalist graduate, skilled in understanding the ‘big picture’ was eloquently articulated by Prof Jannie Hugo (UP

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