Ethical Challenges in Public Health Research and Practice
Professor Shan Naidoo, Wits School of Public Health, and Member of the Human Research Ethics Committee at the University of Witwatersrand.
- Always comply with Ethics requirements of the country for research in health (as articulated in the National Health Act and National Department of Health Guidelines of South Africa).
- Also refer to international guidelines such as WMA Declaration of Helsinki (2008) and CIOMS guidelines for biomedical and epidemiological research.
- As far as public health practice is concerned there is always a tension between the individual rights and the public good and this has to be recognised.
- Routine public health practice such as surveillance or epidemiological studies for outbreaks do not require ethical approval.
- Generally a pragmatic approach is to view each research proposal or public health endeavour on a case by case basis using casuistry as a basis (sound logic to make a decision).
- For any research uncertainties it is advisable to consult your local HREC!
Building a community of practice for Health Policy and Systems Research & Analysis (HPSR+A) in South Africa
Professor Lucy Gilson, Health Policy and Systems, University of Cape Town and London School of Hygiene and Tropical Medicine
Marsha Orgill, Researcher, Health Policy and Systems Programme, Health Economics Unit, University of Cape Town
This workshop was convened by the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). This is a European Union-funded capacity-building and networking initiative of seven African and four European academic institutions. It aims to extend sustainable African capacity to produce and use high quality health policy and systems research by harnessing synergies among a Consortium of African and European universities with relevant expertise. The workshop was attended by policy makers, practitioners, donors, researchers, analysts and academics with an interest in health policy and systems issues, including a ward councillor from the Cape Town City Council.
The key challenges facing health policy implementation and health system development in South Africa are:
- Gaps between research evidence and practice, as well as between policy and practice, as well as contradictory policies, are leading to implementation failure;
- A lack of understanding of what factors guide implementation at the coal face or front line of the health system;
- A lack of attention and understanding of the complexity of systems;
- And a lack of a shared understanding about the terrain of Health Policy and Systems Research and Analysis (HPSR+A).
To address these challenges three future sets of priority activities were identified:
- Developing a ‘community of practice’, drawing in those from all organisations interested in the field, which would strengthen a small and emergent field and amplify the limited existing capacity – and serve as a platform for developing a shared understanding about HPSR for example. Such a community of practice could perhaps take the form of a PHASA special interest group, and might: establish a repository of existing and past research which is publicly accessible; develop a website and/or email list; organise future workshops which bring together actors at regular or even irregular intervals are excellent opportunities for networking, sharing ideas and activities and developing joint agendas;
- Advocacy for the importance and relevance of the field and build acceptance for it in the South African public health community and also, in the world of policy and practice;
- Efforts to better link and align research, teaching and practice in the field.
Climate Change and Public Health
Rajen Naidoo, Occupational and Environmental Health, School of Nursing and Public Health, University of KwaZulu-Natal
Stephen Knight, Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal
James Irlam, Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, South Africa
Irwin Friedman, Seedtrust
“Climate change is the greatest global health threat the 21st century” according to the University College London/Lancet Commission on Climate Change. Low income countries and especially sub-Saharan Africa will bear the brunt of the adverse health outcomes associated with climate change which will further impact on our ability to achieve the Millennium Development Goals.
The workshop was attended by a group of about 20 people – from a range of backgrounds, who participated actively in the workshop.
In the first session the focus was on adverse health outcomes of climate change, and South African climate change policy initiatives. In the second session on Climate Change and the Health Sector, the focus was on the contribution of the health sector to climate change and greening initiatives in the health sector.
- PHASA has an important role in raising awareness of climate change and its effect on public health. We should be improving our data collection and surveillance to better understand the effects on health.
- An enabling policy environment, better enforcement of policy aimed at mitigation is necessary. Development has to become climate-resilient.
- Public awareness and undergraduate training in all disciplines (e.g. medicine, urban planning etc) is essential.
- Focus on alternate sources of energy, invest in public transport and associated infrastructure.
- There must be ethical considerations around climate and health – for example: planning and building of housing complexes for disadvantaged communities in climate vulnerable locations.
- PHASA must adopt greening initiatives, particularly its annual conference. It was proposed that we facilitate a Climate Change and Public Health subgroup as part of PHASA. The annual conference needs to be progressively greener, including carbon offsets from participants, venue energy usage, dietary changes etc.
- Need to strengthen the infrastructure of health systems, such that health care industry can become more responsive to climate change, and reduce its contribution to global warming.
- Impacts on the whole population – not just the marginalised, as the affluent get affected when resource allocation and redistribution becomes necessary.
PHASA members need to be aware of you very useful resources namely: Global Green and Healthy Hospitals and Health Care Without Harm.
When allocating budgets, should the Department of Health (DoH) positively discriminate in favour of rural hospitals?
Dr Richard Cooke, Wits Centre for Rural Health and the Rural Health Advocacy Project
- Both the increased healthcare needs and the operational constraints in rural areas support the argument for allocation of proportionately more money for healthcare delivery in these areas.
- There is merit in developing (and validating the use of) a template to compare proxies of community need (e.g. deprivation index) and ease of health care delivery (e.g. average distance to clinics from the district hospital) across districts in a province. Motivating for more budget using select indicators (e.g. high no of peripheral clinics) can only be successful if the effect of subsequent budget increases can also be properly identified (e.g. improved outreach).
- Technology (e.g. GIS) allows for accurate mapping and calculation of indicators /proxies of community need; this helps inform the methodologies for fair budget allocation, but more research is required.
- There is a danger of “rural” being defined very narrowly in South Africa; as the literature suggests, the purpose of the definition must dictate how rural is defined. A unique definition/classification for the health sector may be warranted, despite the tendency to standardise for policy purposes.
- All models developed to calculate staffing norms for PHC outreach, clinics, CHCs and district hospitals must include a “rurality factor” for those areas where relatively more resources are required to achieve equivalent health outcomes as elsewhere.
- There is concern that district hospitals are being underestimated for their current impact, particularly in rural areas; each district hospital’s partnership with the district office is vital in managing the improved PHC delivery in the districts. This importance should be reflected in the allocation of appropriate resources to these hospitals.
Challenges in the transformation of health sciences education in South Africa
L.D. Dudley, S. Knight, N. Cameron, K. Moodley
MEPI projects based at: Division of Community Health, Faculty of Health Sciences, Stellenbosch University; School of Nursing and Public Health, University of KwaZulu-Natal
The Community Health Department, Stellenbosch University in collaboration with the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) hosted a workshop with the aim of bringing together a national reference group to discuss the next steps in transformative and multidisciplinary education for health professionals in South Africa. This imperative was largely driven by the recent Lancet Commission on Health for the 21st Century; the HPCSA Subcommittee on Undergraduate Education and Training focusing on graduates attributes adapted from CanMEDS; and recent deliberations at WITS University that focused on Public Health in medical education.
Key note speakers presented the rationale for transformation of medical education for the 21st century:
Dr Barry Kistnasamy (NIOH), co-author of the Lancet Commission report, discussed key findings of the Lancet Commission report highlighting the need for transformative education and the importance of graduates acquiring competencies to be change agents within the health system.
Prof Ben van Heerden (SU) representing the HPCSA, described the strategic process from the HPSCA that aims to ensure transformative education in the South African context. The Undergraduate Education and Training subcommittee of the HPCSA embraced the Lancet Commission and have now adapted the CanMEDS core competency framework on graduate attributes. In addition an instrument to measure social accountability has been adapted, developed by the Training for Health Equity Network (THEnet). Both these frameworks have been presented to Medical Schools at National workshops.
Based on the international and national movement towards transformative education, the Public Health Department at WITS University held a workshop in August 2012 to identify key competencies and attributes for undergraduates and postgraduates in Public health. A summary of this workshop was presented by Dr Julia Moorman (Wits).
Dr Bart Willems (SU) presented findings on a survey conducted with recent medical graduates of SU to assess undergraduate teaching and learning with regard to preparedness for internship and community service.
Key messages from group discussions:
Question 1: Which teaching and learning approaches are most appropriate for acquiring ‘transformative’ or ‘change agent’ competencies ? What needs to change for higher education institutions to adopt such teaching and learning approaches?
- Students need to have a reflective practice and critically engage with the environment. Experiential learning should therefore be promoted. Learning should start early and be progressive with theory linking to practical exposure.
- PH should be advocated for in other clinical departments:
- If clinical departments teach public health and link it to practice, it will validate the importance of PH in clinical practice.
- Therefore our engagement with clinical departments is very important.
- Integration and collaboration will be essential for e.g. if students are rotating through paediatrics or obstetrics then students can be encouraged to conduct research in relavant areas of paediatric public health or obstetric public health.
- Interprofessional learning would be advantageous in creating teams and for ensuring that graduates are capable of functioning in teams.
- Collaborations with DoH is also essential in defining the curriculum.
Question 2: How can undergraduate education promote interdisciplinary team work as a core attribute for all health professionals ?
- For the theoretical model, there should be a generic co-module with case scenarios where students can appreciate and understand the social determinants of health and relate it to physiology, anatomy and pathology etc. so they can appreciate the integration and the multidisciplinary approach.
- Practical knowledge and multi-disciplinary exposure should start from early years and continue to internship. For example, students from SU conduct projects in the services that are supervised by different disciplines which include multidisciplinary undergraduate teams.
- PH specialists should be well positioned within the faculty and should have role models in leadership.
Question 3: Using the results of the Wits workshop, further define the critical public health skills all graduates should acquire and be able to demonstrate?
- Educators should think more broadly than just medical education and what health scientists should exit with.
- The current competencies developed at the WITS workshop has gaps in occupational health, surveillance and the use of routinely collected data.
- There is a need to take the document further with other stakeholders and to consult with services and other disciplines.
- Ultimately graduates should be capable of applying the necessary skills in the work service environment.
Question 4: How can we evaluate teaching and learning in terms of achieving ‘transformative’ competencies? (methods of assessment)
There needs to be student centred approaches for evaluation based on the needs of the students. Assessments can include a portfolio of evidence, projects, reports, simulations, and assessments based on blooms taxonomy to determine the students level of learning and understanding.
Tobacco Use and Dependence Treatment workshop
Prof OA Ayo-Yusuf, University of Pretoria and Regional Director of Global Bridges AFRO region
Dr Yussuf Saloojee, Executive Director of National Council Against Smoking
Dr Flavia Senkubuge, PHASA Vice-President and Senior Lecturer at University of Pretoria
Key messages delivered:
Posted in PHASA news
- 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.
- The burden of tobacco use, including snuff use and cigarettes smoking in South Africa has declined due to successes in tobacco control regulations that have been passed, but the decline has plateau for the past 5 years. Therefore 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.
- 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.
- 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 [Motivational interviewing with or without medication], Arrange for follow-up).
- 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.
- 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).
- 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.
- 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).