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We know from the literature that high cognitive load can impede performance and educational outcomes. Previous measures of cognitive load have largely relied on subjective scales but few have explored more objective measures. This paper aims to address this issue by examining the validity of electroencephalography (or EEG) as an objective measure of cognitive load in the context of educational video. EEG is an online brain measure of the electrical activity that a population of neurons elicits when they are activated. Theta power is a brain oscillation ranging from 4 to 7 Hz that has been linked to cognitive and memory performance. We manipulated the linguistic complexity of three texts delivered by a speaker on video to induce a simple, a moderate and a complex level of cognitive load amongst a sample of students pursuing postgraduate studies through the medium of English as a second language (n = 35). We specifically measured intrinsic cognitive load via a subjective scale, a recall test, and theta power as an objective measure (average cognitive load). Our results show that the subjective scale was significantly different across the three levels of linguistic complexity. However, theta power and recall were only significantly different between the two most distinct levels of linguistic complexity. Although, this finding suggests theta power may not be as sensitive for average cognitive load as the subjective scale for intrinsic cognitive load, a correlation analysis shows that theta power was correlated with self-reported cognitive load. However, it may need more power compared to the subjective scale. These findings suggest that theta power may be developed into a valid objective measure of average cognitive load although its true potential lies in the possibility to measure online fluctuations in cognitive load or instantaneous cognitive load.

The use of video has become well established in education, from traditional courses to blended and online courses. It has grown both in its diversity of applications as well as its content. Such educational video however is not fully accessible to all students, particularly those who require additional visual support or students studying in a foreign language. Subtitles (also known as captions) represent a unique solution to these language and accessibility barriers, however, the impact of subtitles on cognitive load in such a rich and complex multimodal environment has yet to be determined. Cognitive load is a complex construct and its measurement by means of single indirect and unidimensional methods is a severe methodological limitation. Building upon previous work from several disciplines, this paper moves to establish a multimodal methodology for the measurement of cognitive load in the presence of educational video. We show how this methodology, with refinement, can allow us to determine the effectiveness of subtitles as a learning support in educational contexts. This methodology will also make it possible to analyse the impact of other multimedia learning technology on cognitive load.

Abstract The establishment of industrial hemp (Cannabis sativa L.) fields near row crops has raised concerns about the potential adverse effects of herbicide drift on hemp production. This study examined hemp susceptibility to drift of herbicides registered for use in corn and/or soybeans. Herbicide solutions (2,4-D, dicamba, glufosinate, glyphosate, imazethapyr, lactofen, mesotrione) were applied separately in the wind tunnel (3.6 m s−1 airspeed), simulating drift scenarios, with conventional TP95015EVS (TP) and air inclusion AI95015EVS (AI) flat fan nozzles calibrated to deliver 140 L ha−1 carrier volume at 230 kPa. Mylar cards and hemp plants (20–25 cm tall) were placed downwind up to 12 m. Spray deposition from mylar cards was quantified using fluorometry and hemp biomass was collected 21 post application. Results indicated the nozzle design influenced downwind deposition; 5% of spray deposits from the TP nozzle reached 5.9 m downwind versus 2.0 m for the AI nozzle. Glyphosate, glufosinate, and mesotrione caused the highest biomass reductions, with 50% reductions observed at 19.3 (inferred), 8.7, and 9.3 m downwind for TP nozzle, and 4.1, 4.0, and 2.9 m for AI nozzle. These findings suggest herbicide applications at airspeeds of 3.6 m s−1 or greater present a risk to nearby hemp fields.

Abstract We investigated the incidence and duration of morbidity symptoms among infants aged 6 to 9 months from a low socioeconomic community receiving one egg daily for 6 months. This was a secondary outcome of a randomised controlled trial (RCT) of 500 infants conducted in Jouberton, South Africa. The primary outcome was linear growth. Morbidity data were collected weekly using a symptoms diary and qualitative data with focus group discussions at the endpoint. Ethical approval was obtained from the North-West University Health Research Ethics Committee. The intervention group had a ~ 5% higher incidence of gastrointestinal morbidity (17.0%) compared to the control group (11.9%). Gastrointestinal morbidity without fever tended to be 1.4 times higher in the intervention group (OR: 1.43, 95% CI: 1.03, 1.93; P = 0.058) and tended to be 4 times higher with fever (OR: 4.07, 95% CI: 0.86, 19.23; P = 0.077). The duration of total gastrointestinal and respiratory morbidity was 1.5 days longer in the intervention group (β: 1.491; 95% CI 0.064, 2.918; P = 0.041). Complementary feeding with eggs may have contributed towards an increased risk for gastrointestinal morbidity.

Abstract As individuals near a desired goal, they become more motivated, and happier. When thwarted in their goal pursuit, frustration and negative affect ensue. Slot-machine research indicates that near-misses (being one symbol away from a jackpot) are highly arousing, frustrating, yet motivating outcomes. We used the popular game Wordle to illustrate goal gradient and near-miss effects. In Wordle, an individual tries to guess a five-letter word in six attempts. Wordle gives feedback — letters turn green, orange, or grey depending on how closely guesses match the target word. By analyzing feedback across guesses, players can gauge whether they are approaching or thwarted in their goal pursuit. Wordle also contains near-misses (guesses only one letter away from the target). When feedback indicated players were approaching their goal, positive affect and motivation significantly increased compared to thwarted outcomes which increased frustration. Near-misses were significantly more subjectively arousing than other outcomes. The first appearance of a near-miss (an “approaching” outcome) led to higher motivation and positive affect and less frustration than if the next guess revealed the same four green letters (a “thwarted” near-miss). These findings shed new light on erroneous cognitions among slot-machine players who misinterpret slots games as having goal gradient properties.

Abstract Despite advances in gut health research, the variability of important gut markers within individuals over time remains underexplored. We investigated the intra-individual variation of various faecal gut health markers using an optimised processing protocol aimed at reducing variability. Faecal samples from ten healthy adults over three consecutive days demonstrated marker-specific intra-individual coefficients of variation (CV%), namely: stool consistency (16.5%), water content (5.7%), pH (3.9%), total SCFAs (17.2%), total BCFAs (27.4%), total bacteria and fungi copies (40.6% and 66.7%), calprotectin and myeloperoxidase (63.8% and 106.5%), and untargeted metabolites (on average 40%). For thirteen microbiota genera, including Bifidobacterium and Akkermansia, variability exceeded 30%, whereas microbiota diversity was less variable (Phylogenetic Diversity 3.3%, Inverse Simpson 17.2%). Mill-homogenisation of frozen faeces significantly reduced the replicates CV% for total SCFAs (20.4–7.5%) and total BCFAs (15.9–7.8%), and untargeted metabolites compared to faecal hammering only, without altering mean concentrations. Our results show the potential need for repeated sampling to accurately represent specific gut health markers. We also demonstrated the effectiveness of optimised preprocessing of human stool samples in reducing overall analytical variability.

Introduction: The phenomenon that has been described as Financial Medicine has been occurring within the South African Healthcare sector for at least the last decade. Despite the ongoing effect of this phenomenon, there is no organised body of knowledge or formulated working definitions to guide knowledge sharing and theorisation within this research focus area. The practice of Financial Medicine exerts a deleterious effect on the South African prehospital healthcare system, and represents an area in dire need of focused research efforts. Establishing appropriate working definitions and associated taxonomy is an important first step in supporting further research efforts into this aspect of South African prehospital healthcare systems. Methods: A qualitative research methodology following a constructivist grounded theory design was used. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. Results: A working definition for Financial Medicine is provided. Six new terms are introduced, with associated working definitions, namely Financial Medicine Practices, Treatment-based profiteering, Cost-of-care-aversion, Personal-gain-at-patient-expense, Money-racketeering-in-healthcare, and Impoverishing-healthcare-earning. Conclusion: The working definitions and suggested taxonomy presented in this article are the first step in formally conceptualising and theorising the phenomenon of Financial Medicine, in order to support further research and collaboration in this space.

Abstract Protected areas are traditionally the foundation of conservation strategy, but land not formally protected is of particular importance for the conservation of large carnivores because of their typically wide-ranging nature. In South Africa, leopard (Panthera pardus) population decreases are thought to be occurring in areas of human development and intense negative interactions, but research is biased towards protected areas, with quantitative information on population sizes and trends in non-protected areas severely lacking. Using Spatially Explicit Capture-Recapture and occupancy techniques including 10 environmental and anthropogenic covariates, we analysed camera trap data from commercial farmland in South Africa where negative human-wildlife interactions are reported to be high. Our findings demonstrate that leopards persist at a moderate density (2.21 /100 km2) and exhibit signs of avoidance from areas where lethal control measures are implemented. This suggests leopards have the potential to navigate mixed mosaic landscapes effectively, enhancing their chances of long-term survival and coexistence with humans. Mixed mosaics of agriculture that include crops, game and livestock farming should be encouraged and, providing lethal control is not ubiquitous in the landscape, chains of safer spaces should permit vital landscape connectivity. However, continuing to promote non-lethal mitigation techniques remains vital.

Abstract Aging involves physical and cognitive deterioration in older adults. Detecting predictors of dementia early is crucial to identify its onset. This study aimed to associate physical and psychological determinants with cognitive performance in older adults. Observational study with 221 older adults, classified according to cognitive impairment. We evaluated cognitive function by Mini-Mental State Examination. Physical determinants encompassed muscle strength, functional mobility, and cardiorespiratory fitness, while psychological consisted of quality of life and activities of daily living. Multiple linear regression was performed to investigate this relationship. Physical and psychological determinants were significantly linked to cognitive impairment, including lower muscle strength, reduced functional mobility and of cardiorespiratory fitness. The influence of environment, autonomy, and engagement in daily activities on cognitive impairment was also observed. The analysis of physical and psychological determinants could help to aid in distinguishing individuals with cognitive impairment.

Abstract Skin tissue is recognized to exhibit rate-dependent mechanical behavior under various loading conditions. Here, we report that the full-thickness burn human skin exhibits rate-independent behavior under uniaxial tensile loading conditions. Mechanical properties, namely, ultimate tensile stress, ultimate tensile strain, and toughness, and parameters of Veronda–Westmann hyperelastic material law were assessed via uniaxial tensile tests. Univariate hypothesis testing yielded no significant difference (p > 0.01) in the distributions of these properties for skin samples loaded at three different rates of 0.3 mm/s, 2 mm/s, and 8 mm/s. Multivariate multiclass classification, employing a logistic regression model, failed to effectively discriminate samples loaded at the aforementioned rates, with a classification accuracy of only 40%. The median values for ultimate tensile stress, ultimate tensile strain, and toughness are computed as 1.73 MPa, 1.69, and 1.38 MPa, respectively. The findings of this study hold considerable significance for the refinement of burn care training protocols and treatment planning, shedding new light on the unique, rate-independent behavior of burn skin.

Abstract The field of integrated photonics has advanced rapidly due to wafer-scale fabrication, with integrated-photonics platforms and fabrication processes being demonstrated at both infrared and visible wavelengths. However, these demonstrations have primarily focused on fabrication processes on silicon substrates that result in rigid photonic wafers and chips, which limit the potential application spaces. There are many application areas that would benefit from mechanically-flexible integrated-photonics wafers, such as wearable healthcare monitors and pliable displays. Although there have been demonstrations of mechanically-flexible photonics fabrication, they have been limited to fabrication processes on the individual device or chip scale, which limits scalability. In this paper, we propose, develop, and experimentally characterize the first 300-mm wafer-scale platform and fabrication process that results in mechanically-flexible photonic wafers and chips. First, we develop and describe the 300-mm wafer-scale CMOS-compatible flexible platform and fabrication process. Next, we experimentally demonstrate key optical functionality at visible wavelengths, including chip coupling, waveguide routing, and passive devices. Then, we perform a bend-durability study to characterize the mechanical flexibility of the photonic chips, demonstrating bending a single chip 2000 times down to a bend diameter of 0.5 inch with no degradation in the optical performance. Finally, we experimentally characterize polarization-rotation effects induced by bending the flexible photonic chips. This work will enable the field of integrated photonics to advance into new application areas that require flexible photonic chips.

Oral cancer is a malignant neoplasia that can originate in the oral cavity or lips. It is a serious global health problem and one of the ten most common cancers worldwide. Over the years, changes in the trends of the oral cavity and oropharyngeal cancers have been observed. The management of oral cancer is complicated due to the functional and cosmetic consequences of treating malignancies at these anatomical locations. The tumor and its treatment can affect a variety of functional activities, including smell, sight, speaking, respiration, taste, jaw function, and mastication, either temporarily or permanently. Based on the importance of this tumor, screening oral cancer for early detection and finding the best biomarkers for diagnosis is a crucial concern. In this review of literature, the etiology, risk factors, treatment, and diagnosis of oral cancer will be reviewed with a focus on the most important biomarkers.

Background: The hepatitis B virus (HBV) is one of the most important biological occupational hazards for healthcare workers. A high percentage of HBV infections are attributable to percutaneous occupational exposure. This study aimed to describe the HBV immunisation and current immune status of all the nurses employed in a regional hospital in central South Africa. Methods: A descriptive record review included all the nurses (N = 388) employed in a regional hospital in central South Africa from 01 January 2018 to 31 January 2020. A total of 289 health records were included in the study. Data were analysed using descriptive statistics. Logistic regression analysis was used to establish factors associated with full immunisation. Results: Most nurses were females (87.9%), working in medical (27.0%) wards. Only 20.4% of nurses received one dose of vaccine, while 51.2% received the three prescribed doses. However, 91.2% of nurses did not receive the vaccine at the correct intervals. Most of the tested nurses (71.0%) were immune. Immunisation status was significantly associated with religion (p 0.001) and schedule (p = 0.003). Nurses who were non-Christians were 35.9% less likely to be fully vaccinated compared to Christians. Conclusion: Half of the nursing staff received three doses as prescribed. All nurses should receive the vaccine against HBV and their immune status monitored to minimise the risk of an infection. It is therefore recommended that proof of immunity should be a requirement. Contribution: This study found a high percentage of nurses with HBV antibodies, which will ensure workplace safety.

The study evaluated the current state and accessibility of tertiary healthcare services in rural Australia. A systematic literature review from 2010 to 2022 was undertaken, utilising databases such as PubMed, MEDLINE, Cochrane Library, ProQuest, and Google Scholar. The PRISMA method was employed to retrieve an initial total of 4768 papers. Upon removal of 2806 duplicates and 1587 irrelevant records, 1962 articles were screened. From these, 375 were assessed for eligibility, leading to the inclusion of eleven studies in the systematic review. Criteria for exclusion included a focus on primary and secondary healthcare, absence of peer review, and unclear methodology.A collective survey of 230,339 individuals, focusing on access to tertiary healthcare in rural and remote areas of Australia, was reported in the chosen studies. Several barriers to healthcare access for rural populations were identified, including lack of informed leadership, inadequate clinical governance, limited awareness of modern care models, suboptimal workforce planning and resource utilisation, incorrect risk perception, and insufficient community engagement.In conclusion, there is an urgent need to address healthcare disparities and improve service accessibility in Australia's rural and remote areas.

Abstract The pauci-cellular nature of cerebrospinal (CSF), particularly ventricular CSF, and the rapid cell death following sampling, incumbers the use of flow cytometric analysis of these samples in the investigation of central nervous system (CNS) pathologies. Developing a method that allows long-term storage and batched analysis of CSF samples without compromising cell integrity is highly desirable in clinical research, given that CSF is often sampled after hours creating logistical difficulties for fresh processing. We examined percentages and relative proportion of peripheral and brain-derived immune cells in cryopreserved and transfix-treated CSF, compared to freshly processed CSF. Cell proportions were more comparable between Fresh and Cryopreserved CSF (mean of differences = 3.19), than between fresh and transfix-treated CSF (mean of differences = 14.82). No significant differences in cell percentages were observed in fresh versus cryopreserved CSF; however significantly lower cell percentages were observed in transfix-treated CSF compared to Fresh CSF [(CD11b++ (p = 0.01), CD4+ (p = 0.001), CD8+ (p = 0.007), NK cells (p = 0.04), as well as CD69+ activation marker (p = 0.001)]. Furthermore, loss of marker expression of various lymphocyte sub-populations were observed in transfix-treated CSF. Cryopreservation is a feasible option for long-term storage of ventricular CSF and allows accurate immunophenotyping of peripheral and brain-derived cell populations by flow cytometry.

Introduction: The phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury. Methods: This study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. Results: The sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list. Conclusion: Understanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.

Emergency care in the primary health care setting is often sub-optimal leading to physician stress and adverse patient outcomes. Formal training opportunities in the management of emergency management are limited in public-sector facilities. Two family physicians conducted emergency simulation drills at primary health care facilities to address this need. The multi-disciplinary team at these facilities were involved, and each drill was followed by reflection and feedback. The drill evolved over an 18 month period, and the simulations as well as the feedback process were reviewed and improved. Reported benefits included improved skills and confidence, teamwork and sharing of information. Staff appreciated the support and the opportunity to review emergency equipment and drugs. Recommendations based on the experience gained and the outcomes of the simulation training include that the feedback is just as important as the simulations and that clinicians need to be trained in order to facilitate simulations successfully.

Abstract In South Africa, the population at risk of malaria is 10% (around six million inhabitants) and concern only three provinces of which Limpopo Province is the most affected, particularly in Vhembe District. As the elimination approaches, a finer scale analysis is needed to accelerate the results. Therefore, in the process of refining local malaria control and elimination strategies, the aim of this study was to identify and describe malaria incidence patterns at the locality scale in the Vhembe District, Limpopo Province, South Africa. The study area comprised 474 localities in Vhembe District for which smoothed malaria incidence curve were fitted with functional data method based on their weekly observed malaria incidence from July 2015 to June 2018. Then, hierarchical clustering algorithm was carried out considering different distances to classify the 474 smoothed malaria incidence curves. Thereafter, validity indices were used to determine the number of malaria incidence patterns. The cumulative malaria incidence of the study area was 4.1 cases/1000 person-years. Four distinct patterns of malaria incidence were identified: high, intermediate, low and very low with varying characteristics. Malaria incidence increased across transmission seasons and patterns. The localities in the two highest incidence patterns were mainly located around farms, and along the rivers. Some unusual malaria phenomena in Vhembe District were also highlighted as resurgence. Four distinct malaria incidence patterns were found in Vhembe District with varying characteristics. Findings show also unusual malaria phenomena in Vhembe District that hinder malaria elimination in South Africa. Assessing the factors associated with these unusual malaria phenome would be helpful on building innovative strategies that lead South Africa on malaria elimination.

Abstract Communication theory suggests that interactive dialog rather than information transmission is necessary for climate change action, especially for complex systems like agriculture. Climate analogs—locations whose current climate is similar to a target location’s future climate—have garnered recent interest as transmitting more relatable information; however, they have unexplored potential in facilitating meaningful dialogs, and whether the way the analogs are developed could make a difference. We developed climate context-specific analogs based on agriculturally-relevant climate metrics for US specialty crop production, and explored their potential for facilitating dialogs on climate adaptation options. Over 80% of US specialty crop counties had acceptable US analogs for the mid-twenty-first century, especially in the West and Northeast which had greater similarities in the crops produced across target-analog pairs. Western counties generally had analogs to the south, and those in other regions had them to the west. A pilot dialog of target-analog pairs showed promise in eliciting actionable adaptation insights, indicating potential value in incorporating analog-driven dialogs more broadly in climate change communication.

IntroductionThe Soweto Derby is one of Africa's largest football derbies. The two rival teams, Kaizer Chiefs and Orlando Pirates, both originate in Soweto, a sprawling township 20km outside Johannesburg. Soweto is infamous for the high levels of violent crime and trauma, but also for Chris Hani Baragwanath Academic Hospital (CHBAH), with one of the world's largest trauma emergency departments (ED). Research globally, describing the impact of sports events on public health care systems is conflicting, with evidence showing both increases and decreases in spectator related trauma. This paper seeks to describe the trauma burden during the Soweto Derby and add to the research concerning trauma relating to sporting derbies in low to middle income countries.ObjectivesTo analyze the impact of the Soweto Derby on the trauma ED at CHBAH over a 24-hour period.MethodsA retrospective comparative study at the CHBAH Trauma ED of 13 Soweto Derbies played over a 5 year period between 2015-2019, compared to the corresponding non-Soweto Derby days of the preceding year. Patients were triaged according to the South African Triage Scale and Advanced Trauma Life Support (ATLS) principles. Data was organized into 3 time frames where the triage score and mechanism of injuries were compared: 1) 4 hours pre-match, 2) 2 hours during the match, and 3) 18 hours post-match.ResultsThirteen Soweto Derbies and 2552 patients were included. The median age was 29 with males accounting for 73.4% of all trauma cases. Significantly more P1 patients presented during the Soweto Derby. Pre-match there were 3x less P1 patients presenting to the ED (4.7% vs 12%, p = 0.044). During the match, there was a 40% drop in males presenting to ED (5.95% vs 9.45%, p = 0.015). Post-match there was a significant increase in P1 patients treated (17.4% vs 13.5%, p = 0.021)), with the majority being young males. There was no increase in either female or paediatric visits to the ED.ConclusionThe Soweto Derby has a direct effect on the trauma burden at CHBAH, with more P1 patients presenting post-match. Young African males are disproportionally affected by severe trauma requiring increased health care resources in an already overburdened hospital.

IntroductionThe role of age and sex in the presentation and outcome of endemic Burkitt lymphoma (BL) has not been studied recently. This study analysed these factors in 934 patients with BL who had received cyclophosphamide and intrathecal methotrexate as treatment.MethodsRecords of 934 children diagnosed with BL from 2004 to 2015 were obtained from our Paediatric Oncology Networked Database (POND) cancer registry. Age at diagnosis, sex, disease stage, time to diagnosis, delay in diagnosis, completion of treatment, rate of abandonment, and one-year survival rates were recorded and statistically analysed.ResultsThe male to female ratio of 1.41 for the study population of 934. The median delay from onset of symptoms to diagnosis was 31 days. The St Jude stage distribution was I = 6.4%, II = 5.9%, III = 71.5% and IV = 16.2%. Significantly more patients presented with stage III disease in age groups 5-9 and 10-14 years than 0-4 years. The overall 1-year survival rate was 53.45%, respectively 77.1% for stage I, 67.9% for stage II, 55.1% for stage III and 32.4% for stage IV disease (pConclusionPatients aged under 5 years presented with less-advanced disease, but survival was not affected by age. Sex did not influence delay to diagnosis and overall survival. The long delay between the onset of symptoms and diagnosis emphasises the need for interventions to achieve an earlier diagnosis and a better survival rate.

Objective When considering proposals to improve diets, it is important to understand how factors like price and income can affect saturated fat (SF) intake and demand. In this study, we examine and estimate the influence of price and income on intake across 160 countries, by age and sex, and derive sensitivity measures (price elasticities) that vary by age, sex and world region.Design We econometrically estimate intake responsiveness to income and prices across countries, accounting for differences by world region, age and sex. Intake data by age, sex and country were obtained from the 2018 Global Dietary Database. These data were then linked to global price data for select food groups from the World Bank International Comparison Programme and income data from the World Development Indicators Databank (World Bank).Results Intake differences due to price were highly significant, with a 1% increase in price associated with a lower SF intake (% energy/d) of about 4.3 percentage points. We also find significant differences across regions. In high-income countries, median (age 40) intake reductions were 1.4, 0.8 and 0.2 percentage points, given a 1% increase in the price of meat, dairy, and oils and fats, respectively. Price elasticities varied with age but not sex. Intake differences due to income were insignificant when regional binary variables were included in the analysis.Conclusion The results of this study show heterogeneous associations among prices and intake within and across countries. Policymakers should consider these heterogeneous effects as they address global nutrition and health challenges.

Introduction Few clinical trials have investigated physiotherapy interventions to treat hypoxaemia following abdominal surgery. The objective of this study is to determine the feasibility and safety of conducting a clinical trial of physiotherapist-led non-invasive ventilation (NIV).Methods and analysis This single-centre, 50-patient, parallel-group, assessor blinded, pilot feasibility randomised controlled trial with concealed allocation will enrol spontaneously ventilating adults with hypoxaemia within 72 hours of major abdominal surgery. Participants will receive either (1) usual care physiotherapy of a single education session (talk), daily walking of 10–15 min (walk) and four sessions of coached deep breathing and coughing (breathe) or (2) usual care physiotherapy plus four 30 min sessions of physiotherapist-led NIV delivered over 2 postoperative days. Primary feasibility and safety outcome measures are; number of eligible patients recruited per week, total time of NIV treatment delivered, acceptability of treatments to patients and clinicians and incidence of adverse events. Secondary feasibility outcomes include measures of recruitment and treatment adherence. Exploratory outcome measures include change in respiratory parameters, postoperative pulmonary complications, length of hospital stay, health-related quality of life, postoperative activity levels and mortality.Ethics and dissemination Ethics approval has been obtained from the relevant institution. Results will be published to inform future research.Trial registration number ACTRN12622000839707.

Abstract To understand how two dominant African savanna trees will continue to respond to climate changes, we examined their regeneration niche and adult tree distributions. Specifically, we wanted to (1) determine if distributional patterns were shifting, (2) predict future distributions under different climate change scenarios and (3) evaluate the realism of predicted future distributions. We randomly placed 40 grids into 6 strata across a climate gradient in the kingdom of Eswatini. Within these grids, we sampled adult and seedling marula (Scelerocarya birrea) and knobthorn (Senegalia nigrecens) trees and used the data to model their abundance. Next, we quantified shifts in distributional patterns (e.g., expansion or contraction) by measuring the current and projected areas of overlap between seedling and adult trees. Finally, we predicted future distributions of abundance based on predicted climate conditions. We found knobthorn seedlings within a small portion of the adult distribution, suggesting it was unlikely to track climate changes. Alternatively, finding marula seedlings on and beyond one edge of the adult distribution, suggested its range would shift toward cooler climates. Predicted future distributions suggest suitable climate for both species would transition out of savannas and into grasslands. Future projections (2041–2070) appeared consistent with observed distributions of marula, but knobthorn predictions were unrealistic given the lack of evidence for regeneration outside of its current range. The idiosyncratic responses of these species to climate change are likely to decouple these keystone structures in the coming decades and are likely to have considerable cascading effects including the potential rearrangement of faunal communities.

Abstract Background Although Entrustable Professional Activities (EPAs) regarding pediatric training in care for children with medical complexity (CMC) exist, it is unknown what US pediatric training programs provide for education related to care of CMC and whether educators perceive that pediatric residents are prepared to care for CMC upon graduation. Methods From June, 2021 through March 2022, we surveyed US pediatric residency program delegates about practice settings, current educational offerings, perception of resident preparedness regarding care of CMC, and likelihood to implement CMC education in the future. Results Response rate was 29% (56 /195). A third of responding programs (34%, n = 19) provide a specific educational CMC offering including combinations of traditional didactics (84%, n = 16), asynchronous modules/reading (63%, n = 12), experiential learning (58%, n = 11), and simulation-based didactics (26%, n = 5). The majority (93%, n = 52) of respondents agreed residents should be competent in providing primary care for CMC upon graduation and CMC should receive primary care from a resident (84%, n = 47). A total of 49% (n = 27) of respondents reported their residents are very or extremely well prepared to care for CMC after graduation. A total of 33% (n = 18) of programs reported CMC receive primary care from residents. Respondent average perception of resident preparedness was significantly higher in programs with educational offerings in five of eleven EPAs (nutrition and weight, transitions, feeding tubes, advocacy, and care coordination). The majority (78%, n = 29) of programs without educational offerings are at least somewhat likely to implement CMC curricula in the next three years. Conclusion Pediatric residency programs report residents should be competent in care for CMC upon graduation. Pediatric residents are exposed to a wide variety of clinical care models for CMC. The minority of responding programs have intentional CMC educational offerings. Of those programs that provide CMC education, the offerings are variable and are associated with a perception of improved preparedness to care for CMC upon graduation.

Abstract This study aimed to investigate the association between maternal postpartum depressive symptoms, household demographic, socioeconomic, and infant characteristics with infant physical growth, and how these factors correlate to determine latent factors. This study was based on the baseline data of a 6-month randomised controlled trial aimed at providing an egg a day to infants aged 6 to 9-months from a low socioeconomic community in South Africa. Information collected on household demographic, socioeconomic, and infant characteristics was by face-to-face structured interviews, and trained assessors took anthropometric measurements. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess maternal postpartum depressive symptoms. The analysis was based on 428 mother-infant pairs. Total EPDS score and its subscales score were not associated with stunting or underweight risk. However, a three- to four-fold increased risk of stunting and underweight, respectively was observed for premature birth. Low birthweight was associated with an estimated six-fold increased risk of underweight and stunting. Being female was associated with about 50% reduced risk of stunting and underweight. In conclusion, more robust studies are needed to substantiate these findings, with more awareness creation on the consequences of LBW and prematurity on the physical growth of infants from resource-limited settings.

Background. With the onset of the COVID-19 pandemic and the subsequent country-wide lockdown, South African (SA) universities were forced to quickly adapt to teaching that minimised or eliminated in-person contact. The pandemic period necessitated rapid changes to the way in which learning occurs and resulted in significant shifts in the academic environment. There is limited evidence in the literature to support e-learning in undergraduate orthopaedic training. This is the first study of its kind evaluating e-learning in orthopaedic surgery in a middle-to-low-income country.Objectives. To identify the University of Cape Town fifth-year MB ChB cohort’s attitudes towards the e-learning component of blended learning during the COVID-19 pandemic. It also aimed to investigate whether e-learning facilitates comparable levels of confidence and results among students and face-to-face methods.Methods. Multi-year cross-sectional survey analysis was completed by retrospectively analysing the students’ end-of-block evaluations and end-of-block marks. Responses from the cohorts between 2016 and 2020 were compared.Results. Regarding course definition, workload, course organisation, intended preparation and course presentation, the 2020 cohort’s responses were similar to those of previous years. The 2020 cohort agreed that the e-learning material was relevant; this response was higher than in previous years. They also agreed that the online practical sessions were useful and that the course stimulated more interest. Significantly, they also strongly agreed that the online course was easier to attend and participate in than in previous years. The 2020 cohort perceived the end-of-block assessment to be somewhat unreasonable; however, this cohort yielded similar grades compared with previous cohorts. Subjectively, the students’ responses to e-learning were positive, as many of them welcomed the usefulness and stimulation of online media as a study tool. Students felt that more time should be made available to work through online material and that there was incongruity between the content taught and the content of the end-of-block assessments.Conclusion. Subjectively, the students’ responses to e-learning were positive, as many of them welcomed the usefulness and stimulation of online media. With comparable outcomes in terms of student confidence and final marks (compared with traditional teaching only), it further encouraged a move towards formulating a novel blended learning curriculum. With these positive findings, we were able to explore the possibilities of developing an e-learning course curriculum incorporating international blended learning practices, using locally sourced SA evidence-based literature to provide orthopaedic teaching relevant to our unique setting.

Abstract To ensure satisfactory clinical outcomes, surgical skill assessment must be objective, time-efficient, and preferentially automated—none of which is currently achievable. Video-based assessment (VBA) is being deployed in intraoperative and simulation settings to evaluate technical skill execution. However, VBA is manual, time-intensive, and prone to subjective interpretation and poor inter-rater reliability. Herein, we propose a deep learning (DL) model that can automatically and objectively provide a high-stakes summative assessment of surgical skill execution based on video feeds and low-stakes formative assessment to guide surgical skill acquisition. Formative assessment is generated using heatmaps of visual features that correlate with surgical performance. Hence, the DL model paves the way for the quantitative and reproducible evaluation of surgical tasks from videos with the potential for broad dissemination in surgical training, certification, and credentialing.

Background: This study aims to investigate whether initiating a cross-hospital bed management system makes a difference in the number of admissions and bed occupancy rates at a selected hospital and how, if at all, the average length of stay is reduced in specific hospital departments. Methods: The study included all sequentially hospitalized patients between June 1, 2016, and June 30, 2019. Results: The total number of patients who were admitted to a referred medical complex between June 2016 and July 2019 was 20,749. The inpatient days after the initiative show a statistically significant increase compared to inpatient days before the initiative (137,630 vs. 72,930 days, respectively). Additionally, bed occupancy rates (BOR) after the initiative had a significant increase compared to BOR beforehand (50.5% vs. 26.6%, respectively). Following the bed management program, bed turnover rates (BTR) had doubled relative to BTR before (27.7% vs. 13.8%, respectively). Inpatients were more likely to be admitted in medical wards for treatment (n = 11,976, 57.8%). The most common reasons for admissions to the medical wards of a referred medical complex were internal medicine diseases (n = 6,472), followed by diseases of the cardiovascular system (n = 3,096). However, comparing the average length of stay before and after the initiative found no difference. Conclusion: This study's findings suggest that the number of patients admitted to the hospital were far greater after the bed management initiative began than before it was implemented. Additionally, the increase in BOR and BTR was significant after the initiative was implemented. In contrast, even though the overall length of stay has not changed significantly since the bed management initiative began, when departments are considered separately, a statistically significant reduction in length of stay was only seen in surgical wards since the initiative began. [SJEMed 2022; 3(2.000): 113-119]

Introduction Titrated application of positive end-expiratory pressure (PEEP) is an important part of any mechanical ventilation strategy. However, the method by which the optimal PEEP is determined and titrated varies widely. Methods for determining optimal PEEP have been assessed using a variety of different study designs and patient populations. We will conduct a scoping review to systematically identify all methods for determining optimal PEEP, and to identify the patient populations, outcomes measured and study designs used for each method. The goal will be to identify gaps in the optimal PEEP literature and identify areas where there may be an opportunity to further systematically synthesise and meta-analyse existing literature.Methods and analysis Using scoping review methodology, we will generate a comprehensive search strategy based on inclusion and exclusion criteria generated using the population, concept, context framework. Five different databases will be searched (MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus). Three investigators will independently screen titles and abstracts, and two investigators will independently complete full-text review and data extraction. Included citations will be categorised in terms of PEEP method, study design, patient population and outcomes measured. The methods for PEEP titration will be described in detail, including strengths and limitations.Ethics and dissemination Given this is a synthesis of existing literature, ethics approval is not required. The results will be disseminated to stakeholders via presentation at local, regional and national levels, as well as publication in a high-impact critical care journal. There is also the potential to impact local clinical care protocols and inform broader clinical practice guidelines undertaken by societies.

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 1ndicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Summary: Background: Arterial stiffening is central to the vascular ageing process and a powerful predictor and cause of diverse vascular pathologies and mortality. We investigated age and sex trajectories, regional differences, and global reference values of arterial stiffness as assessed by pulse wave velocity (PWV). Methods: Measurements of brachial-ankle or carotid-femoral PWV (baPWV or cfPWV) in generally healthy participants published in three electronic databases between database inception and August 24th, 2020 were included, either as individual participant-level or summary data received from collaborators (n = 248,196) or by extraction from published reports (n = 274,629). Quality was appraised using the Joanna Briggs Instrument. Variation in PWV was estimated using mixed-effects meta-regression and Generalized Additive Models for Location, Scale, and Shape. Findings: The search yielded 8920 studies, and 167 studies with 509,743 participants from 34 countries were included. PWV depended on age, sex, and country. Global age-standardised means were 12.5 m/s (95% confidence interval: 12.1–12.8 m/s) for baPWV and 7.45 m/s (95% CI: 7.11–7.79 m/s) for cfPWV. Males had higher global levels than females of 0.77 m/s for baPWV (95% CI: 0.75–0.78 m/s) and 0.35 m/s for cfPWV (95% CI: 0.33–0.37 m/s), but sex differences in baPWV diminished with advancing age. Compared to Europe, baPWV was substantially higher in the Asian region (+1.83 m/s, P = 0.0014), whereas cfPWV was higher in the African region (+0.41 m/s, P

Abstract Immunoproteasomes (IP) serve as an important modulator of immune responses to pathogens and other pathological factors. LMP7/β5i, one of the IP subunits, plays a critical role in autoimmune diseases by downregulating inflammation. Rhinovirus (RV) infection is a major risk factor in the exacerbations of respiratory inflammatory diseases, but whether LMP7 regulates RV-mediated inflammation in the lung particularly in the airway epithelium, the first line of defense against RV infection, remains unclear. In this study, we determined whether airway epithelial LMP7 promotes the resolution of RV-mediated lung inflammation. Inducible airway epithelial-specific LMP7-deficient (conditional knockout, CKO) mice were generated to reveal the in vivo anti-inflammatory and antiviral functions of LMP7. By using LMP7-deficient primary human airway epithelial cells generated by CRISPR-Cas9, we confirmed that airway epithelial LMP7 decreased pro-inflammatory cytokines and viral load during RV infection. Additionally, airway epithelial LMP7 enhanced the expression of a negative immune regulator A20/TNFAIP3 during viral infection that may contribute to the anti-inflammatory function of LMP7. We also discovered that induction of LMP7 by a low dose of polyinosinic:polycytidylic acid (PI:C) reduced RV-mediated inflammation in our CKO mice infected with RV. Our findings suggest that airway epithelial LMP7 has anti-inflammatory and antiviral functions that is critical to the resolution of RV-mediated lung inflammation. Induction of airway epithelial LMP7 may open a novel avenue for therapeutic intervention against RV infection.

Background Walking speed is reduced with aging. However, it is not certain whether the reduced walking speed is associated with physical and coordination fitness. This study explores the physical and coordination determinants of the walking speed decline in older women. Methods One-hundred-eighty-seven active older women (72.2 ± 6.8 years) were asked to perform a 10-m walk test (self-selected and maximal walking speed) and a battery of the Senior fitness test: lower body strength, lower body flexibility, agility/dynamic balance, and aerobic endurance. Two parameters characterized the walking performance: closeness to the modeled speed minimizing the energetic cost per unit distance (locomotor rehabilitation index, LRI), and the ratio of step length to step cadence (walk ratio, WR). For dependent variables (self-selected and maximal walking speeds), a recursive partitioning algorithm (classification and regression tree) was adopted, highlighting interactions across all the independent variables. Results Participants were aged from 60 to 88 years, and their self-selected and maximal speeds declined by 22% and 26% (p < 0.05), respectively. Similarly, all physical fitness variables worsened with aging (muscle strength: 33%; flexibility: 0 to −8 cm; balance: 22%; aerobic endurance: 12%; all p < 0.050). The predictors of maximal walking speed were only WR and balance. No meaningful predictions could be made using LRI and WR as dependent variables. Discussion The results suggest that at self-selected speed, the decrease in speed itself is sufficient to compensate for the age-related decline in the motor functions tested; by contrast, lowering the WR is required at maximal speed, presumably to prevent imbalance. Therefore, any excessive lowering of LRI and WR indicates loss of homeostasis of walking mechanics and invites diagnostic investigation.

Abstract Porcine skin is considered a de facto surrogate for human skin. However, this study shows that the mechanical characteristics of full thickness burned human skin are different from those of porcine skin. The study relies on five mechanical properties obtained from uniaxial tensile tests at loading rates relevant to surgery: two parameters of the Veronda-Westmann hyperelastic material model, ultimate tensile stress, ultimate tensile strain, and toughness of the skin samples. Univariate statistical analyses show that human and porcine skin properties are dissimilar (p

Aims. Salivary gland tumors (SGTs) are a rare and diverse group of tumors that account for 3 to 10% of all head and neck malignancies. We aimed to conduct a comprehensive epidemiological analysis of SGTs in the south of Iran and compare the findings with previous reports from Iran and other parts of the world. Methods. Using a retrospective study, 405 patients diagnosed with SGTs were observed over an eight-year period between April 2013 and October 2021 in Shiraz, Iran. Patients’ demographic and clinicopathological features were obtained from patients’ records. Quantitative and descriptive data analysis was performed using SPSS software. Results. There were 302 benign (74.5%) and 103 (25.4%) malignant SGTs. Pleomorphic adenoma and Warthin’s tumors were the most common benign SGTs (70.5% and 21.5%, respectively). The most common malignant SGTs were mucoepidermoid carcinoma and adenoid cystic carcinoma (26.2% and 22.3%, respectively). There was a statistically significant association between tumor origin and its malignancy status (p

Classic homocystinuria is an inborn error of metabolism caused mainly by missense mutations leading to misfolded and/or unstable human cystathionine β-synthase (CBS) protein, causing the accumulation of excess total homocysteine (tHcy) in tissues. Previously, it has been shown that certain missense containing human CBS proteins can be functionally rescued in mouse models of CBS deficiency by treatment with proteasome inhibitors. The rescue by proteasome inhibitors is thought to work both by inhibiting the degradation of misfolded CBS protein and by inducing the levels of heat-shock chaperone proteins in the liver. Here we examine the effectiveness of two FDA approved protease inhibitors, carfilzomib and bortezomib, on various transgenic mouse models of human CBS deficiency. Our results show that although both drugs are effective in inducing the liver chaperone proteins Hsp70 and Hsp27, and are effective in inhibiting proteasome function, bortezomib was somewhat more robust in restoring the mutant CBS function. Moreover, there was no significant correlation between proteasome inhibition and CBS activity, suggesting that some of bortezomib's effects are via other mechanisms. We also test the use of low-doses of bortezomib and carfilzomib on various mouse models for extended periods of time and find that while low-doses are less toxic, they are also less effective at restoring CBS function. Overall, these results show that while restoration of mutant CBS function is possible with proteasome inhibitors, the exact mechanism is complicated and it will likely be too toxic for long-term patient treatment.

The present study aimed to determine the effect of whole meat GSM powder on gut microbiota abundance, body composition and iron status markers in healthy overweight or obese postmenopausal women. This was a 3-months trial involving forty-nine healthy postmenopausal women with body mass index (BMI) between 25 and 35 kg/m2 who were randomly assigned to receive 3 g/d of either GSM powder (n 25) or placebo (n 24). The gut microbe abundance, serum iron status markers and body composition were measured at the baseline and the end of the study. The between-group comparison at the baseline showed a lower abundance of Bacteroides and Clostridium XIVa in the GSM group compared with the placebo (P = 0⋅04). At the baseline, the body fat (BF)% and gynoid fat% were higher in the GSM group compared with the placebo (P < 0⋅05). No significant changes were found in any of the outcome measures, except for ferritin levels that showed a significant reduction over time (time effect P = 0⋅01). Some trend was observed in bacteria including Bacteroides and Bifidobacterium which tended to increase in the GSM group while their abundance decreased or remained at their baseline level in the control group. Supplementation with GSM powder did not result in any significant changes in gut microbe abundance, body composition and iron markers compared with placebo. However, some commensal bacteria such as Bacteroides and Bifidobacteria tended to increase following supplementation with GSM powder. Overall, these findings can expand the knowledge surrounding the effects of whole GSM powder on these outcome measures in healthy postmenopausal women.

Studies show that maternal behaviors are mediated by the bivariate serotonin transporter (5-HTT) genotype, although the findings are mixed, with some studies showing that mothers with the s allele exhibit increased maternal sensitivity, while other studies show that mothers with the s allele show decreased maternal sensitivity. Nonhuman primate studies offer increased control over extraneous variables and may contribute to a better understanding of the effects of the 5-HTT genotype on maternal sensitivity. This study assesses the influence of 5-HTT genotype variation on maternal sensitivity in parenting in 125 rhesus macaque mothers (Macaca mulatta) during the first three-months of their infants' lives, an age well before typical infants undergo weaning. Mothers were genotyped for the 5-HTT genotype and maternal behaviors were collected, including neglectfulness, sensitivity, and premature rejections during undisturbed social interactions. Results showed that mothers homozygous for the s allele rejected their infants the most and restrained their infants the least, an indication that mothers with the s allele are more likely to neglect their infants' psychological and physical needs. These findings suggest that, at an age when an infant's needs are based on warmth, security, and protection, mothers with an s allele exhibit less sensitive maternal behaviors. High rates of rejections and low rates of restraints are behaviors that typically characterize premature weaning and are inappropriate for their infant's young age. This study is an important step in understanding the etiology of variability in maternal warmth and care, and further suggests that maternal 5-HTT genotype should be examined in studies assessing genetic influences on variation in maternal sensitivity, and ultimately, mother-infant attachment quality.

BackgroundAdvance care planning (ACP) is influenced by several factors (e.g., patient's readiness to engage, clinician's skills, and the cultural environment). Availability of reliable and valid self-reported measures of the ACP domains is crucial, including cross-cultural equivalence.AimTo culturally adapt into Italian the 19-item Quality of Communication (QOC) and the 4-item ACP Engagement (4-item ACP-E) questionnaires.MethodsWe translated and culturally adapted the two questionnaires and produced a significant other (SO) version of the QOC (QOC-SO). Each questionnaire was field tested via cognitive interviews with users: nine patients (QOC, 4-item ACP-E) and three SOs (QOC-SO) enrolled at three palliative care services.ResultsWe made minor changes to 5/19 QOC items, to improve clarity and internal consistency; we changed the response option 'didn't do' into 'not applicable'. Finally, we slightly revised the QOC to adapt it to the paper/electronic format. QOC debriefing revealed that the section on end of life was emotionally challenging for both patients and SOs. We simplified the 4-item ACP-E layout, added a sentence in the introduction, and revised the wording of one item, to improve coherence with the Italian ACP legislation. ACP-E debriefing did not reveal any major issue.ConclusionsResults were satisfactory in terms of semantic, conceptual and normative equivalence of both questionnaires. Acceptability was satisfactory for the 4-item ACP-E, while findings of the QOC cognitive debriefing informed a major amendment of a pilot trial protocol on ACP in multiple sclerosis (ConCure-SM): use of the interviewer version only, in an adaptive form. Psychometric testing of both questionnaires on a large, independent sample will follow.

This systematic review and meta-analysis aimed to examine more recent data to determine the extent of lingual nerve injury (LNI) following the surgical extraction of mandibular third molars (M3M). A systematic search of three databases [PubMed, Web of Science and OVID] was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria encompassed studies on patients who underwent surgical M3M extraction using the buccal approach without lingual flap retraction (BA-), buccal approach with lingual flap retraction (BA+), and lingual split technique (LS). The outcome measures expressed in LNI count were converted to risk ratios (RR). Twenty-seven studies were included in the systematic review, nine were eligible for meta-analysis. Combined RR for LNI (BA+ versus BA-) was 4.80 [95% Confidence Interval:3.28-7.02; P

Background: Community-based primary health care (PHC) forms the foundation of healthcare in South Africa. Medical programmes need to equip future health practitioners to face the challenges of the rising burden of chronic diseases of lifestyle (CDL) in different communities. Community-based education (CBE) contributes to developing knowledge, skills and attitudes appropriate to the challenges experienced in the PHC context. Aim: To explore medical students’ perceptions of the current CDL curriculum and related programmes during CBE rotations. Setting: The study was conducted among fourth- and fifth-year medical students at the University of the Free State, South Africa. Methods: Focus group discussions were conducted and data were analysed thematically. Results: Themes included perceptions of the CDL curriculum, relevance thereof for the PHC setting and barriers and challenges to implementing PHC programmes. This study identified foundational CDL content that needs to be incorporated or revisited at strategic points. Participants identified the need to contextualise educational programmes and focus on affordable, culturally acceptable and holistic healthcare prevention strategies. Barriers and challenges included high patient load, resource constraints, the lack of continuous care and focus on communicable diseases. Community-based education rotations were described as meaningful opportunities to develop professional attributes, competencies and skills. Conclusion: This study identified foundational concepts to consider at key points throughout the curriculum. Incorporating creative and reflective learning activities in CDL modules can prepare students for the realities of PHC settings. Contribution: This study provides insight into medical students’ perceptions of the CDL curriculum and informs future curriculum content for CDL modules.