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Background: In 2021, South Africa introduced a new 6-month internship in family medicine and primary care. This study aimed to assess the new rotation at district health facilities in the Western Cape. Methods: A descriptive survey of interns and supervisors, as phase-two of an exploratory sequential mixed methods study. Questionnaires were developed from a descriptive exploratory qualitative study. Data were analysed with the Statistical Package for Social Sciences. Results: Questionnaires were completed by 72 interns (response rate 21%) and 36 supervisors (response rate 90%), across 10 training programmes. Interns felt more independent (97.2%), confident (90.3%) and resilient (91.6%). They learnt to manage undifferentiated and chronic conditions (91.6%), to refer patients (94.3%) and conduct procedures (77.8%). Most interns were not exposed to community-based services (68.0%) and continuity of care (54.1%). Supervision was mostly adequate during the day (79.1%) and afterhours (80.6%). Many interns reported no structured teaching programme (41.7% – 55.6%). Most supervision was from medical officers and registrars. Supervisors saw interns as valuable members of the clinical team (100.0%), who required extra support and administration (42.5%). The majority of interns (75.0%) and supervisors (72.7%) thought the rotation was the right length and the best preparation for community service (67.6%). Conclusion: The rotation met most expectations of the Health Professions Council of South Africa. Programmes need to improve exposure to community-orientated primary care, public health medicine, palliative and ongoing care. Supervision and orientation of interns needs improvement. Contribution: This is the first evaluation of the new family medicine internship programme in South Africa.

Background: Learning portfolios (LPs) provide evidence of workplace-based assessments (WPBAs) in clinical settings. The educational impact of LPs has been explored in high-income countries, but the use of portfolios and the types of assessments used for and of learning have not been adequately researched in sub-Saharan Africa. This study investigated the evidence of learning in registrars’ LPs and the influence of the training district and year of training on assessments. Methods: A cross-sectional study evaluated 18 Family Medicine registrars’ portfolios from study years 1–3 across five decentralised training sites affiliated with the University of the Witwatersrand. Descriptive statistics were calculated for the portfolio and quarterly assessment (QA) scores and self-reported clinical skills competence levels. The competence levels obtained from the portfolios and university records served as proxy measures for registrars’ knowledge and skills. Results: The total LP median scores ranged from 59.9 to 81.0, and QAs median scores from 61.4 to 67.3 across training years. The total LP median scores ranged from 62.1 to 83.5 and 62.0 to 67.5, respectively in QAs across training districts. Registrars’ competence levels across skill sets did not meet the required standards. Higher skills competence levels were reported in the women’s health, child health, emergency care, clinical administration and teaching and learning domains. Conclusion: The training district and training year influence workplace-based assessment (WPBA) effectiveness. Ongoing faculty development and registrar support are essential for WPBA. Contribution: This study contributes to the ongoing discussion of how to utilise WPBA in resource-constrained sub-Saharan settings.

Healthcare practitioners are regularly faced with treating patients at the end of their life, and this can be very daunting. This article hopes to help the practitioner have an approach to managing end-of-life care that makes it less distressing. The symptoms at the end-of-life include delirium and/or agitation, breathing changes, skin changes, sleeping more, decrease in need for food and drink, incontinence, and increased secretions. These symptoms are discussed and practical ways of management are given. The article further discusses how to approach the difficult conversation with the family and gives guidance as to what needs to be discussed. A number of tips are discussed on how to prepare the family to handle a death at home. It is essential to look at coping mechanisms and selfcare for practitioners dealing with end-of-life care as the death of a patient not only affects the family but also the practitioner.

Background: Palliative care (PC) is a priority in South Africa, focussing on integrating PC into primary health care. Few examples exist showing how this is done. In 2018, a rural PC project was implemented, which subsequently evolved into an integrated service between the hospital and the community. Aim: The aim was to review the PC project over 4 years. Setting: The setting was the George subdistrict of the Garden Route district in South Africa. Community-based services were offered to all patients with PC needs by three non-governmental organisations who deliver home community-based care via community health workers. They were supplemented by primary health care clinics, an intermediate care facility and two hospitals. Methods: This was a retrospective descriptive study. Inpatient ward round data and patient referrals between 2018 and 2022 were analysed using descriptive statistics. Variables included patient demographics, diagnosis, home visits and place of death. Results: A total of 819 patients were referred. Inpatients were reviewed on weekly ward rounds by a multidisciplinary team. The most common diagnosis was cancer (57%). Home visits enabled patient follow-ups, of which 152 were recorded. Conclusion: The programme has become sustainable and integrated in the public healthcare system. Contributing factors included dedicated staff, using simple tools and continuous training. The findings may be useful to PC programmes in similar contexts elsewhere. Contribution: This work adds new knowledge to the field of PC in an underresourced rural healthcare environment in sub-Saharan Africa, by describing how system-wide integration of a new service was navigated to become sustainable.

Background: Workplace-based learning (WBL) provides authentic learning opportunities to develop fit-for-practice healthcare workers. Different types of WBL opportunities have been described in high-income countries, but the opportunities in the district health systems of sub-Saharan Africa have not been characterised. Aim: This study explored family physicians’ (FPs) and registrars’ perceptions of WBL opportunities in a decentralised postgraduate family medicine registrar training programme. Setting: The study was conducted at five decentralised training sites across two provinces affiliated with the University of the Witwatersrand in South Africa. Methods: This instrumental case study involved semi-structured qualitative interviews with 11 FPs and 11 registrars purposively sampled across the training sites. The verbatim transcripts were thematically analysed using Braun and Clark’s six-step approach. Results: Workplace-based learning opportunities were grouped into four themes: Learning from interpersonal interactions, learning from district activities, self-directed learning and contextual influences on learning opportunities. Registrars learnt from patients, peers, FPs and other professionals. Feedback, self-reflection, portfolio use, involvement in various district events, such as student and staff teaching, and continuous medical education augmented learning. Contextual influences originated from health facilities, resource availability, district management and university support, excessive workload and a need for standardised district learning opportunities. Conclusion: Registrars are exposed to several types of WBL opportunities in district health systems. Effective engagement with available opportunities and addressing contextual challenges could enhance registrar learning. Contribution: Maximising learning opportunities to promote registrars’ acquisition of required skills and competencies to efficiently address community needs in a middle-income country such as South Africa.

Background: Family planning (FP) is a key component of primary health care (PHC). Nurses are the first source of FP information to women outside their social context. There is a paucity of research regarding clients’ lived experiences of FP, particularly understanding both the client’s and the healthcare worker’s experiences in the same clinical context and community. Aim: This study aims to explore the lived experiences of nurses and female clients regarding FP services at PHC clinics. Setting: Two PHC clinics in a rural sub-district in South Africa. Methods: A descriptive qualitative study using semi-structured interviews was conducted. Clients and nurses were selected using criterion-based purposive sampling and interviewed by female research assistants in a home language in a private setting. Transcription and translation of audio recordings were done. Data were analysed inductively using the framework method. Results: Ten clients and eight nurses were interviewed, with an equal number from each clinic. The median age of clients was 28.5 years and of nurses was 47.5 years. Four themes emerged: (1) Stigma, culture and the teenage girl; (2) Bad effects – the Big Five, clustered around weight changes, blood blockages and abnormal bleeding, pain, fertility and cancer; (3) FP social dynamics; and (4) FP and the health system. Conclusion: Family planning is highly moralised and stigmatised. Negative effects of FP were not adequately recognised by the health system. Family planning outreach into the community and dedicated FP resources at clinics were suggestions to improve the service. Contribution: This work helps to better understand patients’ experiences of family planning services.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges. Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Background: A major disparity exists in access to specialised healthcare between rural and urban areas. Specialist outreach programmes are one of the ways in which rural specialist healthcare inequality is being addressed. A number of rural district hospitals (RDH) employ local, private specialists (LPS) to supplement public specialist outreach. Limited research exists on private specialist outreach and support (PSOS) in sub-Saharan Africa or South Africa. Methods: This was a descriptive, exploratory, qualitative study using thematic analysis of semi-structured interviews. Non-probability, purposive sampling was used to obtain a sample size of 16 participants. The audio recordings were transcribed verbatim and analysed with the framework method and ATLAS.ti version 8© software. Results: Four major themes emerged, namely roles of LPS, effects, sustainability and feasibility of PSOS. Overall PSOS was considered sustainable, feasible and had positive effects in and beyond the sub-districts. The value of PSOS was supported by improved access and timeliness of services, improved competency of RDH medical practitioners, improved coordination, comprehensiveness and continuity of care. Private specialist outreach and support was, however, associated with increased burden on the RDH resources and required a basic level of RDH infrastructure to function effectively. Conclusion: The perceived contribution of private specialist outreach services was positive overall. Implementation in RDHs is feasible, but should involve consideration of factors in the hospital, town, sub-district and district prior to implementation. Contribution: This paper provides evidence that private specialist outreach and support services are feasible in the state health sector, provided that certain considerations are taken into account.

Background: Clinical training is one of the roles of family physicians (FPs) in decentralised postgraduate training. Effective training requires skilled trainers and sufficient resources. Little is known about the resources available for decentralised clinical training in district health systems in low- to middle-income countries, especially in sub-Saharan Africa. Aim: To explore FPs’ and registrars’ perceptions of the available resources in a decentralised postgraduate family medicine (FM) training programme. Setting: Five decentralised training sites affiliated with the University of the Witwatersrand across two provinces in South Africa. Methods: This qualitative study forms part of a broader project evaluating a FM registrar training programme using the logic model. Semistructured interviews were conducted with a purposive sample of 11 FPs and 11 registrars. The interviews were transcribed verbatim and analysed thematically. Results: Three themes were identified: ‘Impact of resource constraints’, ‘Family physicians’ skills and knowledge could be further improved’ and ‘Family physicians need additional support to optimise their training role’. The additional resources needed include more FPs, equipment, infrastructure and funding. Knowledge and skills of FPs were reported variable and needed further improvement. Additional support was required from peers, the district management and the university. Conclusion: Well-resourced decentralised training environments with sufficient skilled trainers and adequate resources are needed to positively influence FP training and supervision, especially in middle-income countries like South Africa. Contribution: Clinical trainers need adequate resources and support from peers, district management and the university for effective decentralised clinical training.

Background: Postgraduate supervision forms a vital component of decentralised family medicine training. While the components of effective supervisory feedback have been explored in high-income countries, how this construct is delivered in resource-constrained low- to middle-income countries has not been investigated adequately. Aim: This article evaluated supervisory feedback in family medicine registrars’ learning portfolios (LPs) as captured in their learning plans and mini-Clinical Evaluation Exercise (mini-CEX) forms and whether the training district or the year of training affected the nature of the feedback. Setting: Registrars’ LPs from 2020 across five decentralised sites affiliated with the University of the Witwatersrand in South Africa were analysed. Methods: Two modified tools were used to evaluate the quantity of the written feedback in 38 learning plans and 57 mini-CEX forms. Descriptive statistics, Fisher’s exact and Wilcoxon rank-sum tests were used for analysis. Content analysis was used to derive counts of areas of feedback. Results: Most learning plans (61.2%) did not refer to registrars’ clinical knowledge or offer an improvement strategy (86.1%). The ‘extent of supervisors’ feedback’ was rated as ‘poor’ (63.2%), with only 14.0% rated as ‘good.’ The ‘some’ and ‘no’ feedback categories in the mini-CEX competencies (p 0.001 to p = 0.014) and the ‘extent of supervisors’ feedback’ (p 0.001) were significantly associated with training district. Feedback focused less on clinical reasoning and negotiation skills. Conclusion: Supervisors should provide specific and constructive narrative feedback and an action plan to improve registrars’ future performance. Contribution: Supervisory feedback in postgraduate family medicine training needs overall improvement to develop skilled family physicians.

Background: Effective palliative care is an urgent humanitarian need, particularly in less developed countries, including South Africa (SA). People can be palliated within their communities, motivating the integration of palliative care into primary healthcare systems. While community health workers (CHWs) play a vital role in health coverage at the primary care level, literature on their roles in palliation is limited. Aim: To explore the roles of CHWs in palliative care delivery in a rural subdistrict in SA. Setting: This study was conducted in the George subdistrict of the Western Cape province, SA. Methods: A descriptive qualitative study explored the perceptions of a wide range of stakeholders (n = 39) of CHWs’ roles in palliative care. Data were collected via semistructured interviews and focus group discussions and analysed thematically. Results: Patients experienced severe biopsychosocial symptoms and needed home-based palliation. While CHWs identified and referred patients, their main responsibilities were health promotion and disease prevention. Palliation was primarily a registered nurse’s function. Community health workers were conflicted by their limited ability to deliver basic palliative care to patients. Conclusion: While there is a definite need for community-based palliative care, the optimal structure of such a service and the roles of CHWs therein are uncertain. Future research should explore the home-based palliation needs of patients in similar contexts and the service design best suited to address these needs within the primary healthcare domain. Contribution: This study illustrates the influence of individual and system-related factors on CHWs’ roles in palliative care. It can inform service design to optimise CHWs’ contribution to palliation within primary health care.

Background: Specialist training in family medicine (FM) is growing rapidly in sub-Saharan Africa. The strong emphasis on workplace-based learning for speciality training makes it vital to gain in-depth insights into registrar supervision. Previous studies have explored aspects of supervision at decentralised sites in high-income countries, however, little is known about the benefits and constraints of decentralised postgraduate supervision in low- to middle-income countries, especially in Africa. Aim: This study aimed to explore family physicians’ and registrars’ perceptions of the strengths and challenges of clinical and educational supervision across decentralised training sites. Setting: The study was conducted across two provinces at five decentralised training sites affiliated with the University of the Witwatersrand, Johannesburg. Methods: This qualitative study involved semi-structured interviews with a purposive sample of 11 FPs and 11 registrars. The data were thematically analysed. Results: Two of the four themes identified, ‘supervision is context-specific and supervisor-dependent’, and ‘the nature of engagement matters’, involved strengths and challenges. The other two, ‘supervision is not ideal’ and ‘the training environment is challenging’, focussed on challenges. Conclusion: Supervisors and registrars described the postgraduate FM supervision as context-specific and supervisor-dependent. Supervisors displayed good clinical-teacher characteristics and supervisory relationships. However, several challenges, including registrars’ workload, resource shortages and a lack of standardisation across training sites, need to be addressed. Regular faculty development is essential for supervisors to be aware of relevant aspects of, and current trends in, postgraduate training.

South Africa recently experienced the third wave of the coronavirus disease 2019 (COVID-19)pandemic. Social media is flooded with polarised conversations, with opinions for and against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. Many people are hesitant, and some are strongly opposed to vaccination. Vaccine hesitancy must be understood in historical, political and socio-cultural contexts. The aim of this study was to offer a values-driven approach to vaccine hesitancy conversations. It focusses on ethical dilemmas forthcoming from values violations, interrogating the personal and institutional scripts and rationalisations that prevent resolution, and offering ways of re-scripting these. Values-driven conversations provide safe spaces for vaccine-hesitant individuals to voice their reservations. The manner in which conversations are conducted is as important as the contents being discussed. Healthcare professionals are trusted by the public and should use ways of conversing that do not erode this trust. Creating respectful, compassionate platforms of engagement and incentivising vaccination are important measures for change in vaccine perspectives.

Healthcare systems are complex adaptive systems, requiring a change in leadership style, from the traditional model to collaborative, values-driven leadership (VDL). Family physicians are well positioned to facilitate integration and coordination between levels of care, across specialties and within teams, in partnership with local and district management team members. This short report describes a leadership innovation experience in a rural South African district, where a VDL course was introduced in a district health context to build on a strong tradition of relationship-centred outreach and support aimed at creating a learning health system. The authors reflect on the contribution of family physicians to strengthen team-based capacity building, care coordination and a learning culture aimed at quality improvement from the perspectives of the regional and district hospital environments. A values-based leadership style will enable family physicians to strengthen team-relationships and create organisational environments, which support shared learning and quality improvement approaches. Ultimately this approach should lead to improved health systems.

The South African family physician (FP) is an expert generalist who has a number of roles to strengthen the district health system. A research study on FPs in district hospitals has previously demonstrated an impact; however, more evidence on impact in primary health care (PHC) is needed. By serving as a consultant for the PHC team, the FP may improve access to care, capacitate team members, enhance comprehensiveness of care, and improve coordination and continuity of care. This report narrates the story of how one of the FPs at a rural district hospital recorded his experience of being a consultant to the PHC team and was able to self-audit the experience. A self-designed audit tool analysed 1000 patient consultations with the FP and enabled a reflection on the coronavirus disease 2019 (COVID-19)-related changes to the consultant role. There was a clear need for FPs to consult patients with complex multi-morbidity and multifaceted psychosocial aspects to their illness, in consultation with their team members. Patients were referred to them by medical officers, other specialists, family medicine registrars, allied healthcare professionals and nurse practitioners. The FP’s ability to strengthen the PHC service outside the district hospital may be enhanced by creating more FP posts at a subdistrict level to support high-quality, team-based primary care in line with the PHC policy directions.

Background: The coronavirus disease 2019 (COVID-19) pandemic hit South Africa in March 2020, severely disrupting health services and health education. This fundamentally impacted the training of future health professionals and catalysed a significant response from across the health education sector. In 2020, the South African Association of Health Educationalists requested members to submit reflections on different aspects of their COVID-19 related educational responses. Responding to the pandemic: Seven vignettes focused specifically on clinical training in the context of primary care and family medicine. This short report highlights the key insights that emerged from these vignettes, considering what has been learnt in terms of health professions education and what we need to take forward. These insights include building on what was already in place, the student role, technology in the clinical learning context, taking workshops online, vulnerability and presence and the way going forward. Discussion and conclusion: The contributions emphasised the value of existing relationships between the health services and training institutions, collaboration and transparent communication between stakeholders when navigating a crisis, responsiveness to the changed platform and dynamic environment and aligning teaching with healthcare needs. It is more important than ever to set explicit goals, have clarity of purpose when designing learning opportunities and to provide support to students. Some of these learning points may be appropriate for similar contexts in Africa. How we inculcate what we have learned into the post-pandemic period will bear testimony to the extent to which this crisis has enabled us to re-imagine health professions education.

Abstract Background In South Africa it is compulsory to submit a satisfactory portfolio of learning to gain entrance to the national exit examination of the College of Family Physicians and to qualify as a family physician. A paper-based portfolio has been implemented thus far and the need for an electronic portfolio (e-portfolio) was identified. The aim of the study was to describe and evaluate the implementation of an e-portfolio for the training of family medicine registrars in the Western Cape province of South Africa. Methods Mixed methods were used. A quasi-experimental study evaluated paper- and e-portfolios from the same 28 registrars in 2015 compared to 2016. Semi-structured interviews were conducted with 11 registrars or supervisors to explore their experiences of using the e-portfolio. Quantitative data was analysed in the Statistical Package for Social Sciences and qualitative data in Atlas.ti. Results Most respondents found the e-portfolio easier to use and more accessible. It made progress easier to monitor and provided sufficient evidence of learning. Feedback was made easier and more explicit. There were concerns regarding face-to-face feedback being negatively affected. It was suggested to have a feedback template to further improve feedback. Several aspects were significantly better in the e-portfolio such as feedback on the registrar’s general behaviour, alignment with learning outcomes, less feedback based on hearsay and acknowledgement of the feedback by the registrar. Although not statistically significant, there was an increase in the usage of the e-portfolio, compared to the paper portfolio. Conclusion In general, the e-portfolio is an improvement on the paper-based portfolio. It is easier to access, more user-friendly and less cumbersome. It makes feedback and monitoring of progress and development of registrars easier and more visible and provides sufficient evidence of learning. Its implementation throughout South Africa is recommended.

Background: South African doctors work up to 60 h per week to ensure 24-h service delivery. Many doctors are physically and emotionally exhausted, neglecting families, self-care, patient empathy and innovative thinking about complex health issues. Exposure to clinical work hours demonstrated a dose effect with burnout, suggesting cause and effect, affecting up to 80% of doctors. To retain good doctors, their complex needs must be recognised and allowances made for flexible work options. Taking a risk: George Hospital, a large regional training hospital in a rural district, converted some full-time medical officer posts to part-time posts. This was in response to doctors’ requests for more flexible work options, often after returning from maternity leave or in response to burnout. Perceived risks revolved around institutional resource security and that part-time post vacancies would be difficult to fill. Reaping the benefits: Employing doctors in part-time posts has created stability and continuity in the health team. The hospital had generated a cohort of young professionals who care with empathy and have emotional resilience to train others and plough their skills back into the healthcare service. Conclusion: Reducing working hours and creating flexible options were concrete ways of promoting resilience and retaining competent doctors. We recommend that training and work of doctors be structured towards more favourable options to encourage retention, which may lead to better patient care.

The coronavirus disease 2019 (COVID-19) pandemic has spread throughout the world, with devastating effects of the virus as well as the repercussions of the resulting ‘lockdowns’. South Africa went into a national lockdown in March 2020 to mitigate the impact of the virus. This included a ban on the sales of tobacco and electronic cigarette products. The ban has been a highly contentious issue in South Africa, discussed worldwide, which has drawn many criticisms. The prevalence rate of smoking in South Africa was around 21.5%, with the Western Cape province having a prevalence rate of 39%. We compared the number of chronic obstructive pulmonary disease (COPD) presentations at a large regional referral hospital in the Western Cape province from January to August 2019 with the same period in 2020. Electronic emergency centre data showed a reduction of 69.28% in COPD presentations. To control for some confounders for the same period, we also reviewed patients presenting with urinary tract infections, which showed only a 30.60% reduction. This notable reduction in COPD presentations reduced service pressure of emergency centre and most likely benefitted patients’ health. Further research and policies are needed to ensure ongoing reduction in the prevalence of smoking.

As the coronavirus disease 2019 (Covid-19) pandemic evolves globally, we are realising its impact on communities from the disease itself and the measures being taken to limit infection spread. In South Africa (SA), 62 300 adults die annually from alcohol-attributable causes. Alcohol-related harm can be reduced by interventions, such as taxation, government monopolising retail sales, outlet density restriction, hours of sales and an advertising ban. To mitigate the impact of the Covid-19 pandemic, SA instituted a lockdown that also prohibited alcohol sales. This led to a sharp reduction in unnatural deaths in the country from 800–1000/week to around 400/week during the lockdown. We reviewed three 2-week periods at a large rural regional hospital: Before Covid-19 (February), during social distancing (March) and during lockdown with alcohol ban (April). A dramatic drop in patient numbers from 145 to 64 (55.8%) because of assault, from 207 to 83 (59.9%) because of accidents, from 463 to 188 (59.4%) because of other injuries and from 12 to 1 (91.6%) because of sexual assaults was observed during the first 2 weeks of lockdown. As healthcare professionals, we need to advocate for the ban to remain until the crisis is over to ensure that health services can concentrate on Covid-19 and other patients. We encourage other African states to follow suit and implement alcohol restrictions as a mechanism to free up health services. We see this as an encouragement to lobby for a new normal around alcohol sales after the pandemic. The restrictions should focus on all evidence-based modalities.

Ten family physicians and family medicine registrars in a South African semi-rural training complex reflected on the coronavirus disease 2019 (COVID-19) crisis during their quarterly training complex meeting. The crisis has become the disruptor that is placing pressure on the traditional roles of the family physician. The importance of preventative and promotive care in a community-oriented approach, being a capacity builder and leading the health team as a consultant have assumed new meanings.

Background: Primary care needs research to generate evidence relevant to community needs; however, there is a lack of research engagement among primary care physicians, especially in sub-Saharan Africa. Improved research mentorship for family physicians (FPs) can help address prevailing knowledge and practice gaps in primary care research. Workshop process: During the 6th annual Africa Regional Conference of the World Organization of Family Doctors (WONCA), we conducted three workshops on research mentorship for African FPs. Two workshops (one online and one onsite at the pre-conference) were geared towards the young doctors’ movement of WONCA Africa. The third was onsite during the main conference. Following a brief presentation on the concept of research mentorship and known gaps, participants broke into small groups and discussed additional gaps, solutions and anticipated readiness for implementing these solutions. We used a content analysis to summarise key concepts and had participants to review the findings. Workshop findings: Identified gaps related to mentees’ difficulty initiating and maintaining mentorship relationships and an overall shortage of capable and willing mentors. Organisational solutions focused on capacity building and creating a culture of mentorship. Interpersonal solutions focused on reducing the power distance and increasing reflectivity and feedback. Increasing the use of research networks and both peer and online mentorship were advocated. Barriers to readiness included resource constraints and competing priorities. Conclusion: A multi-level approach is needed to address the gaps in research mentorship for African FPs. Identified solutions hold potential for supporting the research engagement needed to improve the population health across Africa.

No abstract available.

Introduction: Caring for people with life-threatening illnesses is a key part of working in health care. While South Africa launched the National Policy Framework and Strategy for Palliative Care 2017–2022, integrating palliative care into existing public health care is in its infancy. Most patients in the Western Cape have poor access to palliative care, an inequality felt hardest by those living in rural areas. Building the model: In 2018, with district wide institutional managerial support, a palliative care model for rural areas was initiated in the Western Cape. The process involved setting up hospital- and community-based multi-professional palliative care teams, initiating weekly palliative care ward rounds, training champions in palliative care and raising awareness of palliative care and its principles. Discussion: Establishing regular ward rounds has changed the way patients needing palliative care are managed, particularly in challenging the mindsets of specialist departments. The emergence of the multi-professional team listening and planning together at the patient’s bedside has restored some of the dignity and ethos of patient-centred care, which is a core principle of the provincial Health Care 2030 vision. Conclusion: In a short time period, we have managed to build a service that aims to improve care for palliative patients in rural areas. Its strength lies in a multi-professional patient-centred approach and improved communication between different components of the health system, providing a more seamless service that supports patients when they need it most.

Background: Tuberculosis (TB) is a major global health challenge, and South Africa is one of the high-burden countries. A national TB infection control (TBIC) guideline has stipulated three areas of infection control at health facilities: work practice and administrative control, environmental control, and personal protection for health workers. Aim: The aim of this study was to identify the gaps and address the challenges in institutional TBIC. Setting: The district hospital and a primary health care clinic within the Mossel Bay sub-district in the Western Cape. Methods: According to the national TBIC draft guideline, a quality improvement cycle was used to evaluate and improve TBIC. Each facility had an existing infection and prevention control and occupational health and safety team, which were used as the audit teams. Results: A baseline assessment was followed by a set of interventions, which did not show a significant improvement in TBIC. The difference between the pre- and post-intervention TB screening rate was not statistically significant. An assessment of time interval between 101 patients presenting with TB symptoms and diagnosed with TB was 4 days at baseline and post-intervention. Most of the anticipated improvements were dependent on the health workers’ adherence to the local TBIC policies, which emerged as an unexpected finding. Conclusion: We found good managerial commitment reflected by the presence of various policies, guidelines, specific personnel and committees to deal with infection control in general. This study has created awareness about TBIC among staff and pointed out the complexity of health workers’ behaviour towards adhering to policies.

Background: Integrating mental health into primary care is a global priority. It is proposed to ‘task-share’ the screening, diagnosis and treatment of common mental disorders fromspecialists to primary care workers. Key to facilitating this is training primary care workers to deliver mental health care. Mental health training in Africa shows a predominance of short-term, externally driven training programmes. Locally, a more sustainable delivery system was needed. Aim: The aim of the study was to develop and evaluate a locally delivered, long-term, inservice training programme to facilitate mental health care in primary care. Methods: This was a quasi-experimental study using mixed methods. The in-service training programme was delivered in weekly 1-h sessions by local psychiatry staff to 20 primary care nurses at the clinic over 5 months. The training was evaluated using quantitative data from participant questionnaires and analysis of the referrals from primary to specialist care. Qualitative data were collected via semi-structured interviews and 14 observed training sessions. Results: The training was feasible and well received. Referrals to the mental health nurse increased in quality and participants’ self-rated competence improved. Additional benefits included the development of supervision skills of mental health nurses and providing a forum for staff to discuss service improvement. The programme acted as a vehicle to pilot integration in one clinic and identify unanticipated barriers prior to rollout. Conclusions: Long-term, in-service training, using existing local staff had benefits to the integration of mental health into primary care. This approach could be relevant to similar contexts elsewhere.

Background: This article reports on the findings of a workshop held at the joint 5th World Organisation of Family Doctors (WONCA) Africa and 20th National Family Practitioners Conference in Tshwane, South Africa, in 2017. Postgraduate training for family medicine in Africa takes place in the clinical workspace at the bedside or next to the patient in the clinic, district hospital or regional hospital. Direct supervisor observation, exchange of reflection and feedback, and learning conversations between the supervisor and the registrar are central to learning and assessment processes. Objectives: The aim of the workshop was to understand how family medicine registrars (postgraduate trainees in family medicine) in Africa learn in the workplace. Methods: Thirty-five trainers and registrars from nine African countries, the United Kingdom, United States and Sweden participated. South Africa was represented by the universities of Cape Town, Limpopo, Pretoria, Sefako Makgatho, Stellenbosch, Walter Sisulu and Witwatersrand. Results: Six major themes were identified: (1) context is critical, (2) learning style of the registrar and (teaching style) of the supervisor, (3) learning portfolio is utilised, (4) interactions between registrar and supervisor, (5) giving and receiving feedback and (6) the competence of the supervisor. Conclusion: The training of family physicians across Africa shares many common themes. However, there are also big differences among the various countries and even programmes within countries. The way forward would include exploring the local contextual enablers that influence the learning conversations between trainees and their supervisors. Family medicine training institutions and organisations (such as WONCA Africa and the South African Academy of Family Physicians) have a critical role to play in supporting trainees and trainers towards developing local competencies which facilitate learning in the clinical workplace dominated by service delivery pressures.

Introduction: Brazil and South Africa share many sociodemographic and health features that provide many learning opportunities. Brazil’s national health system, the Sistema Único de Saúde (SUS) prioritises primary health care since 1994, the year democracy came to South Africa. Two family physicians from these countries met in Rocinha favela in Rio de Janeiro, a densely populated area where poverty, danger, drugs, tuberculosis and mental illness are the focus of the health system. Maria do Socorro Family Clinic: Central to the SUS are the Family Health Teams, consisting of community health workers, nurses, doctors and allied health workers. This clinic in Rocinha has 11 teams, caring for 2700 people each, all visited monthly, preventing illness and promoting health. Patients with mental illness are cared for in a therapeutic residency, with an onsite psychiatrist, psychologist and social worker. The relationships between the health carers and the clinic and the community are collegial and equal, sharing care. Larger than life photos of patients from the community line the walls. Training: A culture of learning is evident, with 18 family medicine residents, student nurses, a small library and a learning centre at the clinic. Local authorities compensate trainees in family medicine more than traditional specialties. Conclusion: Brazil has made massive progress in providing universal health coverage over the last 20 years. South Africa, with not too dissimilar challenges, is embarking on this road more recently. The lessons learnt at clinic and community level in this inner-city clinic could be very useful for similar settings in South Africa and other countries.

Background: The inappropriate use of emergency centres (ECs) is an expanding problem globally. The high attendance of non-urgent return presentations to ECs is recognised as part of the problem, placing an unnecessary demand on limited staff and resources. Of unscheduled returns 34% of cases had no change to diagnosis or treatment with the conclusion that 80% of re-attendance could be attributed to deficiencies in the initial consultation. This study aimed to evaluate the reasons why patients sought an early second consultation for the same complaint at a hospital EC in South Africa, by exploring the patient’s experience and shortcomings in the first consultation. Method: A qualitative study was conducted using in-depth, semi-structured interviews with 20 purposively selected participants who presented to a rural regional provincial hospital’s EC within 7 days of a prior consultation for the same complaint. Verbatim transcripts were analysed using the framework method. Results: The main reasons for a second consultation were symptom related factors and the need for diagnostic certainty. The major themes around patient experience of the initial consultation were shortcomings in effective evaluation and management of pain, diagnostic uncertainty including poor examination, poor explanation, uncertain access and follow-up and societal encouragement to utilise a hospital EC. Conclusion: Further interventions should explore pain as a presenting symptom of the illness experience, and promote competence in addressing physical and psychological causative factors within a patient-centred approach for all health staff, especially in primary care services.

Background: Access to health services is one of the Batho Pele (‘people first’) values and principles of the South African government since 1997. This necessitated some changes around public service systems, procedures, attitudes and behaviour. The challenges of providing health care to rural geographically spread populations include variations in socio-economic status, transport opportunities, access to appointment information and patient perceptions of costs and benefits of seeking health care. George hospital, situated in a rural area, serves 5000 outpatient visits monthly, with non-attendance rates of up to 40%. Objectives: The aim of this research was to gain a greater understanding of the reasons behind non-attendance of outpatient department clinics to allow locally driven, targeted interventions. Methods: This was a descriptive study. We attempted to phone all patients who missed appointments over a 1-month period (n = 574). Only 20% were contactable with one person declining consent. Twenty-nine percent had no telephone number on hospital systems, 7% had incorrect numbers, 2% had died and 42% did not respond to three attempts. Results: The main reasons for non-attendance included unaware of appointment date (16%), out of area (11%), confusion over date (11%), sick or admitted to hospital (10%), family member sick or died (7%), appointment should have been cancelled by clerical staff (6%) and transport (6%). Only 9% chose to miss their appointment. The other 24% had various reasons. Conclusions: Improved patient awareness of appointments, adjustments in referral systems and enabling appointment cancellation if indicated would directly improve over two-thirds of reasons for non-attendance. Understanding the underlying causes will help appointment planning, reduce wasted costs and have a significant impact on patient care.

Background: Since 2007, the postgraduate training of family physicians for South African district hospitals has been formalised. This training differs from European and North American programmes as up to 30% of the skills needed rely on district hospital surgical, obstetrics and anaesthetics procedures, particularly in rural areas, as outlined in the national unit standards. The aim of this study was to evaluate the appropriateness and sufficiency of learning opportunities for these skills in a rural district hospital. Methods: A descriptive, cross-sectional study was undertaken of the number and type of procedures performed in theatre for a 1-year period and compared with the required procedural skills stipulated in the national unit standards. Descriptive statistical analyses were used to analyse categorical data. Results: Three thousand seven hundred and forty-one procedures were performed during the study period. Anaesthesia was the most common procedure, followed by Caesarean section. There were adequate opportunities for teaching most core skills. Conclusions: Sufficient and appropriate learning opportunities exist for postgraduate family medicine training in all the core skills performed in a theatre according to the national unit standards. Keywords: Post Graduate Training, Family Medicine, Procedural Skills, Rural, District hospitals

Background: The theme of the 2014 Southern African Rural Health Conference was ‘Building resilience in facing rural realities’. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. Conference workshop: The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, ‘What is it that keeps you going to work every day?’ Participants reflected on their work situation and listed and rated the important reasons for continuing to work. Results: Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. Conclusion: Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported.