Doctoral Degrees (Health Systems and Public Health)

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Browsing Doctoral Degrees (Health Systems and Public Health) by browse.metadata.advisor "Clarke, Mike"

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    Development of a best practice model for teaching and learning evidence-based health care at Stellenbosch University, South Africa
    (Stellenbosch : Stellenbosch University, 2016-03) Young, Taryn; Volmink, Jimmy; Clarke, Mike; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
    ENGLISH ABSTRACT: This thesis used a mixed-methods approach to investigate how teaching and learning of Evidence-based Health Care (EBHC) could best be integrated in medical student training to enhance student EBHC knowledge, attitude and skills. An overview of systematic reviews assessing the effects of teaching EBHC showed that clinically integrated multifaceted strategies with assessment were more effective than single interventions or no interventions for enhancing knowledge, attitude and skills. Implementation of clinically integrated EBHC teaching and learning was further explored through interviews with programme coordinators from around the world. Informants were requested to provide data on the various approaches used, and on barriers and facilitators encountered with programmes aimed at teaching and learning EBHC in an integrated manner. By far the most common challenges were lack of space in the clinical setting, EBHC misconceptions, resistance of staff and lack of confidence of tutors, time, and negative role modelling. Critical success factors identified were pragmatism and nimbleness in responding to opportunities for engagement and including EBHC learning into the curriculum, patience, and a critical mass of the right teachers who have EBHC knowledge, attitudes and skills and are confident in facilitating learning. In addition, role modelling within the clinical setting and the overall institutional context were found to be important for success. The next phase involved conducting a set of studies to determine the opportunities for, and barriers to, implementing EBHC teaching and learning at Stellenbosch University’s (SU) Faculty of Medicine and Health Sciences. This included a curriculum document review, survey of recent graduates and interviews with faculty. EBHC teaching was found to be fragmented and recent graduates called for more teaching of certain EBHC competencies. Module convenors identified a number of factors that needed to be addressed: contextual factors within the faculty (e.g. recognition for teaching), health sector issues (e.g. clinical workload), access to research evidence, and issues related to educators (e.g. competing priorities) and learners (e.g. motivation). Interviewees also emphasised the importance of educators as facilitators and role models. A cross-sectional study of SU was conducted to assess SU educators’ knowledge of, attitude to and confidence in practicing and teaching EBHC as well as perceived barriers to practicing and teaching EBHC. Limitations to practicing EBHC identified included lack of time, clinical workload, limited access to internet and resources, knowledge and skills. Respondents’ called for reliable internet access, easy point-of-care access to databases and resources, increasing awareness of EBHC, building capacity to practice and facilitate learning of EBHC, and a supportive community of practice. Finally, drawing on the findings of the preceding quantitative and qualitative studies, and taking into account the context of various EBHC initiatives in the African region, an outline proposal is presented for a cluster randomised trial to evaluate alternative options for implementing a clinically integrated EBHC curriculum in an African setting.
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    Strengthening pre-hospital clinical practice guideline development for South Africa
    (Stellenbosch : Stellenbosch University, 2020-12) McCaul, Michael Gilbert; Clarke, Mike; Young, Taryn; Bruijns, Stevan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY : In 2016, the first evidence-based prehospital clinical practice guideline was developed for South African paramedics, replacing outdated and eminence-based practice protocols. Rather than de novo development, alternative methods were used to develop these guidelines. These methods, however, require further strengthening and there is a modest gap in the literature regarding such methods. This strengthening would make it possible to address issues in current and future guideline development and implementation practices in South Africa and beyond, especially in resourcelimited settings. Issues include poor guideline quality and lack of appropriate methods, especially in prehospital care. In this thesis, I explore how to strengthen prehospital clinical practice guideline (CPG) development and implementation in low-resource settings. Using the African Federation for Emergency Medicine (AFEM) prehospital CPG as a case study, I used various research methods to i) identify, map and appraise global and regional prehospital guidelines (via a descriptive study and a scoping review); ii) describe and strengthen guideline development methods (via a qualitative case study, an expert review and a critical reflection/report); and iii) identify guideline implementation challenges and solutions (via a qualitative implementation research study). I show that overall, both global and regional (African) prehospital guidance quality is poor; however, an existing pool of high-quality CPGs can be adapted to fit national and local settings. I identify guideline development and implementation challenges within the AFEM guideline project and provide solutions and linked priority actions for guideline stakeholders. Considering these results, I have produced an alternative guideline development roadmap for prehospital guideline development in South Africa and beyond. This PhD argues that in order to strengthen existing and future prehospital CPG and end-user products, I suggest developers use existing high-quality guidelines, together with national policy and evidence to support context-specific recommendations. I argue that when developing and implementing guidelines, careful consideration of conflicts of interest during implementation decisions must be considered, together with ensuring wide and open consultation with stakeholders. To support robust development, I provide a critical report and roadmap for guideline development producers in resource-limited settings. This PhD highlights implications for future research, including the need to determine the cost-effectiveness of alternative versus de novo methods, identify prehospital topics with the greatest impact where CPGs are lacking, exploring the roles, need and objectives of policy-makers in prehospital guideline development, and testing and evaluating methods of dealing with consolidating multiple conflicting CPG recommendations and levels of evidence.