Shared learning experiences: Pilot study of an online exchange project between pharmacy students in South Africa and the United States

INTRODUCTION

Internationalisation enhances students' understanding of social, cultural, and ethical differences, preparing them to be global-minded, socially accountable healthcare practitioners. Traditionally, internationalisation of education involves international student travel. Online tools provide opportunities for international, peer-driven learning and collaboration without costly travel. This research described the experiences of pharmacy students from South Africa (SA) and the United States (US) that participated in a virtual peer exchange project during the COVID-19 pandemic.

METHODS

The virtual peer exchange project allowed students in SA and the US to establish connections within the global pharmacy community and compare healthcare, pharmacy education, and pharmacy practice between the countries. Students engaged in facilitated dialogue through video recordings, video conferencing, and a group discussion board. Student introduction video comments and discussion board posts were thematically analysed.

RESULTS

Twenty-one students participated in the pilot project that met some of the intentions and goals of internationalisation via a virtual platform. Two over-arching themes of Practice of Pharmacy and Pharmacy Education emerged from both the introduction video and discussion board comments. Students described lessons learned about similarities and differences in socioeconomic determinants of health as well as structure, functioning, and financing of the different healthcare systems.

CONCLUSIONS

This project was a unique way to conduct exchange programmes via a virtual platform, and bypassed challenges of traditional exchange programmes. Through technology, more students in diverse geographic locations can be exposed to various perspectives and healthcare experiences with international students.

Critical appraisal of clinical guidelines for prevention and management of doxorubicin-induced cardiotoxicity

OBJECTIVE

Doxorubicin is a valuable chemotherapeutic drug; however, it is associated with a high risk of cardiotoxicity. Several institutions and organizations have developed guidelines for risk factor assessment, monitoring and prevention strategies against chemotherapy-induced cardiotoxicity. This review aimed to assess the quality of current practice guidelines, using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). This tool was used to compare the recommendations with regards to their strength and evidence recommendations were based on.

DATA SOURCES

This review identified guidelines in literature from January 1960 to February 6, 2022, through a systematic search that included PubMed, EMBASE, MEDLINE, Cochrane Database and Google Scholar. The quality, consistency and the strength of supporting evidence was evaluated using the AGREE II method.

DATA SUMMARY

Eight guidelines met the inclusion criteria and 144 recommendations were extracted from these guidelines. The results from the AGREE II evaluation showed that the total assessment scores of guidelines ranged from 2 to 5, indicating the guidelines need modifications. The recommendations were evaluated according to the references used, and it was found that 12 (11%) recommendations had high evidence, 36 (33%) had moderate evidence, 38 (35.19%) had low and 22 (20.37%) had insufficient evidence. Recommendations for risk factors assessment, prophylaxis of cardiotoxicity, management of cardiotoxicity and monitoring of cardiotoxicity were quite varied amongst the different guidelines evaluated.

CONCLUSIONS

All studied guidelines need modifications as per the AGREE II evaluating tool. Several shortcomings were identified, including a lack of evidence-based studies supporting the recommendations in the guidelines.

A quantitative comparison of essential cardiovascular medicines from countries in the Southern African Development Community to the WHO model essential medicines list

BACKGROUND

Globally, cardiovascular disease (CVD) is a leading cause of death and disproportionately affects low- and middle-income countries (LMICs). The WHO Model List of Essential Medicines (WHO EML) is a tool for improving accessibility and availability of medicines. This study compared the 2021 WHO EML CVDs basket of medicines with latest available national essential medicines list (NEMLs) for South Africa and 15 Southern African Development Community (SADC) countries to assess consistency in CVDs medicine listing.

METHODS

This descriptive, desktop review study compared SADC NEMLs. A comparator list was extracted by combining cardiovascular medicines listed in the 2021 WHO EML for adults and children. SADC country NEMLs were obtained from the WHO Essential Medicines and Health Products Information Portal. Consistency of NEMLs was calculated as a percentage coverage of CVD medicines listed in the 2021 WHO EML. SA hospital and primary health care (PHC) level NEMLs were included as separate formularies.

RESULTS

The SA hospital level NEML scored 70% consistency with the 2021 WHO EML. Tanzania (84%), Namibia (81%) and Angola (79%) scored the highest consistency. The mean consistency for SADC NEMLs was 66%. The lowest scoring country was Eswatini at 26%. The SA PHC NEML scored 35%. The least listed medicines were beta-blockers, angiotensin receptor blockers (ARBs), clopidogrel (43%) and paediatric formulations (furosemide (21%); digoxin (43%)). Individual antihypertensive medicines were most commonly listed. Botswana and Lesotho were the only countries to list a single pill combination (SPC) for the treatment of hypertension.

CONCLUSIONS

This comparison indicates that South Africa and most SADC countries are aligned with 2021 WHO EML recommendations. The inclusion of age-appropriate formulations for children as well as ARBs and SPC for the treatment of hypertension may improve patient adherence and cardiovascular outcomes in these countries. More frequent updates to NEMLs should improve consistency. NEMLs were not available for two countries, and these therefore did not form part of this study. Country health expenditure in ranking the consistency of NEMLs was not accounted for. LMICs adopting the essential medicine list strategy should consider imposing minimum consistency thresholds to the WHO EML to improve accessibility and availability of CVD medicines.

TRIAL REGISTRATION

Not applicable.

Extending Pharmacist Roles in Primary Healthcare to Meet the Needs of Universal Health Coverage in Zimbabwe: A Pharmacist Perspective and Curriculum Evaluation

Zimbabwean pharmacists undergo university level education to understand the biochemical mechanisms and actions of medicines but are limited in their scope of practice. They are called medicines experts, yet they are not allowed to apply their specialized knowledge independently in direct patient management. We aim to obtain Zimbabwean pharmacists’ perceptions on extending their scope of practice and to evaluate the Zimbabwe pharmacy honours degree curriculum to determine the competencies covered and whether these are in-line with an extended scope of practice. Qualitative semi-structured interviews with selected pharmacists were conducted to gather perspectives on the BPharm (Hons) curricula and extending pharmacists’ scope of practice. A desktop review of the pharmacy curricula was also conducted to determine competencies covered. The results showed that pharmacists are keen to extend their scope of practice but the curriculum does not equip them with the required exit level competencies. “The pharmacist is obviously not equipped currently but needs to be involved in direct patient care such as identifying and managing medicine therapy problems, prescription extension, ordering and reviewing laboratory data and administrationof vaccines and immunizations”. There exists an opportunity for pharmacists to extend their scope of practice in order to achieve universal health coverage.

The availability of priority medicines for children under 5 years in eThekwini, South Africa

Background

Globally, an estimated 8.1 million children under 5 years die annually in developing countries. Ensuring essential medicines are accessible and affordable to the population is key to saving lives. This study investigated accessibility, availability and affordability of a basket of priority medicines for children under 5 years in public and private healthcare sector pharmacies in the eThekwini Metropolitan area in Durban, South Africa.

Methods

The WHO/HAI survey tool for assessing medicine prices, availability and affordability was adapted and employed for a basket of WHO Priority life-saving medicines for children under 5 years. Six district hospitals in the north, south and central eThekwini Metropolitan were selected as major facility reference points and for data collection and pharmacies within a 5 km radius from each major facility were also invited to participate in the study, as outlined in the WHO/HAI tool methodology. Of the 58 pharmacies selected, a total of 27 pharmacies from both private and public healthcare sectors agreed to participate and were surveyed, representing a 47% response rate. Data was analysed using Microsoft excel.

Results

All participating pharmacies (and hence the selected basket of priority medicines at these facilities) were deemed accessible. Overall the public sector had more medicines available on the shelf (averaging 64%) than the private sector (48%) which had more medicines available on order (84%). At least one medicine for each of the eight (8) conditions was available at both sectors which meant patients could be treated for these conditions. Medicines for priority conditions (except HIV, which was a 28-day course) were deemed affordable as these regimens were obtainable within a day’s wage for the lowest paid unskilled worker. Priority medicines for children under 5 years were more available and more affordable in the public sector.

Conclusion

The basket of WHO essential medicines for priority conditions for children under 5 years were accessible, available and affordable in the eThekwini Metropolitan areas. This was the first study in eThekwini to determine access to the WHO basket of priority medicines for children and can be scaled-up to a national study to provide a holistic comparison of these medicines in the country, and also for global comparison.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00402-y.

Polypharmacy and the occurrence of potential drug-drug interactions among geriatric patients at the outpatient pharmacy department of a regional hospital in Durban, South Africa

Background

Polypharmacy is the administration of an excessive number of medicines and a significant irrational medicine use practice. Little is known about this practice in South Africa. This study aimed to determine the level of polypharmacy and potential drug–drug interactions amongst the geriatric patient population in a facility in South Africa.

Method

A cross-sectional retrospective prescription chart review for 250 geriatric patients was conducted at the outpatient pharmacy department of a regional hospital. Variables extracted included demographic information, diagnosis, type of prescriber contact, and polypharmacy. Potential drug–drug interactions were determined with web-based multi-drug interaction checkers.

Results

The average (SD) number of diagnosed clinical problems was 3.54 ± 1.26, with hypertension, diabetes mellitus, and heart disease occurring most frequently. The level of polypharmacy was high with patients receiving an average (SD) of 12.13 ± 4.25 prescribed medicines from 3032 prescribed medicines. The level of polypharmacy was highest within the age categories, 60–64, and 70–74 years of age, respectively. The level of potential drug–drug interactions was also high with an average (SD) of 10.30 ± 7.48 from 2570 potential drug interactions. The majority of these interactions were moderate (72.5%) and pharmacodynamic (73.2%) by nature of the clinical severity of action and mechanism of action, respectively. Polypharmacy and type of prescriber contact were statistically significant contributors to the occurrence of potential drug–drug interactions, (F (2, 249) = 68.057, p < 0.05). However, in a multivariate analysis of variables to determine the strength of the association, polypharmacy was determined to be the strongest contributor to the occurrence of potential drug–drug interactions (p < 0.05) when compared with the type of prescriber contact (p value = 0.467). Therefore, irrespective of the type of prescriber contact, polypharmacy increases the potential for drug interactions among the sampled patient population.

Conclusion

A comprehensive consideration of disease management guidelines, patient factors, and rational medicine review could be measurable strategies towards improving medicine use. This would also limit the occurrence of significant drug interactions among the geriatric patient population. A national study is required to determine if differences occur across hospitals and regions.

Evaluating the implementation of the standard treatment guidelines (STGs) and essential medicines list (EML) at a public South African tertiary institution and its associated primary health care (PHC) facilities

Background

The standard treatment guidelines (STGs) and essential medicines list (EML) were a policy option recommended in the National Drug Policy for South Africa in 1996 to address the irrational and bloated medicines procurement list. STGs/EML serve as a tool to promote cost-effective use of medicines; rational prescribing; and improve accessibility to medicines for all citizens. The purpose of this study was to evaluate the use and implementation of the STGs/EML by prescribers at a public tertiary institution and its associated Primary Health Care (PHC) facilities in the uMhlathuze subdistrict of KwaZulu Natal. The study aimed to provide feedback and to make recommendations to policy makers to improve the use and implementation of the STGs/EML and to inform National Health Insurance (NHI) policy development.

Method

An observational quantitative descriptive research design was used. A retrospective audit of prescriptions was conducted, and questionnaires were utilized to collect data from prescribers and the facilities to evaluate the utilization of the STGs/EML and the rational use of medicines. All descriptive analyses were presented as counts with percentages, and Fisher’s exact test was used to compare results. The data was summarized, reduced, and analysed using SAS statistics software.

Results

107 medical doctors (97%) responded to the questionnaire at hospital level and 98 nurses (98%) responded to the questionnaire at the PHC level. Results revealed that the majority of doctors, 94.4%, had access to the latest STGs/EML compared with only 41.8% of nurses. 70.3% and 78.3% of doctor’s and nurse’s prescriptions, respectively, adhered to the guidelines. 94.9% of nurses requested training on the use of STGs/EML as most of them had not received formal training on its use.

Conclusion

This study showed suboptimal adherence to STGs/EML by all prescribers, in contrast to previous research amongst nurses when hardcopies were available. Training on the use of the STGs/EML is needed at PHC level and improved monitoring of STGs/EML compliance is necessary. This study may be replicated for a wider population to paint a national picture and to periodically assess the extent of the implementation of the STGs/EML.

Perceptions from pharmaceutical stakeholders on how the pharmaceutical budget is allocated in South Africa

Background

South Africa faces a heavy burden of disease, which impacts resource allocation. The needs of South Africa require efficient translation into pharmaceutical expenditure for medicine provision, to ensure availability of medicines. Given that South Africa faces various challenges with medicine provision accompanied by rising pharmaceutical expenditure, this study aimed to report on the considerations and methods used to determine the healthcare budget for South Africa, and how it is translated into pharmaceutical expenditure for medicines provision on the Standard Treatment Guidelines and Essential Medicines List and non-essential medicines in the public sector.

Method

Qualitative, semi-structured interviews guided by a discussion guide were conducted with seven pharmaceutical officials involved in the budget and resource allocation process, between October 2019 and March 2020. Interviews were recorded and transcribed verbatim. Once the interviews were coded by the first author they were verified by the other authors. Data were thematically analysed.

Results

This study depicted the knowledge and participation of pharmaceutical services in the budget process. The National and Provincial Department of Health have improved pharmaceutical budgeting by making strides towards a collaborative, informed, and more evidence-based approach. Pharmaceutical services have roles in advising on requirements; commenting where necessary, constantly monitor and taking accountability for their budget. The main considerations that determined the budget included population size and growth, historical expenditure, the extra heavy burden of disease and incidence rate, demand data and forecasting. The local and provincial pharmacy and therapeutics committee play a vital role in monitoring the budget and expenditure; ensuring adherence to guidelines; controlling the extent to which non-Essential Medicine List items are used and advising accordingly.

Conclusion

This was the first study to report on the decision and thought processes of the healthcare budget and its translation into pharmaceutical expenditure for medicine provision in South Africa. Many factors were considered to inform the budget, with the Standard Treatment Guideline and Essential Medicines List being the principal guide for medicine provision. This process was well-controlled and monitored by the pharmaceutical therapeutics committee. Documenting the South African experience can assist other countries in their budget decisions for medicines.

Pharmacy students experience with PharmacyPhlash - a pilot educational board game

BACKGROUND AND PURPOSE

Pharmacy academics are consistently challenged to incorporate innovative, active-learning strategies to encourage student participation while imparting knowledge. To achieve this, a board game entitled "PharmacyPhlash" was developed by academics teaching in an undergraduate bachelor of pharmacy program. The study sought to document student experience on playing a pilot version of the game and to understand the design strengths and weaknesses as well as the ability of the game to achieve envisaged educational and competency outcomes.

EDUCATIONAL ACTIVITY AND SETTING

Third-year pharmacy students were invited to participate in the pilot study. Student experience was evaluated using a questionnaire to determine general characteristics of game-playing, students' perceived engagement in the game and its ability to fulfil its anticipated design objectives, how playing the game helped or limited learning, aspects students enjoyed/did not enjoy about the activity, and suggestions for improvement.

FINDINGS

Ten participants (six males, four females) volunteered for the pilot. Overall, playing the game improved understanding and application of knowledge and promoted sharing of knowledge and collaboration. Students were able to link pharmacy practice and pharmacology knowledge. It enhanced learners' ability to think and communicatee concisely and quickly. The competitive aspect of the game was the main negative associated with playing the game. Suggestions for improving the game included making it shorter, including mixed groups of students from different levels of study, and introducing a referee to oversee the game.

SUMMARY

The current study found that students reported high levels of satisfaction from playing the game.

Understanding the decision making process of selection of medicines in the private sector in South Africa - lessons for low-middle income countries

BACKGROUND

The affordability of essential medicines is a challenge in achieving Universal Health Coverage (UHC). One of The Lancet Commission's recommendations on financing of essential medicines is to ensure governments and national health systems include essential medicines in the benefit packages provided by public and private healthcare sectors. Currently in South Africa (SA), there is a dearth of information on the processes for medicines selection for private sector medical scheme formularies. This study aimed to improve the understanding of how formulary managers of selected medical schemes made decisions for the selection of medicines for their formularies. This paper described their opinions obtained from in-depth interviews.

METHODS

Qualitative in-depth interviews were conducted with 10 individuals from 7 private sector medical schemes and administrators in SA. All participants interviewed were involved in formulary development and management. Interviews were conducted from June 2013 - January 2015. Interviews were guided by a discussion guide and audio recorded. Recorded interviews were transcribed verbatim. Transcripts were coded by the first author, corroborated by the second author, reconciled, and imported into NVIVO for data analysis.

RESULTS

Schemes and administrators had similar formulary decision making and management committees in place (viz. Clinical and Therapeutics committees). The process of and criteria for medicines selection and evidence based review of formularies were also similar. Selection of medicines was inherent in the formulary review process. Medicine price was important in the decision taken to list medicines. Most schemes expressed a difficulty with lack of information to support pharmacoeconomic evaluations of medicines for inclusion on the formulary. This together with the basic monitoring of use of medicines by patients for most schemes left room for improvement in the decision making process for those schemes.

CONCLUSIONS

This is one of the first studies in SA describing interviews with private sector medical scheme Formulary managers. It contributes to an increased understanding of how decisions are taken to include/exclude medicines on private sector medical scheme formularies. It provides insight into the medicine selection and review processes, including processes on monitoring and evaluation of medicines use by the private sector which serve as lessons for Low-Middle income countries moving towards UHC.

Evaluating the Use of Pictograms for the Improvement in Patient Understanding of Medication Instruction–A Pilot Study

The first step in ensuring patient compliance is to ensure that the patient understands how to use their medication. The aim of the study was to determine if patients understanding of medication use can be improved by using pictograms. A simple randomized control test was set up whereby 50 patients were selected to participate, of which 25 people were included in the test group to receive medication labels based on pictograms as well as the usual counselling and 25 people were included in the control group and received the usual labelling of their medication and counselling. Questionnaires were used to determine the patient&rsquo;s demographic information and health literacy on the day of inclusion into the study, while another questionnaire was completed 3 to 7 days later to determine patient understanding of how to use their medication and if they used their medication correctly. At a 95% confidence interval and p&lt;0.05 there is a relationship between improved understanding and the use of pictograms. Pictograms improve patient&rsquo;s understanding of how to use their medication, which in turn lead to an improvement in adherence.

Parents' and guardians' perceptions on availability and pricing of medicines and healthcare for children in eThekwini, South Africa - a qualitative study

Background

Inadequate access to affordable essential medicines poses a challenge to achieving Universal Health Coverage. Access to essential medicines for children has been in the spotlight in recent research. However, information from the end users of medicines, i.e. patients is scarce. Obtaining information at a household level is integral to understanding how people access, obtain and use medicines. This study aimed to gather opinions and perceptions from parents/guardians on availability, affordability and quality of medicines and healthcare for children in SA.

Methods

Eight Focus group discussions were held with 41 individuals in eThekwini, South Africa (SA), from September–November 2016. Participants were parents/guardians of children up to 12 years from different ethnicities, ages, gender, and socio-economic backgrounds. Key informants identified by the principal researcher recruited participants using snowball sampling. Focus group discussions were recorded, transcribed verbatim, coded by the first author, verified by the second author, reconciled for consensus and imported into NVIVO for data analysis.

Results

Medicines and healthcare facilities are accessible in urban and peri-urban areas in eThekwini. Medicines may not always be available in public sector facilities due to medicine shortages, compelling parents to purchase medicines from private sector pharmacies. Common medicines were perceived as affordable for most socio-economic groups except the ‘Poor’ group. Quality of medicines was perceived as ‘good’ especially if obtained from the private sector but sometimes perceived as ‘poor’ and viewed with suspicion when received from public sector clinics. Quality of healthcare was perceived as ‘good’ but requires improvement for both sectors.

Conclusions

This is the first study in SA to report on parent/guardian perceptions on availability, affordability and quality of medicines and healthcare for children. It has the potential to be up-scaled to a country-wide investigation to paint a national picture of parents’ opinions of healthcare for children. This will allow for patient input into pharmaceutical and healthcare policy governing access to and availability of essential medicines and services within the country. The study recommends that patient input be sought to assess impact of policies on the intended target group in the country to ensure that the policy objectives are achieved.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2385-y) contains supplementary material, which is available to authorized users.

Selection of essential medicines for South Africa - an analysis of in-depth interviews with national essential medicines list committee members

BACKGROUND

The South African (SA) public health system has employed an Essential Medicines List (EML) with Standard Treatment Guidelines (STGs) in the public sector since 1996. To date no studies have reported on the process of selection of essential medicines for SA EMLs and how this may have changed over time. This study reports on the decision making process for the selection of essential medicines for SA EMLs, over the years, as described by various members of the National Essential Medicines List Committee (NEMLC) and their task teams.

METHODS

Qualitative in-depth interviews, guided by an interview questionnaire, were conducted with 11 members of the SA NEMLC and their task teams (both past and present members) during the period January - April 2015. Interviews were recorded and transcribed verbatim. Transcripts were then coded by the first author and verified by the second author before being reconciled and input into NVIVO, a qualitative software, to facilitate analysis of the data.

RESULTS

The interviews conducted suggest that the NEMLC process of medicine selection has been refined over the years. This together with the EML review process is now essentially predominantly an evidence based process where quality, safety and efficacy of a medicine is considered first followed by cost considerations which includes pharmacoeconomic evaluations, and pricing of medicines.

CONCLUSIONS

This is the first study in SA to report on how decisions are taken to include or exclude medicines on SA national EMLs and provides insight into the SA EML medicine selection, review and monitoring processes over time. The results show that the NEMLC has undergone tremendous transformation over the years. Whilst the membership of the committee largely remains unchanged, the committee has developed its policies and processes over the years. However there is still a need to strengthen the monitoring and evaluation aspects of the SA EML policy process.

Quantitative evaluation of essential medicines lists: the South African case study

BACKGROUND

The South African (SA) health system has employed an Essential Medicines List (EML) with Standard Treatment Guidelines (STGs) since 1996. To date no studies have reported the changes in SA STG/EMLs. This study describes these changes over time (1996-2013) and compares latest SA STG/EMLs with the latest World Health Organization (WHO) Model EMLs to assess alignment of these lists.

METHODS

A quantitative evaluation of SA STGs/EMLs at 2 levels of healthcare was performed to assess changes in the number and ratio of molecules, dosage forms, and additions and deletions of medicines. The most recent WHO EMLs (18th list, 4th list for children) and 2012 priority life-saving medicines for women and children (PMWC) list were compared to the most recent available SA STG/EMLs (Primary Health Care (PHC 2008), Adult Hospital 2012, and Paediatric Hospital 2013) at the time of the research.

RESULTS

The number of molecules over the years increased for PHC STG/EMLs but decreased slightly for Adult and Paediatric hospital STG/EMLs. The most additions and deletions over time occurred in the Adult hospital level STG/EML (27 in 2006 and 44 in 2012). A comparison between the most recent SA STG/EMLs and WHO Model EML (18th list) showed that a total of 112 medicines were absent on all SA STG/EMLs. A comparison of medicines for children between the 2013 SA Paediatric Hospital level STG/EML and PMWC indicated that these lists were somewhat aligned for most conditions as only 3 of 14 medicines and 11 of 20 vaccines were absent from SA STG/EMLs.

CONCLUSION

This is the first study in SA to investigate changes in National EMLs over time in relation to molecules, dosage forms and therapeutic classes. It is also the first to compare the latest SA STG/EMLs to the WHO Model lists. The results therefore provide insight into the trends and SA STG/EML processes over time.