Twenty-three individuals from the HPER TWG participated in topic generation. Ninety responses were received in Round One. For Round Two, the survey was sent via email to the 82 individuals from Round One who provided their email addresses. We received 52 responses (52/90, 58% response rate) in Round Two. Round One’s respondents were from thirteen countries in SSA, with the majority from Nigeria, South Africa, and Uganda. In Round Two, 23/52 (44%) of the respondents were from Nigeria, 10/52 (19%) were from South Africa, and 7/52 (13%) were from Uganda. (Table 2) To account for the fact that the majority of respondents in both rounds were Nigerian, an additional sensitivity analysis was performed to determine if research priorities were different among respondents from Nigeria compared to elsewhere in SSA. The final list of priority research issues was the same among Nigerian respondents as compared to respondents from other countries.
Table 2: Country of primary practice of survey respondents by round
Country
|
Round 1 Respondents
(n=90)
|
Round 2 Respondents
(n=52)
|
Democratic Republic of Congo
|
5
|
1
|
Ethiopia
|
7
|
6
|
Ghana
|
1
|
0
|
Kenya
|
2
|
0
|
Lesotho
|
1
|
1
|
Namibia
|
2
|
1
|
Nigeria
|
38
|
23
|
South Africa
|
11
|
10
|
Tanzania
|
2
|
1
|
Uganda
|
8
|
7
|
Zambia
|
2
|
2
|
Zimbabwe
|
2
|
1
|
United States
|
1
|
0
|
Respondents reported a median of 14 years’ experience working in HPE, with a range from one to 42 years. Although the majority of the respondents were medically and nursing qualified, the individuals represented a wider range of health professions as well as a few others (Table 3).
Table 3: Occupations of survey respondents by round
|
Round 1 Respondents
(n=90)
|
Round 2 Respondents
(n=52)
|
Health professional
|
Dentist
|
1
|
1
|
Medical doctor
|
36
|
23
|
Nurse
|
14
|
11
|
Occupational therapist
|
1
|
1
|
Pharmacist
|
6
|
4
|
Physiotherapist
|
1
|
1
|
Psychologist
|
1
|
0
|
Public health
|
2
|
2
|
Scientist
|
3
|
2
|
Other
|
2
|
2
|
Not a health professional
|
Accountant
|
1
|
1
|
Anthropologist
|
1
|
0
|
Education specialist
|
2
|
2
|
Health economist
|
1
|
0
|
Health manager
|
1
|
0
|
Information technology
|
1
|
0
|
Law
|
1
|
0
|
Research administrator
|
1
|
1
|
Sociologist
|
1
|
0
|
In Round One, 71/90 (79%) of respondents regarded themselves as experienced or somewhat experienced in HPE, with 25/90 (28%) having published more than five articles in the field. In Round Two, 41/52 (79%) of respondents regarded themselves as experienced or somewhat experienced in HPE, with 25/52 (48%) having published more than five articles in the field (Table 4).
Table 4: Characteristics of survey respondents by round
|
Round 1 Respondents
(n=90)
|
Round 2 Respondents
(n=52)
|
Health professional
|
Yes
|
71
|
47
|
No
|
11
|
5
|
Experience in HPER
|
Novice
|
19
|
11
|
Somewhat experienced
|
46
|
23
|
Experienced
|
25
|
18
|
Number of HPE-related publications
|
None
|
35
|
18
|
Less than 5
|
30
|
9
|
More than 5
|
25
|
25
|
No answer
|
2
|
--
|
HPER = Health professions education research, HPE = Health professions education
Thirty-four topics and topic descriptions were generated by the TWG members, which were reduced to 26 topics by the research team (see previously). In Round One, ten topics met consensus criteria. Twenty-three new topics were suggested, and four of these were incorporated into the next round; those that were not included were deemed sufficiently similar to ones already included in the existing list. In the second topic prioritisation round, ten topics met consensus criteria. (Table 5)
Table 5: Final list of topics in order from highest consensus rating to lowest
Rank order
|
Topic
|
(%) Rating
“Must Include”
|
1
|
Addressing the human resources for health challenges in rural and remote areas
|
98
|
2
|
Interprofessional collaboration and practices in SSA
|
95
|
3
|
Teaching a holistic and person-centered care approach
|
92
|
4
|
The role of information communications technology in HPE
|
85
|
5
|
Faculty development for clinical teaching
|
82
|
6
|
Quality assurance processes and procedures in health professions education
|
80
|
7
|
Resources, political commitment, and funding for HPE in SSA
|
76
|
8
|
Responsive curricula to the health needs of SSA
|
75
|
9
|
Potential of rural communities as platforms for training health care professionals
|
71
|
10
|
Relevance of communication skills training in culturally diverse contexts
|
70
|
Synthesis of Topics
The process of synthesis that occurred as a result of establishing consensus within the Delphi saw interesting shifts in perspectives from the initial set of 26 topics, to the final list of ten priorities. The early list, for example, included more generic issues such as ‘assessment practices’, ‘student retention’, ‘graduate competencies’, ‘post-graduate training’ and ‘self-regulation skills’ – topics that would likely resonate with health professions educators all over the world. The final list, however, represents what could be regarded as higher-order topics which, with one or two exceptions, speak to national and regional issues. They reflect the context within which health professionals in SSA are being trained and the challenges that characterise this context. During the topic generating phase of the study, the rationales that respondents provided in support of their selections emphasised the need for understanding ‘our own’ challenges in order to ‘decolonise our way of teaching and assessment.’ It was also argued that existing frameworks had been generated in ‘developed countries’ acknowledging the need for locally, relevant and responsive research. Ultimately, second-tier analysis by the research team resulted in three over-arching, but inter-connected themes: (1) creating an enabling environment with sufficient resources and relevant training; (2) enhancing student learning; and (3) identifying and evaluating strategies to improve pedagogical practice. These could be regarded as a triumvirate of educational endeavors – the teaching (pedagogy), the learning, and then the environment (context) within which it should occur. The themes are discussed below, supported in some instances with direct quotations from some of the rationales provided during the topic generation phase, and with several priorities having relevance across more than one.
An enabling environment
A key message from this Delphi is that a first step to defining and addressing the HPER priorities in SSA is to create the environment that will foster researchers, with sufficient training and resources to address the most pressing questions. This thesis is underscored by the fact that the top 10 priority topics include three that are focused on understanding the factors that currently make HPER challenging in SSA:
Priority # 1 – Addressing the human resources for health challenges in rural and remote settings
This first ranked topic focuses on addressing human resources for health challenges in rural and remote settings. This may be an unexpected result for colleagues around the world, but needs to be seen in the context of HPE in SSA as described in the introduction and points to the lived experience of many educators in the field who practice their teaching in resource-constrained contexts. The importance of the environment in influencing teaching and learning has been well-documented. [18] It can be inferred that for our respondents, addressing the need for practitioners who can respond to the increasing burden of disease, particularly in rural areas, is a non-negotiable imperative whether in terms of the taught curriculum (as many medical schools and health sciences faculties embrace distributed clinical learning [19]), or in terms of ensuring an environment in which teaching can meaningfully occur. Linked to this was the underlying premise of providing quality health care for all.
Priority # 5 – Faculty development for clinical teaching
Supporting those responsible for teaching, specifically clinical teaching, ranked fifth. Recommendations spoke specifically to looking to discern the status of faculty development in the region, describing it as a particular area requiring further investigation. Given the current drive towards the professionalisation of the educational role, and the growing need for faculty who can teach the growing numbers of HPE students, this focus was expected as there has been limited work in this area. An exception is research into the role of emerging clinical teachers which has been conducted in the region in recent years, [20, 21] with studies emphasising the need for further work and ongoing support for those responsible for HPE students in clinical training, particularly those who are placed in rural or distributed sites.
Priority # 7 – Resources, political commitment and funding for HPE in SSA
This priority picks up on the higher order focus established in Priority # 1, foregrounding the economic and political instability that characterises much of the SSA region, the impact that this has on health care and the subsequent effect on HPE. During topic generation, respondents felt that education, research and service delivery activities should all be directed, “towards addressing priority health concerns of the community, region and/or nation that they have a mandate to serve.”
Enhanced student learning
Among the priorities identified, four foregrounded approaches could potentially enhance student learning. An important proviso for these priorities was that the ultimate aim of enhanced student learning was the delivery of graduate professionals who could respond to local and regional health care imperatives and provide quality health care.
Priority # 2 – Interprofessional collaboration in clinical practice in SSA
Priority #2 highlights an essential approach to healthcare training and practice, namely interprofessional education and collaborative practice (IPECP), that should inform the student learning experience. IPECP is currently foregrounded in HPE research, visible in a plethora of publications. [2] In the rationales provided for interprofessional collaboration during the topic generating phase of this study, respondents spoke directly to the under resourced context within which many in SSA work, and the extent to which collaboration across all healthcare practitioners will be crucial to address the workforce challenges identified under Priority # 1 including that it would enhance patient care. It should be noted that the establishment of a SSA organisation dedicated to fostering IPECP (The African Interprofessional Education Network (AfrIPEN): https://afripen.org/) in 2017 may account for why this particular topic was ranked so high. AfrIPEN has an affiliate relationship with AFREhealth, and it is plausible that some of our respondents are members of both organisations. In their rationales, however, respondents also made reference to the ‘African patriarchal social system’ that needs to be problematised as it is ‘contrary to the philosophical underpinnings of shared leadership, shared decision-making etc.’ that are so needed in the region.
Priority #9 – Potential of rural communities as platforms for training health care professionals
Linked strongly to the need to address human resources for health challenges was a focus on enhancing student learning through distributed clinical training, specifically in rural areas. This priority emphasised the growing awareness of how large academic hospitals are not necessarily the best environment for training students to meet community needs.
Priority # 3 – Teaching a holistic and person-centered approach and
Priority # 10 – Relevance of communication skills training in culturally diverse contexts
Teaching person-centered and holistic care underscores the value of a comprehensive approach to the person in the African context which also takes into account the person’s values and needs, as well as their family and community. [23] A further indicator of the complexity of context can be seen in priority # 10 which recognises the need for students to be trained to communicate effectively with patients across multiple contexts and different cultures. This links with previously mentioned perspectives of respondents who felt it was important to support research initiatives that would provide responses for local and regional contexts.
Identifying and evaluating strategies to improve pedagogical practice
A final group of priorities, which includes some already mentioned above, relates to identifying and evaluating strategies to improve pedagogical effectiveness or assess new modes of curricula and pedagogical innovation.
Priority # 4 – The role of information communications technology in HPE
It could be argued that a focus on the role of information communications technology (ICT) in HPE would have been expected given the ubiquitous nature of blended and e-learning approaches in modern-day HPE. [24] Interestingly, however, this topic did not feature in the topic generating process, but was introduced in Round One and validated in Round Two. There can be no doubt as to the importance of this research focus, particularly investigation that can explore options for drawing out the affordances of ICT amid resource constraints. For example, while many rural areas in SSA may be isolated in terms of connectivity, the region is known for its high rate of cellular telephone coverage providing a lifeline for health care workers in these remote regions. Investigating the potential for HPE using mobile technology could, therefore, have particular relevance. [25]
Priority # 6 – Quality assurance processes and procedures in health professions education
This priority demonstrates the intent of respondents to ensure that educational practices and teaching innovations are carefully monitored and evaluated. Responses provided during the topic generation phase suggested that this focus has to do with being accountable given expectations by stakeholders for the provision of quality education.
Priority # 8 – Determining how to develop and implement curricula that are responsive to the health needs of SSA
In 2010, the Lancet commissioned article exploring Health professional in the 21st Century, [26] argued that curricula had not kept pace with community healthcare needs, catalysing introspection among health professions educators and curriculum developers across the world. Given SSA specific resource constraints, and its unique burden of disease, exploring what a responsive curriculum for the region might look like would appear to be of significant value for the HPE community. It could be argued that this priority possibly provides a research focus that could encapsulate most if not all of the others that made the final list.