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Few youth-friendly health services worldwide have been scaled up or evaluated from young people's perspectives. South Africa's Youth Friendly Services (YFS) programme is one of the few to have been scaled up. This study investigated young people's experiences of using sexual and reproductive health services at clinics providing the YFS programme, compared to those that did not, using the simulated client method. Fifteen primary healthcare clinics in Soweto were randomly sampled: seven provided the YFS programme. Simulated clients conducted 58 visits; young men requested information on condom reliability and young women on contraceptive methods. There were two outcome measures: a single measure of the overall clinic experience (clinic visit score) and whether or not simulated clients would recommend a clinic to their peers. The clinic visit score was based on variables relating to the simulated clients' interactions with staff, details of their consultation, privacy, confidentiality, the healthcare workers' characteristics, and the clinic environment. A larger score corresponds to a worse experience than a smaller one. Multilevel regression models and framework analysis were used to investigate young people's experiences. Health facilities providing the YFS programme did not deliver a more positive experience to young people than those not providing the programme (mean difference in clinic visit score: −0.18, 95% CI: −0.95, 0.60, p=0.656). They were also no more likely to be recommended by simulated clients to their peers (odds ratio: 0.48, 95% CI: 0.11, 2.10, p=0.331). More positive experiences were characterised by young people as those where healthcare workers were friendly, respectful, knew how to talk to young people, and appeared to value them seeking health information. Less positive experiences were characterised by having to show soiled sanitary products to obtain contraceptives, healthcare workers expressing negative opinions about young people seeking information, lack of privacy, and inadequate information. The provision and impact of the YFS programme are limited. Future research should explore implementation. Regular training and monitoring could enable healthcare workers to address young people's needs.

Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of this form of education. The goal of this study was to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, compared with other types of digital education, and design variants of virtual patients in health professions education. The outcomes of interest were knowledge, skills, attitudes, and satisfaction. We performed a systematic review on the effectiveness of virtual patient simulations in pre- and postregistration health professions education following Cochrane methodology. We searched 7 databases from the year 1990 up to September 2018. No language restrictions were applied. We included randomized controlled trials and cluster randomized trials. We independently selected studies, extracted data, and assessed risk of bias and then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. A total of 51 trials involving 4696 participants met our inclusion criteria. Furthermore, 25 studies compared virtual patients with traditional education, 11 studies investigated virtual patients as blended learning, 5 studies compared virtual patients with different forms of digital education, and 10 studies compared different design variants. The pooled analysis of studies comparing the effect of virtual patients to traditional education showed similar results for knowledge (standardized mean difference [SMD]=0.11, 95% CI -0.17 to 0.39, I =74%, n=927) and favored virtual patients for skills (SMD=0.90, 95% CI 0.49 to 1.32, I =88%, n=897). Studies measuring attitudes and satisfaction predominantly used surveys with item-by-item comparison. Trials comparing virtual patients with different forms of digital education and design variants were not numerous enough to give clear recommendations. Several methodological limitations in the included studies and heterogeneity contributed to a generally low quality of evidence. Low to modest and mixed evidence suggests that when compared with traditional education, virtual patients can more effectively improve skills, and at least as effectively improve knowledge. The skills that improved were clinical reasoning, procedural skills, and a mix of procedural and team skills. We found evidence of effectiveness in both high-income and low- and middle-income countries, demonstrating the global applicability of virtual patients. Further research should explore the utility of different design variants of virtual patients.

In the field of health care, knowledge and clinical reasoning are key with regard to quality and confidence in decision making. The development of knowledge and clinical reasoning is influenced not only by students' intrinsic factors but also by extrinsic factors such as satisfaction with taught content, pedagogic resources and pedagogic methods, and the nature of the objectives and challenges proposed. Nowadays, professors play the role of learning facilitators rather than simple \"lecturers\" and face students as active learners who are capable of attributing individual meanings to their personal goals, challenges, and experiences to build their own knowledge over time. Innovations in health simulation technologies have led to clinical virtual simulation. Clinical virtual simulation is the recreation of reality depicted on a computer screen and involves real people operating simulated systems. It is a type of simulation that places people in a central role through their exercising of motor control skills, decision skills, and communication skills using virtual patients in a variety of clinical settings. Clinical virtual simulation can provide a pedagogical strategy and can act as a facilitator of knowledge retention, clinical reasoning, improved satisfaction with learning, and finally, improved self-efficacy. However, little is known about its effectiveness with regard to satisfaction, self-efficacy, knowledge retention, and clinical reasoning. This study aimed to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students. A randomized controlled trial with a pretest and 2 posttests was carried out with Portuguese nursing students (N=42). The participants, split into 2 groups, had a lesson with the same objectives and timing. The experimental group (n=21) used a case-based learning approach, with clinical virtual simulator as a resource, whereas the control group (n=21) used the same case-based learning approach, with recourse to a low-fidelity simulator and a realistic environment. The classes were conducted by the usual course lecturers. We assessed knowledge and clinical reasoning before the intervention, after the intervention, and 2 months later, with a true or false and multiple-choice knowledge test. The students' levels of learning satisfaction and self-efficacy were assessed with a Likert scale after the intervention. The experimental group made more significant improvements in knowledge after the intervention (P=.001; d=1.13) and 2 months later (P=.02; d=0.75), and it also showed higher levels of learning satisfaction (P<.001; d=1.33). We did not find statistical differences in self-efficacy perceptions (P=.9; d=0.054). The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, and it increases the satisfaction with the learning experience among nursing students.

Communication is a crucial element of every health care profession, rendering communication skills training in all health care professions as being of great importance. Technological advances such as artificial intelligence (AI) and particularly machine learning (ML) may support this cause: it may provide students with an opportunity for easily accessible and readily available communication training. This scoping review aimed to summarize the status quo regarding the use of AI or ML in the acquisition of communication skills in academic health care professions. We conducted a comprehensive literature search across the PubMed, Scopus, Cochrane Library, Web of Science Core Collection, and CINAHL databases to identify articles that covered the use of AI or ML in communication skills training of undergraduate students pursuing health care profession education. Using an inductive approach, the included studies were organized into distinct categories. The specific characteristics of the studies, methods and techniques used by AI or ML applications, and main outcomes of the studies were evaluated. Furthermore, supporting and hindering factors in the use of AI and ML for communication skills training of health care professionals were outlined. The titles and abstracts of 385 studies were identified, of which 29 (7.5%) underwent full-text review. Of the 29 studies, based on the inclusion and exclusion criteria, 12 (3.1%) were included. The studies were organized into 3 distinct categories: studies using AI and ML for text analysis and information extraction, studies using AI and ML and virtual reality, and studies using AI and ML and the simulation of virtual patients, each within the academic training of the communication skills of health care professionals. Within these thematic domains, AI was also used for the provision of feedback. The motivation of the involved agents played a major role in the implementation process. Reported barriers to the use of AI and ML in communication skills training revolved around the lack of authenticity and limited natural flow of language exhibited by the AI- and ML-based virtual patient systems. Furthermore, the use of educational AI- and ML-based systems in communication skills training for health care professionals is currently limited to only a few cases, topics, and clinical domains. The use of AI and ML in communication skills training for health care professionals is clearly a growing and promising field with a potential to render training more cost-effective and less time-consuming. Furthermore, it may serve learners as an individualized and readily available exercise method. However, in most cases, the outlined applications and technical solutions are limited in terms of access, possible scenarios, the natural flow of a conversation, and authenticity. These issues still stand in the way of any widespread implementation ambitions.

Virtual patients (VPs) are computer screen-based simulations of patient-clinician encounters. VP use is limited by cost and low scalability. We aimed to show that VPs powered by large language models (LLMs) can generate authentic dialogues, accurately represent patient preferences, and provide personalized feedback on clinical performance. We also explored using LLMs to rate the quality of dialogues and feedback. We conducted an intrinsic evaluation study rating 60 VP-clinician conversations. We used carefully engineered prompts to direct OpenAI's generative pretrained transformer (GPT) to emulate a patient and provide feedback. Using 2 outpatient medicine topics (chronic cough diagnosis and diabetes management), each with permutations representing different patient preferences, we created 60 conversations (dialogues plus feedback): 48 with a human clinician and 12 \"self-chat\" dialogues with GPT role-playing both the VP and clinician. Primary outcomes were dialogue authenticity and feedback quality, rated using novel instruments for which we conducted a validation study collecting evidence of content, internal structure (reproducibility), relations with other variables, and response process. Each conversation was rated by 3 physicians and by GPT. Secondary outcomes included user experience, bias, patient preferences represented in the dialogues, and conversation features that influenced authenticity. The average cost per conversation was US $0.51 for GPT-4.0-Turbo and US $0.02 for GPT-3.5-Turbo. Mean (SD) conversation ratings, maximum 6, were overall dialogue authenticity 4.7 (0.7), overall user experience 4.9 (0.7), and average feedback quality 4.7 (0.6). For dialogues created using GPT-4.0-Turbo, physician ratings of patient preferences aligned with intended preferences in 20 to 47 of 48 dialogues (42%-98%). Subgroup comparisons revealed higher ratings for dialogues using GPT-4.0-Turbo versus GPT-3.5-Turbo and for human-generated versus self-chat dialogues. Feedback ratings were similar for human-generated versus GPT-generated ratings, whereas authenticity ratings were lower. We did not perceive bias in any conversation. Dialogue features that detracted from authenticity included that GPT was verbose or used atypical vocabulary (93/180, 51.7% of conversations), was overly agreeable (n=56, 31%), repeated the question as part of the response (n=47, 26%), was easily convinced by clinician suggestions (n=35, 19%), or was not disaffected by poor clinician performance (n=32, 18%). For feedback, detractors included excessively positive feedback (n=42, 23%), failure to mention important weaknesses or strengths (n=41, 23%), or factual inaccuracies (n=39, 22%). Regarding validation of dialogue and feedback scores, items were meticulously developed (content evidence), and we confirmed expected relations with other variables (higher ratings for advanced LLMs and human-generated dialogues). Reproducibility was suboptimal, due largely to variation in LLM performance rather than rater idiosyncrasies. LLM-powered VPs can simulate patient-clinician dialogues, demonstrably represent patient preferences, and provide personalized performance feedback. This approach is scalable, globally accessible, and inexpensive. LLM-generated ratings of feedback quality are similar to human ratings.

Introduction Resistant strains of bacteria are rapidly emerging with increasing inappropriate use of antibiotics rendering them less efficacious. Self-purchasing of antibiotics particularly for viral infections is a key driver of inappropriate use, especially in lower- and middle-income countries. There is a particular issue in countries such as Pakistan. Consequently, there is a need to assess current rates of self-purchasing especially for reserve antibiotics to guide future policies. Aims Assess the extent of current antibiotic sales without a prescription in urban areas of Pakistan. Methodology A multicenter cross-sectional study was conducted in different areas of Punjab, Pakistan using Simulated Client technique. The investigators demanded different predefined antibiotics from WHO AWaRe groups without prescription. Three levels of demand were used to convince the pharmacy staff in order to dispense the antibiotic without a prescription. A data collection form was completed by simulated clients within 15 min of each visit. Results Overall 353 pharmacies and medical stores were visited out of which 96.9% pharmacies and medical stores dispensed antibiotics without demanding a prescription (82.7% at demand level 1 and 14.2% at demand level 2), with only 3.1% of pharmacies refusing to dispense antibiotics. The most frequently dispensed antibiotic was ciprofloxacin (22.1%). Surprisingly, even the reserve group antibiotics were also dispensed without a prescription. In only 25.2% visits, pharmacy staff guided patients about the use of antibiotics, and in only 11.0% pharmacists enquired about other medication history. Conclusion Currently, antibiotics are easily acquired without a legitimate prescription in Pakistan. There is a need for strict adherence to regulations combined with a multi-dimensional approach to enhance appropriate dispensing of antibiotics and limit any dispensing of WHO restricted antibiotics without a prescription.

Virtual patients (VPs) are computer-based simulations of clinical scenarios used in health professions education to address various learning outcomes, including clinical reasoning (CR). CR is a crucial skill for health care practitioners, and its inadequacy can compromise patient safety. Recent advancements in large language models (LLMs) and social robots have introduced new possibilities for enhancing VP interactivity and realism. However, their application in VP simulations has been limited, and no studies have investigated the effectiveness of combining LLMs with social robots for CR training. The aim of the study is to explore the potential added value of a social robotic VP platform combined with an LLM compared to a conventional computer-based VP modality for CR training of medical students. A Swedish explorative proof-of-concept study was conducted between May and July 2023, combining quantitative and qualitative methodology. In total, 15 medical students from Karolinska Institutet and an international exchange program completed a VP case in a social robotic platform and a computer-based semilinear platform. Students' self-perceived VP experience focusing on CR training was assessed using a previously developed index, and paired 2-tailed t test was used to compare mean scores (scales from 1 to 5) between the platforms. Moreover, in-depth interviews were conducted with 8 medical students. The social robotic platform was perceived as more authentic (mean 4.5, SD 0.7 vs mean 3.9, SD 0.5; odds ratio [OR] 2.9, 95% CI 0.0-1.0; P=.04) and provided a beneficial overall learning effect (mean 4.4, SD 0.6 versus mean 4.1, SD 0.6; OR 3.7, 95% CI 0.1-0.5; P=.01) compared with the computer-based platform. Qualitative analysis revealed 4 themes, wherein students experienced the social robot as superior to the computer-based platform in training CR, communication, and emotional skills. Limitations related to technical and user-related aspects were identified, and suggestions for improvements included enhanced facial expressions and VP cases simulating multiple personalities. A social robotic platform enhanced by an LLM may provide an authentic and engaging learning experience for medical students in the context of VP simulations for training CR. Beyond its limitations, several aspects of potential improvement were identified for the social robotic platform, lending promise for this technology as a means toward the attainment of learning outcomes within medical education curricula.

Background Community pharmacy practice worldwide has been shifting from product-focused to patient-oriented. However, due to the absence of separation between prescribing and dispensing in Malaysia, community pharmacists may have limited roles in the provision of pharmaceutical care to patients with chronic diseases. Therefore, the main functions of community pharmacists in Malaysia are related to self-medication requests for minor ailments and the supply of non-prescription medications. The objective of this study was to determine the practice of pharmaceutical care by community pharmacists within the Klang Valley, Malaysia in response to self-medication requests for a cough. Methods This study utilised a simulated client method. A research assistant, acting as a simulated client, visited community pharmacies in the Klang Valley, Malaysia to consult the pharmacists on the treatment of a cough experienced by his father. Upon leaving the pharmacy premise, the simulated client entered the pharmacist’s responses in a data collection form which was structured based on pharmacy mnemonics for the response to symptoms, OBRA’90 on counselling elements, the five practice principles of pharmaceutical care by the American Pharmacists Association and literature review. Visits to the community pharmacies were conducted from September to October 2018. Results The simulated client visited a total of 100 community pharmacies. None of these community pharmacists practised adequate patients’ data collection, with only a low proportion who practised all the components studied under medication information evaluation (13%), formulating a drug therapy plan (15%) and monitoring and modifying the plan (3%). Of the 100 community pharmacists, 98 recommended treatment but none of them provided all the counselling elements studied in implementing the drug therapy plan. Conclusion The present study showed that community pharmacists within the Klang Valley, Malaysia were not providing adequate pharmaceutical care services to patients seeking self-medication for a cough. Such practice may compromise patient safety if inappropriate medicines or advice are given.

To determine the prevalence of and factors associated with dispensing antibiotics without a prescription in online and community pharmacies in China. We conducted a nationwide cross-sectional study of online and community pharmacies in 27 cities and counties in nine provinces in China (selected by multistage sampling) from July 2017 to December 2018. We assessed sale of antibiotics without a prescription and quality of pharmacy services through simulated clients who asked to buy specific antibiotics. We compared the prevalence of sales between online and community pharmacies, and between location and features of community pharmacies. Of 220 online and 675 community pharmacies, 174 (79.1%) and 586 (86.8%) sold antibiotics without a valid prescription, respectively. About half of the online pharmacies had a notice on their website about the illegality of selling prescription-only medicines without a prescription while none of the community pharmacists had. More online pharmacies without this notice dispensed antibiotics without a valid prescription (  < 0.001). Antibiotics' sale without a prescription was significantly less prevalent in provincial capital cities (71.6%; 161/225) than prefectural-level cities (95.1%; 214/225) and counties (93.8%; 211/225;  < 0.001). Most pharmacy staff did not ask for important information from clients before dispensing the antibiotic or provide them with necessary information about the antibiotic. Given the high proportion of sales of prescription-only medicines without a prescription, there is a need to strengthen enforcement of regulations, improve public education on antibiotics, train pharmacy staff and consolidate public involvement in antibiotic stewardship in retail pharmacies in China.

Background Although there has been momentum in implementing sexual and reproductive health services in Ethiopia, young people remain underserved despite their demonstrated needs. Quality care improves utilization of health service and increases the likelihood of obtaining ongoing care. However, little is known about the quality of youth-friendly sexual and reproductive health service in Ethiopia. Therefore, this study sought to investigate the quality of youth-friendly sexual and reproductive health service in West Gojjam Zone, North West Ethiopia. Methods Health facility-based cross-sectional study was conducted in West Gojjam zone in 2018 to assess the quality of the service using the Donabedian model. The assessment was done through the triangulation of multiple methods: simulated client study; structured interviews with service providers; observations; and key informant interview with providers and expertise. Fifty-four visits were made to 18 randomly selected health facilities by three simulated clients trained to present three different scenarios (i.e., adolescent with sexually transmitted infection, pregnancy test request and a lady with dry cough). Data were entered and analyzed using SPSS version 21. Facility visit score of ≥ 75% in all quality component categorized as “good quality” otherwise classified as performing below the standard. Thematic analysis was done to analyze qualitative data. Results In this study, none of the health facilities achieved ≥ 75% in the three components of quality measurement. From 18 health facilities, 6(33.3%) provided low quality in all domains. Process component, which measures client-provider interaction and privacy/confidentiality, was the most compromised one. However, a promising result was reported in the input quality that measured the availability of trained providers, drugs, and supplies. The presence of community-based health insurance and age driven comprehensive youth-friendly service delivery approach were identified as challenges to deliver quality services. Conclusions The quality of the service ranges from low to medium, with adolescent related elements performing poorly. Minor renovations of health facilities, training on client handling, and contextual modifying the age driven youth-friendly service approach may improve the quality of the services.