Introduction:
It has been suggested to ensure exposure of medical undergraduates to skills-based training program on research methods.[1] In response to this, to begin with, we have developed a short hands-on training program for medical undergraduates and implemented it for a year during their small group posting in the Department of Community Medicine. Subsequently, it was noted that we were just facilitating too many short cross-sectional studies for apparently visible health and environmental problems. We realized it as a missed opportunity to link students to local community through feasible problem-solving action research. Next year, we refined our program and encouraged our students to work in team and carry out an action research on a common health or environmental problem. Such community-based experiential learning was expected to offer an opportunity to develop problem solving ability, leadership ability, communication skills, altruism and give benefit to local community.[2] It has been suggested to study if such programs foster cognitive growth, critical thinking and individual development of the participants.[2] Since, it was a new initiative for us, we decided to obtain learners’ reactions to such program.
Material and Methods:
Setting: The present study was done in the surrounding villages of Sri Manakula Vinayagar Medical College and Hospital, a private medical college in rural Pondicherry, India. Pondicherry, a union territory in South India, has an average literacy of 76% and predominantly spoken language is ‘Tamil’. Common health problems in our surrounding villages are communicable diseases such as diarrhea, respiratory tract infections, tuberculosis and Non-communicable diseases such as diabetes, hypertension, and problems related to kidneys, and accidents.
Study design: In the present study, we obtained both quantitative (post-then-pre rating)[3] and qualitative (response to open ended questions) feedback from the students exposed to this program.
Participants: 125 second year medical undergraduates.
Exposure to community-based action research program: During small group (30 in each) posting in second year in the Department of Community Medicine, Students were exposed to some interactive sessions on basic steps in conducting research. We conducted some interactive sessions on communication skills, participatory action-research and qualitative research and showed them a brief animation film titled – ‘Whose reality count?’ which emphasizes how important it is to retain communication with a local community while doing a needs assessment and implementing any intervention program in a community.[4] Later, students formed their small self-managed groups (5-6 in each group) and selected one problem for action-research. Faculties helped them to identify a common health problem in local villages and develop a feasible action research on it. Students were encouraged to apply their innovative ideas for problem solving. After its implementation, groups of students were asked to share their learning and experiences in a small plenary session, where all the faculties and post-graduates in the Department were invited. It was an appreciative enquiry, where students could share photographs taken in field, survey findings, and content of interviews with villagers, health education materials in the form of charts and flipbook and any other innovations if they did for their projects.
Data collection: Retrospective pre-post feedback was taken at the end of their posting where students were asked to self-rate their acquired skills on the five point scale. Apart from this, students were asked to respond to three open ended questions – 1) a thing, s/he liked about this program, 2) how can s/he use this knowledge in the future? 3) How can this program be improved in future?
Data analysis: Mean were calculated for pre and post self-rating on skills acquired by the students in retro-pre feedback. We have applied paired t test to compare mean values. p value less than 0.05 was considered significant. The content analysis of the qualitative data was undertaken.
Results
Overall 23 action research projects were done on topics related to- a) Preventive measures of non communicable diseases, b) prevention of communicable diseases such as diarrhoea and tuberculosis b) Menstrual hygiene c) Personal hygiene d) waste disposal (including plastic usage) d) breast feeding and contraception e) Iodization of salt f) Immunization practices g) Self-medication h) injury management, i) addiction to alcohol and tobacco. Most of the actions taken were health education of target population.
Learning of steps in research methods: Of the 125 students, 101 filled in the Questionnaire, a response rate of 81%. Overall the response from the feedback questionnaires were positive, The mean post-exposure scores were significantly higher for perceptions such as identifying the public health problem, doing a review of literature, writing methodology, developing a questionnaire for the identified problem (p<0.01) (Table-1). The mean post exposure score is significantly higher for data collection in the field, data analysis, preparation of tables and graphs, writing results, writing conclusions and recommendations and communication skills as a presenter (p< 0.01). (Table 1)
| Table 1: Post-then-pre ratings from students (n=101) soon after exposure to the survey research process |
| Response questions |
Pre –exposure Mean+SD |
Post exposure Mean+SD |
p- value |
I am able to identify public health problem |
1.78 + 0.89 |
3.9 + 0.86 |
<0.01 |
I can do the review of literature( online) |
2.02 + 0.95 |
3.85 + 0.96 |
<0.01 |
I have basic orientation in writing methodology |
1.85 + 0.97 |
4 + 0.92 |
<0.01 |
I can prepare a questionnaire |
2.28 + 1.1 |
4.41 + 0.72 |
<0.01 |
I can collect data in the field |
2.29 + 1.3 |
4.31 + 0.97 |
<0.01 |
I think, I can enter using EPI_INFO |
1.59 + 1.06 |
4.03 + 1.18 |
<0.01 |
I sensitised for data analysis |
1.8 + 1.06 |
3.88 + 1.07 |
<0.01 |
I can prepare tables |
2.07 + 1.1 |
4.08 + 0.95 |
<0.01 |
I can prepare graphs |
2.13 + 1.2 |
4.25 + 0.93 |
<0.01 |
I think can able to write the results for a project |
2.1 + 1.06 |
4 + 1.05 |
<0.01 |
Writing conclusion &recommendations |
2.2 + 1.15 |
4.1 + 0.8 |
<0.01 |
I can prepare and present the slides in PowerPoint |
2.9 + 1.4 |
4.4 + 0.75 |
<0.01 |
Communication skills (community members) |
2.4 + 1.2 |
4.1 + 0.96 |
<0.01 |
Communication skills as presenter of your project |
2.3 + 1.16 |
3.8 + 0.9 |
<0.01 |
Learning in/from community: This short exposure contributed to development of three domains – 1) Cognitive: Students acquired knowledge of local health problems, 2) Social-emotional: It improved communication in them and with community members and 3) vocational: Students started anticipating their future professional role. Students wanted more exposure in field settings, supervision by more trained faculties and early exposure in first year (Table 2).
| Table 2: Content analysis of open ended responses from students |
What did you learn in this posting? |
Domains developed |
Student’s Statements (Number of students making statements) |
Cognitive |
|
Social-emotional |
-
It helped us in working together as a group with a common objective (15) Improvement in communication with the people (7)
-
Came to the know the difficulties in public health (5)
-
Developed good interaction with the students (8)
-
It helped us in identifying public health problems in the community (15)
-
Making us think practically (2)
|
Vocational |
-
I will have to use this knowledge in identifying health problems and control it in my community (15)
-
This learning going to help me in future research work (41)
-
Awakened interest in the subject (5)
|
How can this approach be even better? |
Duration |
More time is required in the field (7) |
Resources |
Increase the number of faculties per group (10) |
Scope |
Teaching in first year will improve the scope (2) |
Discussion
There was significant improvement in their perceived abilities to follow basic steps in carrying out research such as – problem identification, literature search, drafting a proposal, preparation of questionnaire, data collection, analysis and its reporting. It is also perceived to improve their communication skills with local community. Dongre et al have reported similar achievements by exposing medical undergraduates to a short community-based survey on epidemiology injuries in local community.[5] However, the scope of learning in the present approach was broad, where students were allowed to select local health problem which they wanted to study\address in a team. The present approach improved their communication skills with local villagers and improved their inter-personal communication, which is crucial for effective team work, a requirement for primary care physician in a developing country context.
Through service learning or community-based learning, students participate in the kind of ‘experiential learning (Kolb’s cycle)’ that engages cognitive, moral-ethical and psychosocial dimensions of learning as they confront complex issues and concepts within the context of human life.[2] This methodology offers adult learners the opportunity to interact with others whose community or class differs from their own. Our approach could contribute to development of cognitive, social-emotional and vocational domains of the students. More sustained efforts are required in future to consolidate and improve the gains achieved so far.
Our approach was in alignment with ‘Problem Solving for Better Health’ (PSBH) initiative, a global movement by Dreyfus health foundation, which is coordinated by a non-profit organization called as Health Action by People in India. It had a specific focus on sensitizing medical students on community health through individual projects.[6] We have ensured adequate exposure to basics of research methods with more emphasis on group projects and use of participatory/qualitative research methods in community setting. To foster their learning, we conducted an appreciative enquiry of their work done.
The important characteristics this program had were – 1) evolution of clear objectives to link medical undergraduates to local community, 2) activities which benefits to students and community, 3) activities based on local health problems, 4) Encouragement to use qualitative/participatory research methods. However, other characteristics of community-based learning such as – community partners as co-educator, intellectually challenging reflection activities and assessment strategies capturing students learning and improving community partnerships were missing. It may be achieved by improving its duration of exposure, scope, intensity and scope of faculty and student reflection.
There are five strategies for implementing community-based learning for adult learners: 1) Give adult students purposeful (no abstract) assignment and activities, 2) Present a variety of engaging learning models and experiences – structured assignments or needs-based, feasible projects, 3)Help adult students discover the link between academic learning and their future success, 4) Include adult learners in institutional governance and recognize their skills, and 5) Offer training for faculty to increase their knowledge of adult learners.[2] Our approach could partly claim some aspects of above strategies. However, motivating faculties for sustaining such community-based activities in long run is a challenge.[7]
Overall, our community-based action research program is taking a shape and getting mainstreamed in the exiting curriculum. It could sensitize students to basic steps in research and contributed to their cognitive, social-emotional and vocational development. Further work is needed to increase its scope and intensity to achieve the development of cultural, moral and ethical domains. Ultimately, it could enhance student learning, facilitate civic engagement, foster partnerships between medical schools, community and promote social change.
References
- Deo MG. Need for research oriented medical education in India. Indian J of Medical Research. 2009;130:105-107.
- Reed SC, Marienau C. (editors). Linking adults with community: Promoting civic engagement through community based learning. San Francisco: Jossey-Bass; 2008.
- Using the retrospective Post-then-Pre design. (Online). Retrieved 22 November 2010. Available from http://www.uwex.edu/ces/pdande/resources/pdf/Tipsheet27.pdf
- Training in Participation Series [PRA tips on CD-ROM]. Patna (India): Institute for Participatory Practices; 2004.
- Dongre AR, Kalaiselvan G, Mahalakshmy T. The benefits to medical undergraduates of exposure to community-based survey research. Educ Health (Abingdon). 2011 Dec;24(3):591. Epub 2011 Dec 2.
- Health Action by People. Problem Solving for Better Health. (Online). Retrieved 22 November 2010. Available from http://www.hapindia.org/?cat=4
- Mostafa SR, Khashab SK, Fouaad AS, Abdel Baky MA, Waly AM. Engaging undergraduate medical student in health research: students’ perceptions and attitudes and evaluation of a training workshop on research methodology. Journal of the Egyptian Public Health Association. 2006;81(1-2):99-118.
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