Strengthening public health medicine training for ...

2008; 30: e196–e218

WEB PAPER

Strengthening public health medicine training for medical students: Development and evaluation of a lifestyle curriculum PETER BARSS, MICHAL GRIVNA, FATMA AL-MASKARI & GERALDINE KERSHAW Departments of Community Medicine & Medical Education, Faculty of Medicine & Health Sciences, United Arab Emirates University, United Arab Emirates

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Abstract Background: Lifestyle factors are major determinants for health and safety. Although many graduates lack interviewing and observational skills for prevention and student lifestyle often deteriorates during training, few medical schools teach comprehensive assessment of lifestyle, particularly in the context of the home environment. Aims: A lifestyle curriculum was developed to teach basic causality and provide practical experience in assessing nutrition, exercise, safety, tobacco addiction, and food hygiene, together with generic skills in history taking, on-site observation, researching and presenting. Methods: Lifestyle has been integrated into the first-year curriculum, evaluated, and improved at the United Arab Emirates University since 2001. After an introduction to determinants of health, students conduct a home interview and observational survey for family residential and traffic safety, smoking, and food hygiene. For nutrition and exercise, students assess personal lifestyle. Generic skills are developed in the context of lifestyle. Evaluations were by faculty and students, including assessed impact on knowledge, skills, and personal lifestyle. The lifestyle curriculum was compared with other countries by detailed search. Results: Detailed evaluation found strong agreement/agreement among students that knowledge had improved on: counselling of patients and families 97%, promoting healthy lifestyles 100%; interviewing 88%; history taking 84%; using research for medical practice 89%; and importance of prevention 96%. Eighty six percent were stimulated to think in new ways about health. Improved personal diet was reported by 60% (p < 0.0004) and exercise by 55% (p < 0.0004), while 36% of non-users started wearing a safety belt in front (p < 0.0004) and 20% in the rear (p ¼ 0.008). Literature review found comprehensive lifestyle curricula to be rare. Conclusions: A lifestyle curriculum developed prevention-oriented history-taking and observation skills for health maintenance, addressing health priorities, improving medical student lifestyle, and strengthening generic skills. Since lifestyle is a major determinant of health, medical schools should consider development of an appropriate curriculum to address their local and national health priorities.

Introduction According to the World Federation for Medical Education, the improved health of all peoples is the main goal of medical education, and it is also the overall mission of the Federation (International Association of Medical Colleges 2001). In this sweeping context, training of medical students in the theory and practice of population health is no longer a luxury but a central element of medical education. While competencies in population-based prevention are now considered essential for practicing physicians (Cleary 2003) and some medical schools teach patient counselling in clinic settings, few faculties have developed a strong curriculum in population health based on primary prevention in family and home settings. It is scarcely surprising that most graduates are unprepared to provide population-based prevention. In the United Kingdom, as part of their 1993 recommendations on undergraduate medical education Tomorrow’s Doctors, the General Medical Council declared public health

medicine should be a prominent theme in the medical curriculum and should include health promotion and illness prevention, assessment and targeting of population needs, and the importance of environmental and social factors in disease (General Medical Council 1993). Five years later, the Council carried out an assessment and found that all but a few exceptional medical schools had failed to succeed in giving public health the high profile it deserved. This failure was attributed to a low profile for public health medicine due to lack of stimulating teaching methods and shortage of funds for good faculty (Bligh 2002; Christopher et al. 2002; Gillam & Bagade 2006). The Institute of Medicine in the United States also emphasized the importance of training in population health for all medical students in both 1988 and 2003. As in the United Kingdom, practical problems in implementation have been noted (Tilson 2006). Key determinants of health, disease, and injury of populations and subpopulations include risk factors described

Correspondence: Dr Michal Grivna, Department of Community Medicine, Faculty of Medicine & Health Sciences, UAE University, PO Box 17666, Al Ain, United Arab Emirates. Tel: þ971-3-7137653 or þ971-3-7137483; fax: þ971-3-7672002; email: [email protected]

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ISSN 0142–159X print/ISSN 1466–187X online/08/09–100196–23 ß 2008 Informa UK Ltd. DOI: 10.1080/01421590802334267

Strengthening public health medicine training for medical students


Practice points . Although public health medicine has been mandated as a prominent theme for the medical curriculum, few medical schools have succeeded due to lack of stimulating teaching methods and inspiring faculty. In many, students become progressively less healthy, are poor models for future patients, and unable to counsel in health issues. Students frequently lack generic skills for searching, writing, and presenting. . A lifestyle curriculum based upon knowledge of main health determinants, a structured family interview and observation survey in the home, and lifestyle selfassessment provides practical skills in nutrition, exercise, safety, tobacco addiction, food hygiene, personal lifestyle, history taking, on-site observation, literature searching, and presentations. . Evaluation showed significant success in preventionoriented history-taking and observation skills for health maintenance and promotion of population health priorities, generic skills, and personal lifestyle including diet, exercise and safety practices. . Medical schools should consider strengthening their training in public health medicine by developing a locally appropriate lifestyle curriculum to address main national health priorities.

collectively as ‘lifestyle’ (Last 2001). Medical students not only arrive lacking knowledge about fundamentals of lifestyle, but in many universities personal lifestyle and perceptions about the importance of prevention deteriorate during their studies (General Medical Council 1993; Delnevo et al. 1996; Bligh 2002; Christopher et al. 2002; Carter et al. 2003; Centers for Disease Control and Prevention 2005; Cape et al. 2006; Gillam & Bagade 2006; Spencer et al. 2006). When they qualify and begin practice, such physicians provide a poor role model for patients and communities (Abramson et al. 2000; Frank et al. 2000). Hence many American and Canadian medical schools have begun to introduce health promotion and support groups for students (Wolf & Scurria 1995). An issue of great practical importance is the inability of many medical students and primary care residents to take histories and provide appropriate education and advice to patients, populations, or communities on topics such as injury prevention for families (Phillips et al. 1993; Wright & Litaker 1998; Xiang et al. 2000; Ball & Bax 2002; Vekefiliu et al. 2002). Although a few medical schools have introduced teaching of counselling on at least one lifestyle factor with patients in a health facility (Conroy et al. 2004; Centers for Disease Control and Prevention 2005), few if any teach a more comprehensive assessment of lifestyle and environmental assessment in a community setting (Garr et al. 2000) in order to provide the social and environmental awareness recommended by the General Medical Council (Christopher et al. 2002). In response to a study of our medical students’ unhealthy lifestyles in 2000 (Carter et al. 2003), including inappropriate diet and exercise, failure to use safety restraints in motor vehicles, as well as insufficient knowledge of prevention in

a community setting, a lifestyle curriculum was developed to introduce first-year students to the main national determinants of health, disease, and injury and to develop practical skills useful for both populations and patients. Such skills would be acquired in the environment where people live, play and work, as contrasted with standard teaching of history taking and physical examination in health facilities with patients. Community Medicine initiated the programme and it evolved in collaboration with Medical Education, who perceived that lifestyle issues would provide a rich source of topics for presentations, searching medical literature, and written synthesis of findings; such ‘generic skills’ are typically weak in new medical students (Whittle & Murdoch-Eaton 2004). The lifestyle curriculum was developed to provide early introduction to: . main national health determinants, including nutrition, exercise, safety, smoking; . practical skills in interviewing, history taking, and observation, specifically oriented to assessment of determinants of health for individuals and families in a population setting; . a healthy and safe personal lifestyle, to protect students’ health and allow them to serve as models for patients and communities; . basic concepts for more advanced phases of the public health medicine and population curriculum; . transferable generic skills. Since comparable practical lifestyle curricula were evident neither in the literature nor in discussion with international colleagues at medical education conferences, this paper reports evolution of the programme based on eight years of annual evaluations, together with results of a detailed assessment in 2007.

Methods Student population and setting First-year students in a 6-year programme, all UAE Arab nationals and about 75% female, at the national medical school in Al Ain, United Arab Emirates; the language of instruction is English.

Curriculum content This includes four main elements: (1)

(2)

(3)

Introduction to lifestyle and causality of health, disease and injury. Five lectures introduce main national determinants of health, emphasising history taking and conduct of an observational home survey. Family lifestyle history and home observational survey. Each student identifies a family with one or more children willing to receive a home visit to assess smoking, injury, and food hygiene by interview and observation. Students are instructed not to advise families, but to formulate recommendations in their reports. Personal lifestyle history. Students log their nutritional intake and physical activity for a week and complete an assessment using appropriate software; this includes measurement of their body mass index.

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(4)

Oral presentation. Each student chooses one aspect of a healthy lifestyle and prepares and delivers a short presentation.

Faculty roles Community Medicine plays a coordinating and primary teaching role on health determinants. Medical Education supports development of independent learning skills through a process approach, emphasising drafting, editing, revision, and solving problems with personal written expression; methods include peer editing and one-to-one counselling.


Student assessment Knowledge of health determinants is evaluated by questions in unit examinations. Fieldwork is assessed by three in-class reports, with access to their completed family questionnaire which is submitted with their report; findings for each determinant in the family’s lifestyle are summarized and evaluated, including recommendations and barriers to change. Reports are graded for substantive content by community medicine faculty and for language appropriate to academic discourse by medical education. Students are also graded on their personal nutrition and exercise assessments, on written responses to several pages of questions on the role of nutrition and exercise in improving and maintaining health, and on their individual oral presentation.

Evaluation of the lifestyle curriculum The programme was assessed and improved annually, including efficiency and acceptability in meeting main objectives (Goldie 2006). Evaluations consisted of written feedback from students, written and verbal review of student and faculty critiques, and assessment of performance on main topic objectives by reports of home visits and personal lifestyle and by presentations. Student presentations were categorized by main determinants for academic years 2004–2007, verifying congruency with national public health priorities. In 2007, a structured evaluation of students was undertaken by an anonymous self-administered questionnaire, including scaled responses, with 21 questions on knowledge and skills development, 16 on changes in personal lifestyle, and 8 on broader aspects of community medicine and population health. For a comparative review, papers on lifestyle teaching in other medical schools were identified using Google Scholar and Pub Med, searching on overall and specific determinants, in all languages.

Results Description of lifestyle curriculum The curriculum has evolved into two main phases, including development of: (1)

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knowledge of health determinants and competence in field assessment of family lifestyle, hazards in the home, and personal lifestyle;

(2)

generic skills in researching, writing, and presentation.

Phase one. Health determinants selected for national priorities are reviewed with students. Practical skills are developed in this context (curriculum map 1), contributing to understanding of causality of health, disease and injury. These determinants, excepting food hygiene, are leading causes of mortality and/or morbidity in the UAE. During field work with a family, students learn to conduct interviews on determinants of health, and document injury hazards and food hygiene by observation. Detailed evaluation of personal lifestyle is also practiced; the logs are reviewed by one faculty and remain confidential. Home interviews and observational surveys are done by structured questionnaire using closed-ended questions with sections on family safety, smoking, and food hygiene (electronic version available via link). Phase two. Each student chooses a topic to research and present in greater depth, developing generic skills (curriculum map 2). Public presentations are attended by colleagues and other students and interested faculty from all departments. Depth of understanding is tested and enhanced by questions and comments from audience. Integration with other curriculum. The first two medical science years are divided into five units of about two months’ duration. The lifestyle curriculum is part of the third and fourth units of the first year, followed in the fifth by a health promotion curriculum (curriculum map 3). These years also include curriculum on other public health topics related to research for medical practice, such as population survey research, epidemiology, biostatistics, and other public health substantive topics such as injury epidemiology, prevention, and management, together with a community or laboratory research project. The final-year community medicine clerkship incorporates a rapid field survey and/or intervention for a target population, review of epidemiology, biostatistics, and research methodology, and more advanced topics such as disease and injury reporting and death certification, disease outbreaks, and occupational medicine. Lifestyle presentation topics selected by students. Topics (n ¼ 130) during 2004–2007 generally reflected national health priorities of injury, cancer, and cardiovascular diseases: nutrition/diet 37% (n ¼ 48), injury prevention/safety 20% (26), exercise 15% (20), smoking 5% (6), food hygiene 2% (2), and others 22% (28). While students consistently had free choice of topics, they needed guidance on understanding which potential topics were congruent with the main public health priorities; during one year when faculty were not available to guide them, 42% (21/50) of presentations were in the ‘other’ category and of marginal or no public health significance. Examples of topics included: child obesity, traffic safety for the family car, yoga of praying, weight loss in nursing homes, children and second hand smoke, stairway safety, osteoporosis and exercise, junk food, safety for agricultural workers, safety of children’s toys, home and yard safety, diet and hypertension, and food-borne diseases.



Curriculum map 1.

Curriculum map 2.

Lifestyle curriculum: steps in acquiring population health knowledge & skills.

Lifestyle curriculum – development of generic presentation & researching skills in the context of lifestyle.

Evaluation and evolution of the lifestyle curriculum Results of the final evaluation are presented first, followed by brief summaries of annual evaluations and resulting improvements of the curriculum.

(a) Structured student evaluation A comprehensive student evaluation was done in 2007; 87% (27/31) of females and 84% (16/19) of males were present

and responded. Over 90% of students agreed or strongly agreed they had met most lifestyle objectives for awareness, knowledge, and skills (Table 1). As for personal lifestyle, students reported major changes in diet, exercise, and use of safety belts (Table 2). Overall views of the lifestyle curriculum were positive (Table 3).

(b) Annual evaluation of faculty and students, issues, & improvements Several issues were identified and improved.

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Population health components of curriculum 1st

Other components of curriculum

year Life style curriculum:

Health promotion curriculum

Life style curriculum:

health & safety assessment skills

generic skills

Other basic medical sciences

2nd year Epidemiology Research in medical practice course

Other population health topics

Community or laboratory research project

Practical research skills Organ systems: problem-based learning


3rd & 4th years

5th & 6th years

Other clinical clerkships

Community medicine clinical clerkship

Curriculum map 3. Life style curriculum – integration with other medical curricula. Table 1. Impact of lifestyle curriculum on development of knowledge and skills of first-year medical students, United Arab Emirates University 2007 (n ¼ 43).

Strongly agree The lifestyle curriculum was helpful in terms of:

Agree

Disagree

Strongly disagree

n

%

n

%

n

%

n

%

Improving my awareness with regard to: Home safety Food hygiene Hazards of smoking Need for a healthy diet/nutrition Benefits of exercise for health Overall improvement in awareness

17 25 25 23 23 113

40 58 58 54 54 53

26 18 17 19 18 98

60 42 40 44 42 46

0 0 1 1 2 4

0 0 2 2 5 2

0 0 0 0 0 0

0 0 0 0 0 0

Improving my knowledge for future counselling of patients and families on: Home safety Traffic safety Smoking prevention Food hygiene Appropriate and healthy diet Benefits of exercise Overall improvement in knowledge for counselling

18 15 20 22 15 19 109

42 35 47 51 35 44 42

23 26 22 21 27 24 143

54 60 51 49 63 56 55

2 1 1 0 1 0 5

5 2 2 0 2 0 2

0 1 0 0 0 0 1

0 2 0 0 0 0 0

Developing my observational skills in terms of identifying: Home safety hazards Food hygiene hazards Developing my interviewing (communication) skills Developing my history taking skills (asking proper questions) Protecting my future patients & populations Promoting healthy lifestyles Learning to work in a community Learning to work with a target population Using research to improve my future medical practice Understanding research journals for my future medical practice Overall improvement in skills development

21 22 12 13 16 21 15 14 14 21 169

49 51 28 30 37 49 35 33 33 49 39

21 20 26 23 24 22 26 23 24 17 226

49 47 60 54 56 51 60 54 56 39 53

1 1 5 7 3 0 2 6 4 5 34

2 2 12 16 7 0 5 14 9 12 8

0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0

(1)

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Scope and duration of family interview. When the project was initiated it was based around home interview of a family, including assessment of nutrition and exercise for the family members, as well as safety, smoking, and food hygiene. This task was challenging

for students new to interviewing; hence the programme was modified. Family interview and observation were retained for safety, smoking, and food hygiene, while each student also reported on their personal food intake and exercise.


Table 2. Impact of lifestyle curriculum on personal lifestyle of first-year medical students, United Arab Emirates University 2007 (n ¼ 43). Yes

Already did it before

Change


Have you made any changes to your lifestyle as a result of this curriculum in terms of:

n

%

n

%

%

Diet More fruits More vegetables More fiber Less fatty food Less junk food (potato chips etc.) Less eating in fast food restaurants Fewer carbonated drinks Less coffee

28 25 23 27 25 32 30 15

65 58 54 63 58 74 70 35

na na na na 1 2 7 8

na na na na 2 5 16 19

65 58 54 63 2900 1480 4375 184

49%, 79% 42%, 73% 38%, 69% 47%, 77%