QUALITATIVE AND QUANTITATIVE RESEARCH
Technology-enhanced Learning of Community Health in Undergraduate Medical Education Kalyani Premkumar, MBBS, MD, MSc (MedEd), PhD,1 Allen G. Ross, MD, PhD,2 Jennifer Lowe, RN, MSc,3 Carla Troy, RN, BEd, MHSc,3 Cheryl Bolster,2 Bruce Reeder, MD, DTM&H, MHSc, FRCPC2
ABSTRACT Objectives: The purpose of this evaluation study was to identify the feasibility of repurposing specific online modules developed by the Public Health Agency of Canada as continuing education modules for front-line practitioners, in teaching clinical epidemiology to undergraduate medical students. Specifically, relevancy of the content, quality of online material, time-effectiveness of using the online component, required resources, and student satisfaction were investigated. Method: Both qualitative and quantitative data were collected. Semi-structured interviews were conducted with stakeholders from the Skills Enhancement Program, technical support personnel, instructors, a web administrator and an assignment marker. Surveys measuring student satisfaction were administered to students in the middle of the online component and at the end of the course. Two student focus groups were conducted. As well, other documents (e.g., online materials, course packages) were reviewed. Results: Instructors felt that the content of the modules was appropriate and would enhance learning, although making changes was time consuming. Medical students reported that the content was relevant and they enjoyed the flexibility allowed by the online components. However, students reported that there were too many assignments and too much content for the allotted time frame. Conclusion: The Public Health Agency’s online content seems to be relevant to medical students, but needs to be fine-tuned further to cater to their specific needs. Instructors required a lot of time to review and revise the content. The time allocated for online content in this course was too little compared to the volume of information. It is feasible to repurpose the online modules in undergraduate medical education. Key words: Community health education; undergraduate medical education; online learning La traduction du résumé se trouve à la fin de l’article.
W
ith the growing evidence that premature mortality and increasing morbidity among the global population is a result of unhealthy lifestyle and environment, the medical curricula has to change from a purely physical model of disease causation to a biopsychosocial and preventive model that embodies a wholistic view of health. The World Health Organization has defined Social Accountability as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”1 In other words, the medical curricula should equip physicians with the skills that align with societal needs. In line with this, the Association of Faculties of Medicine of Canada (AFMC) has numerous initiatives in place, including a task force to develop public health curriculum objectives for medical students.2-5 While policies are being made at the global and national levels, there is increasing difficulty in accommodating and implementing these changes at the grassroots level. A survey of 17 Canadian medical schools to identify barriers to implementation of the new public health objectives indicates among others the following impediments: lack of curriculum time, lack of faculty, inadequate support from local champions, high cost of developing resources and learning modules, and poor image as an attractive specialty.4 Medical schools continue to struggle with the questions: Where within the curriculum should population and preventive health be introduced? If new elements are added, what should be taken out? © Canadian Public Health Association, 2010. All rights reserved.
Can J Public Health 2010;101(2):165-70.
How should the curriculum be modified to integrate these elements? How can technology be used? How can attitudes be changed? One study indicates that medical students believe that population and preventive health issues are a matter of ‘common sense’ and spending time on such ‘soft skills’ may jeopardize their clinical knowledge, skills and patient management.6 From literature and informal conversations, the sentiments of Canadian medical students seem to be similar.7 Curriculum planners need to find innovative ways to introduce population and preventive health information into the medical curricula. One of the initiatives of the Public Health Task Group of AFMC is to obtain an inventory of resources available in order to share and support public health teachers in medical schools.4 Since public health is an important topic that spans all health professions, it may also be possible to repurpose learning resources developed for other health professions. One such resource is the Public Author Affiliations 1. Educational Support and Development Unit, Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK 2. Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK 3. Public Health Agency of Canada, Ottawa, ON Correspondence and reprint requests: Dr. Kalyani Premkumar, Educational Support & Development, College of Medicine, University of Saskatchewan, Room B103 Health Sciences, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Tel: 306-9661409, Fax: 306-966-7920, E-mail:
[email protected] Conflict of Interest: None to declare.
CANADIAN JOURNAL OF PUBLIC HEALTH • MARCH/APRIL 2010 165
TECHNOLOGY-ENHANCED LEARNING
Figure 1.
Undergraduate medical curriculum at the University of Saskatchewan, College of Medicine
Figure 2.
Community Health & Epidemiology Course site
Table 1.
The Skills Enhancement for Health Surveillance Program Online Modules
The Medical Curriculum Y E A R
4
Clinical Clerkship - Junior Undergraduate Rotating Student Intern (JURSI) Anesthesiology; Family Medicine; Emergency Medicine; Internal Medicine; Surgery, Obstetrics & Gynecology; Pediatrics; and Psychiatry. Elective time (any discipline) & Selective time (defined set of options)
Y E A R
3
Y E A R
2
Y E A R
1
Phase D (contd.) June - May (47 weeks)
Phase C
Phase D January - May
August - December
(15 weeks)
(20 weeks)
Systemic Study of Disease (contd.) Population Health Clinical Sciences (Obstetrics & Gynecology, Pediatrics, Psychiatry, Physical Medicine & Rehabilitation, Diagnostic Imaging)
Clinical Clerkship
Phase B August - May (33 weeks)
Systemic Study of Disease Pathology Microbiology Genetics Pharmacology & Therapeutics Clinical Sciences (Internal Medicine & Surgery)
Phase A
August - May
(33 weeks)
Form & Function of the Human Body Biochemistry & Nutrition Neurosciences Core Pathology Life Cycles & Humanities
Health Agency of Canada’s (PHAC) Skills Enhancement for Public Health online modules.8 This paper describes our attempt to repurpose the online modules in the training of undergraduate medical students.
Community Health & Epidemiology Course, College of Medicine At the College of Medicine, the course on Community Health and Epidemiology is introduced in the third year, primarily in a face-toface environment (Figure 1). The course is taught between August and November as three units: Population Health and Canada’s Health Care system, Clinical Epidemiology, and Preventive Medicine. To promote the C.A.S.E. (Cooperative, Active, Self-directed, Experiential learning) philosophy of the medical school,9 and in keeping with the directives of AFMC, the instructors of this course were looking for innovative ways to meet the objectives and utilize new learning experiences. One suitable resource identified was the Skills Enhancement for Health Surveillance Program online modules.10
PHAC’s Online Program The Program consists of a series of internet-based, facilitated modules, made available to public health professionals across Canada as continuing professional education opportunities.7,9 The modules (Table 1) are designed to provide easily accessible and affordable training. These modules were developed in partnership with a content consortium comprised of 10 Canadian educational institutions and in collaboration with key public health professional organizations. 166 REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 101, NO. 2
EPI1 EPI2 EPI3 APP1 APP2 APP3 SUR1 SUR2 STA1
Basic Epidemiological Concepts Measurement of Health Status Epidemiological Methods Outbreak Investigation and Management Epidemiology of Chronic Diseases Applied Epidemiology: Injuries Introduction to Surveillance Communicating Data Effectively Basic Biostatistics
Organization of modules Each module has been developed to be highly interactive and selfdirected, capitalizing on effectively using multimedia to introduce the content. Clear objectives, video recordings of interviews with experts, bulletin board exercises, relevant assignments, links to additional resources, pre- and post-module quizzes are some of the features of each online module (see Figure 2 for examples of the course site). Blackboard/WebCT content management system11 is used as a learning platform for all modules. In the original form, participants work on each module over 8 weeks with a trained online facilitator. The modules have been pilot tested and evaluated extensively. Evaluation reports and participant feedback indicate that they are
TECHNOLOGY-ENHANCED LEARNING
Table 2.
Evaluation Questions and Sources of Data
Questions
Indicators
Data Sources
Project Rationale and Objectives 1. What are the rationale and objectives of the project?
• Original rationale and objectives
• Documents (if available) • Interviews with Drs. Reeder and Ross
• Factors facilitating objectives achievement • Factors hindering objectives achievement
• Documents • Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members)
2.
What types of factors impeded or facilitated achievement of the objectives? Was the time frame for the project adequate? Was everybody who needed to be involved, involved in a timely fashion?
Project Implementation 3. What problems were faced during implementation? • Problems encountered during How were they resolved? What problems remain? How implementation might they be overcome? How was the project coordinated? • Resolutions to problems How well did each member of the team work? 4.
What were the specific problems faced relating to the online environment? E.g., Uploading material; determination of content; determination of assessment methods; correction of assignments; facilitation of discussion; marking of discussion; feedback to students
5.
How were assignment markers identified/recruited and • Process for identifying, recruiting, selected? What role did assessors play? How were they selecting and training assignment trained for their role? What improvements do they suggest? markers/discussion facilitators
• Interviews with Instructors • Interviews with graduate student/s correcting assignments
6.
What were the strengths and weaknesses of project design?
• Inconsistencies between design and implementations • Reasons for inconsistencies • Strengths and weaknesses of design
• Document review • Administrative data review • Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members)
• Stakeholder roles specified • Expectations of stakeholders • Were the expectations met
• Documents • Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members)
• Satisfaction ratings • Suggested improvements
• Interviews with stakeholders • Survey of students • Student focus groups
• Description of processes • Unexpected results
• Documents • Student assessment • Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members)
Partnerships 7. What stakeholders played what role in the project and what do they bring to the project in terms of resources and expertise? What does each stakeholder expect from the project? Were expectations met? What are the advantages and disadvantages to the collaboration? 8.
How satisfied are the various players (Instructors; Web administrators; Skills Enhancement; students; assignment markers; discussion facilitators) involved with the processes and outputs of the project? What suggestions do they have for improvement?
Project Outcome and Implications 9. What are the main outputs and outcomes of the project? Are these in line with what was intended? What unexpected results were there?
Project Impact 10. Were the online modules truly an effective learning experience? How does it compare with face-to-face experiences?
• Description of test development and testing process • Time allowed for assessment
• Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members); • Student survey
• • • •
Interviews with Instructors Assignments marker Survey of students Examination of turn-around time in WebCT
Student satisfaction • Interviews with core project team (Drs. Reeder Instructor satisfaction and Ross; BCIT Web Administrators; Skills Appropriateness of content Enhancement Team members) Level of difficulty (content; use of WebCT) • Survey of students • Student focus groups
Project Resources 11. How much money and other resources were allocated to • Breakdown of project expenditures the project? How much time was spent by Instructors to • Time spent by students decide on online content, monitor the online course? • Time spent by Instructors How much time was spent by students in learning online content? How much time was spent on resolving technical difficulties, accessing online content? Sustainability 12. What recommendations were made? What are the next steps? What strategies will help ensure sustainability of the efforts?
• • • •
• • • •
Survey of students Student focus groups Interviews with Instructors Interviews with web administrators
• Recommendations • Interviews with core project team (Drs. Reeder • Identified strategies to ensure sustainability and Ross; BCIT Web Administrators; Skills Enhancement Team members) • Student survey • Student focus groups
Lessons 13. What lessons have been learned so far? What are the main • Identified lessons strengths and weaknesses of the project? What • Strengths and weaknesses improvements are needed to continue with inclusion of the Skills Enhancement online component as developed by PHAC?
of high quality and relevant to public health professionals.8,12 Although the benefits of using hybrid and online courses in general have been demonstrated,13,14 the relevance and feasibility of these modules for medical students have not been examined. Thus, the objectives of the evaluation were to: 1) identify the feasibility of using specific modules from PHAC’s online program in
• Interviews with core project team (Drs. Reeder and Ross; BCIT Web Administrators; Skills Enhancement Team members) • Surveys of students • Student focus groups
the teaching of undergraduate medical students, 2) identify content relevancy, 3) assess the quality of the online material, 4) measure the effectiveness of using the online component – specifically in terms of student and instructor time, 5) identify resources required for using the online component, and 6) measure students’ satisfaction. CANADIAN JOURNAL OF PUBLIC HEALTH • MARCH/APRIL 2010 167
TECHNOLOGY-ENHANCED LEARNING
Table 3.
Results of the Surveys of the Online Component of the Course CHEP 401.6
Survey Statements Administered in the Middle of the Course (1= strongly disagree, 10 = strongly agree)
# of Responses
Mean
SD
Content 1. For the most part the online content of this course was well organized. 2. The content of the course was at an appropriate level of difficulty. 3. The amount of material covered in the online component was reasonable. 4. In general, there was sufficient time to complete each module. 5. The content was relevant and helped me understand the topic better. 6. The videos and audios contributed to my learning. 7. The articles used were relevant. 8. The articles used were current. 9. The online component of the course encouraged me to take responsibility for my own learning.
49 49 49 49 49 39 47 43 48
4.61 6.08 4.47 4.22 4.86 3.13 5.23 6.44 4.27
2.71 2.92 2.90 2.69 2.78 2.29 2.57 2.21 2.71
Learning Exercises 10. The learning exercises helped me see how the theoretical knowledge we learned applied to clinical situations. 11. The learning exercises were at an appropriate level of difficulty. 12. For the most part, the time given for completion of learning exercises was adequate. 13. I had no difficulty uploading assignments. 14. The assignments were corrected and returned in a timely manner. 15. The feedback given following learning exercises was helpful.
48 48 48 48 48 35
4.13 5.71 4.15 8.15 3.31 1.54
2.45 2.67 2.74 2.73 2.38 1.20
Bulletin Board 16. The bulletin board gave us the opportunity to work as part of a group. 17. The bulletin board gave us the opportunity to ask questions, participate in discussions and reflect on the information presented. 18. The topics for discussion were relevant. 19. It was easy to participate and contribute to the online discussion. 20. The discussions were facilitated well. 21. The criteria used for assessment of discussion were transparent.
48
3.54
2.57
48 48 47 40 47
3.42 4.44 6.23 2.95 2.77
2.56 2.51 2.72 2.48 2.23
Navigation and User-friendliness 22. It was easy to navigate within the online component of the course. 23. The organization of the course was user-friendly.
49 49
5.20 4.86
2.53 2.56
Mean 7.85 4.67 4.19 6.63 5.63
SD 1.46 2.63 2.62 2.10 2.17
Survey Statements Administered at the End of the Course 1. The content of the course was at an appropriate level of difficulty. 2. The volume of material was reasonable. 3. The time allocated for the online component was adequate. 4. The information provided is relevant to my medical career. 5. There was sufficient time allocated for reflection and applying the knowledge gained.
METHODS Supercourse development After obtaining permission from PHAC, instructors examined the various modules and decided to use four in their course offered in the fall of 2006: Basic epidemiological concepts, Measurement of health status, Descriptive epidemiological methods, and Outbreak investigation and management. In order to improve relevancy to medical students, the instructors thoroughly reviewed each module and identified content and elements that needed to be modified or removed. Modifications were minor, and included changing sentence structure to address the target audience appropriately and altering assignments. Since the time available was much less that that originally planned for these online modules (100 hours/4 original modules), many of the assignments and bulletin board exercises were eliminated. In the original design, each module is covered over 8 weeks with a trained online facilitator. Here, the adaptation of each module was to be covered over approximately 2 weeks, with the online self-directed learning complemented by face-to-face seminars. With the help of British Columbia Institute of Technology (BCIT) that administered the modules for PHAC, changes were made and the four modules converted into one “supercourse.” The supercourse was housed in BCIT’s server and was offered to 58 medical students as a component of the face-to-face course in a WebCT content management system. Online content was integrated with faceto-face sessions and comprised 6 of 29 classes, or approximately 20% of the course. One of the instructors (AR) served as the online discussion facilitator and a graduate student was hired to correct assignments. A local web administrator (CB) was identified for day168 REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 101, NO. 2
# of Responses 27 27 27 27 27
to-day administration of the online component and a consultant (KP) was contracted to evaluate the implementation of the modules in the course.
Evaluation Evaluation questions and data sources are presented in Table 2. Although a thorough evaluation of the online component was conducted with data collected from multiple sources, this paper’s primary focus is on student perceptions. Students completed two surveys, one halfway through the course and one at the end of the course (see Table 3). Two focus groups with second-year medical students (n=5; n=10) were conducted after the course was finished to help triangulate survey responses and were facilitated by a researcher not involved with course instruction (KP). Focus group questions were similar to those asked in the surveys. Analysis of the quantitative data was done using standard statistical software. For the quantitative data obtained (primarily from the surveys), descriptive statistics such as central tendency (mean), variability (e.g., standard deviation, range), and frequency were calculated. Focus groups were transcribed and sections relevant to each question were identified and all sections relating to a specific issue were interpreted together.
RESULTS Instructors and partners The instructors felt that the introduction of the online component would increase the time available for self-directed learning and enhance learner interaction. They found the online information relevant and that it more than met the specific objectives of certain
TECHNOLOGY-ENHANCED LEARNING
sections of the course. Making modifications proved to be timeconsuming, despite the fact that the changes being made were small. Instructors found that they spent more time than anticipated to identify content to be modified.
Medical students Survey results revealed that students rated the majority of items close to neutral perception of the course (Table 3). Items pertaining to course facilitator, such as unreasonable due dates, turnaround time, feedback for assignment submissions and discussion facilitation, received low ratings. The students were also dissatisfied with the videos and audios as they were recordings of experts directly addressing public health professionals. As expected, students did not have difficulties accessing the course site, participating in discussions or uploading the assignments. Students also reported that the information provided was relevant to their medical career and that the content of the course was at an appropriate level of difficulty. Students in the focus group felt that the information was both useful and relevant and liked the flexibility that the online component afforded: “I like the idea. It just needs to be fine-tuned by decreasing repetition, highlighting important points. The links were very useful.” “The links were very good. I didn’t have to search – if I needed information, I would have had to go and Google it or find a reputable source...” “When I did the self test – whenever you answered wrong – there was feedback; feedback was useful.” The intended outcomes were to increase time available for selfdirected learning, meet some of the objectives of the course and enhance online interaction. In the focus group, students expressed that though they did have more time for self-directed learning, there was too much information in the online component and too many assessments, given the time frame. When presented with student feedback, instructors expressed surprise at the mismatch between the time actually spent by students outside class hours (3-4 hours/week) compared to the expected 6-9 hours. All stakeholders were generally satisfied with the project and felt that such collaborations are advantageous and beneficial. However, to improve implementation, they felt that there should be sufficient time, proper project design, specification of roles and a formal agreement made between the various partners.
DISCUSSION From the feedback obtained from students, using online content originally developed for a different target audience and the process of implementation, as followed in this course, did not prove to be an effective learning experience in some regards. However, by improving project implementation and with further revision of the information such as reducing repetitions and increasing complexity of assignments and training faculty in online discussion facilitation, it has the potential to be a truly effective learning experience. The content seems to be relevant to medical students, but needs to be fine-tuned further to cater to their specific needs. The quality of PHAC’s modules is good – specifically the links and the self tests. Instructors required a lot of time to review and revise the course. The time allocated was too little compared to the volume of
information. There was also a mismatch in terms of time actually invested by students as compared to that expected by instructors. One explanation for this mismatch, as expressed by some students in the focus group, could be the lower importance given to clinical epidemiology compared to other courses students were taking. Thus, strategies to emphasize the importance of clinical epidemiology in health professions are needed. We continue to use the PHAC modules in our undergraduate program with ongoing modifications being made, based on this experience and other research.15,16
CONCLUSIONS Collaborations between various health agencies and professionals are of benefit to all stakeholders and should be pursued and encouraged. However, time and resources are needed to modify the content. Since one medical school has already modified the content to suit medical students, it may be possible for other medical schools to use this modified content. Further effort should be made to disseminate and share these high-quality resources with all health professionals at the national and international level. Repurposing and sharing learning resources between medical schools and across health professions could be one innovative way of introducing population and preventive health information within the medical school curricula.
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TECHNOLOGY-ENHANCED LEARNING 15. Rossiter JR. Adapting e-learning courses for new contexts: Two case studies of continuing professional development courses in Public Health [dissertation]. Oxford, UK: University of Oxford, 2009. 16. Rossiter JR, Robinson H. Repurposing online continuing professional development courses in health into new educational contexts. 5th Pan-Commonwealth Forum on Open Learning; 2008 July 13-17; University of London. Available at: http://www.wikieducator.org/images/4/43/PID_414.pdf (Accessed July 20, 2009).
partenaires du programme Amélioration des compétences, du personnel d’assistance technique, des enseignants, d’un webmestre et d’un correcteur de travaux. Des questionnaires mesurant la satisfaction des étudiants ont été administrés au milieu du module en ligne et à la fin du cours. Il y a eu deux groupes de discussion avec des étudiants. D’autres documents ont aussi été examinés (documents en ligne, trousses d’enseignement).
Received: July 24, 2009 Accepted: November 19, 2009
Résultats : Selon les enseignants, le contenu des modules était pertinent et susceptible d’améliorer l’apprentissage, mais les changements à y apporter prenaient du temps. Les étudiants en médecine ont trouvé le contenu pertinent et apprécié la souplesse que leur offraient les modules en ligne. Les étudiants ont cependant déclaré qu’il y avait trop de travaux à remettre et trop de contenu pour le temps accordé.
RÉSUMÉ Objectif : Cette étude d’évaluation visait à déterminer la faisabilité de transformer certains modules en ligne mis au point par l’Agence de la santé publique du Canada en modules de formation continue pour les praticiens de première ligne (enseignement de l’épidémiologie clinique aux étudiants de premier cycle en médecine). Plus précisément, nous avons étudié la pertinence du contenu, la qualité des documents en ligne, le gain de temps associé à l’utilisation du module en ligne, les ressources nécessaires et la satisfaction des étudiants. Méthode : Nous avons recueilli des données qualitatives et quantitatives. Des entretiens semi-dirigés ont été menés auprès des
Conclusion : Le contenu en ligne de l’Agence de la santé publique semble pertinent pour les étudiants en médecine, mais doit être peaufiné pour mieux répondre à leurs besoins. Les enseignants ont eu besoin de beaucoup de temps pour examiner et réviser le contenu. Le temps accordé pour la portion en ligne du cours était trop restreint pour le volume d’information. Il est faisable de transformer des modules en ligne pour l’enseignement médical de premier cycle. Mots clés : éducation à la santé communautaire; enseignement médical premier cycle; apprentissage en ligne
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