Reflections by potential health care providers on a research methodology course taught under a primary health care centre: An experience of inter-professional education.

OBJECTIVES: Public health research demands a collaborative approach in working with communities to combat expected challenges in the field. Therefore, to improve primary care services, a training programme on research methodology, focusing on the principles of inter-professional education (IPE), was introduced at Karachi Medical and Dental College. The objectives of this study were to assess the level of learning by participants in the domain of communication and to explore participants' opinions and evaluations of the training programme.
METHODS: A total of 96 participants, including faculty members, medical students, social works students and health technicians in the research methodology course, were selected during March to September 2010. The study employed mixed method research in which communication competencies and participants' perceptions, as captured by course evaluations, were analysed, and findings were triangulated.
RESULTS: The results showed that 87% of faculty enjoyed contributing to 'inter-professional relationships' and that 'teamwork' skills in community-focused areas improved among 90% of students. As many as 78% of students and 70% of faculty members identified 'active listening' and 'communicating information to families', respectively, as being learned to a lesser extent. These findings were defended by their deliberations on course evaluation.
CONCLUSION: Learning through inter-professional relationships was found to be most effective among faculty, whereas learning through teamwork was found to be most effective among students. Moreover, it was found that information was better communicated to families by students than by faculty staff.

Introduction

Professional education in the 21st century has adapted to increasing health interdependence, changes in educational pedagogy and the public prominence of health by increasing opportunities for mutual learning. The concept of shared learning dates back to 1960s. It then flourished over the subsequent thirty years, as evidenced by the structure and practices of inter-professional education (IPE). These parallel developments gathered momentum, especially in community care, primary care, learning disabilities, mental health, care of the elderly, and palliative care. Consequently, educational initiatives at first were mostly work-based and took the form of workshops, seminars, etc.; later, they included qualifying courses and postgraduate structured programmes.

Recently, a commission report identified the need for a third-generation educational reform, one that develops systems focused on improving the performance of health systems by adapting core professional competencies to specific contexts, with a focus on global knowledge. The first generation of reform, at the beginning of 20th century, involved a science-based curriculum, whereas around mid-century, the second generation of reform involved problem-based instructional innovations. The Commission advocated a third generation of reform by encouraging all health professionals in all countries to become educated, to transfer knowledge and to engage in critical reasoning and ethical conduct, so that health professionals are competent to participate in patient and population-centred health systems.

Correspondingly, the World Health Organization (WHO) presented a framework for implementing inter-professional education (IPE) and collaborative practice. The report defined IPE as students from two or more professions learning about, from, and with each other to enable effective collaboration and improve health outcomes.

Four basic domains of core competencies within inter-professional collaborative practices were identified, as shown in Table 1.

Table 1

Core Competencies of inter-professional education.

Domain 1	Values and ethics in inter-professional practice
Domain 2	Roles and responsibilities
Domain 3	Inter-professional communication practices
Domain 4	Teamwork and team-based inter-professional practice

Pertinent to public health, inter-professional prevention education has been used to advocate for concepts of Healthy People 2010. Recently, IPE's role was highlighted in the Healthy People 2020 Education for Health framework. In general, the delivery of preventive services provides equally important contributions from multiple professions, such as dentistry, dermatology, neurology, gynaecology, social science, etc. Prevention education requires teamwork training in the early phase of the educational continuum to develop effective practices.

Similarly, the “Seamless Care” model of inter-professional education was designed with input from medicine, dentistry and the health professions. The primary goal of Seamless Care was to develop students' inter-professional patient-centred collaborative skills through experiential learning. The model was assessed through role modelling and self-reflection.

IPE can be effectively woven into an experiential setting via simulations, service learning, practicums, etc. Hays's study provided examples of how IPE could be addressed in a community setting through activities that may involve multiple health care providers.8, 9, 10

In one study, researchers developed and implemented the “research-intensive community” model where diverse groups of participants are trained to achieve optimal research productivity in a coherent way. The program, similarly, was found to ensure programme efficiency in another study, in which biology, engineering and mathematics were combined.11, 12 All these examples are limited to assessing knowledge and attitudes and sometimes patient care skills but rarely inter-professional skills.

In the wake of educational reforms, Karachi Medical and Dental College [KMDC] took the initiative to offer training in research methods and communication skills under the auspices of the department of community health sciences. The course was offered to all those contributing to health services within the primary health care centre, situated in a nearby squatter settlement.

The purpose of this case study was to assess the learning outcomes of the communication component of the course through self-reflection by the participants and to explore their opinions regarding strengths and weaknesses of the course. This report describes the benefits of teaching research methodology, with a focus on communication skills, to a wide variety of programme participants and the challenges they encountered.

Materials and Methods

Since 2004, the training programme has been conducted under the auspices of the department of community health sciences of KMDC. In this article, we describe reflections of participants in the research methodology course, which took place in March and September 2010. The curriculum of research methodology was designed separately to offer it both to a ‘faculty Group’ [FG] and a ‘student group’ [SG]. The faculty group comprised medical faculty, dental faculty, health educators, and social workers. In the SG, there were medical students, social work students, postgraduate public health students, health technicians and CHW or LHWs. The durations of the courses for the FG and SG were 4 weeks and 10 weeks, respectively, and the courses were offered twice during the year. The total number of participants was 96, including 24 faculty members, 50 medical students, 10 PGs and 12 technicians. The didactic sessions were delivered separately for each group of participants, while field attachments were conducted in sub-groups comprised of a minimum of 10 members with representatives from all of the main groups. Participants were assigned to various primary health functions, such as MCH, chronic diseases, health promotion and outbreak management, etc.

In this study, the focus was on the application of research methods to determining social and health problems in the community. Outcomes were assessed through introspective reflection by participants regarding the innovative learning of research methods, particularly in the domain of inter-professional communication skills. Participants also reflected on the strengths or weaknesses of the training sessions, as these were perceived in the field or in the classroom. Strengths and weaknesses were described in terms of basic principles of IPE, that is, whether the sessions were connected, continuous, contextual, challenging, and communicative, with reference made to few, if any, of their experiences. Participants in the student group, they were prompted to reflect on how they would evaluate the course in particular and on learning in general.

At the end of the course, participants were asked to submit a structured reflective note of 200–400 words in English, focusing on specific communication competencies and an analysis of course dynamics, particularly the course's strengths and weaknesses.

Two key terms were extracted, namely, “learned to a greater extent” and “learned to a lesser extent,” from their various hyponyms such as ‘excellent’, ‘happy’, ‘satisfied ’ and ‘remarkable’ in the former case and ‘comfortable’, ‘okay’, ‘good enough’, ‘reasonable’, ‘sufficient ’ and ‘at ease ’ in the latter case.

Content analysis was initially performed by 3 authors, as agreed upon by educational expert and social scientists. Descriptive analysis was applied to communication competencies as core learning areas in the research course. Opinions of participants, expressed in their course evaluations, were noted at the end of the course and quoted in the narrative of this report.

Characteristics of participants were analysed in terms of percentages for qualitative variables and in terms of means ± standard deviations for quantitative variables. SPSS version 19 by IBM was used in the analysis. Inferential analysis was not performed; rather, findings were triangulated to explain each theme that emerged.

The participants were guided to evaluate the course offered to them on the basis of the core principles of IPE, namely, coaching, connection, continuity, context, challenge and communication.

Results

The sample characteristics are shown in Table 2. Out of a total sample of 96, there were 35 (36.4%) males and 61 (63.6%) females. The ratio of males to females in the faculty group was 1:3, and in the student group, it was 1:1.5. The mean age of the sample was 28.4 ± 5.8 years, and the median age was 23 years.

Table 2

Characteristics of the participants (n = 96).

Variables	Options	Frequency (%)
Gender	Male	35 (36.4)
	Female	61 (63.6)
Participant Groups	Faculty	24 (25)
	Students	72 (75)
Faculty n = 24	Pathology	2 (8.3)
	Paediatrics	3 (12.5)
	Pharmacology	2 (8.3)
	Neurology	2 (8.3)
	Medicine	5 (20.8)
	Gynaecology	4 (16.6)
	Dermatology	2 (8.3)
	Community Med	4 (16.6)
Students n = 72	MBBS	50 (69.4)
	Social Works	6 (8.3)
	Trainees Public health	4 (5.5)
	Health technicians	12 (16.6)
Research training in past	Yes	28 (29)
	No	68 (70.8)
Past experience of reflective writing	Yes	66 (68.7)
	No	30 (31.2)
Exposure to work in primary care setting	Yes	80 (83.3)
	No	16 (16.6)

Seventy-five percent of the total sample were students including medical, social works, health technicians and residents in public health. All were supposed to have rotations at some point during their training, and they may or may not have taken up practice during the period.

Seventy-one percent (68) of the sample had never had research training. This was true of nearly all students but not residents in public health.

Reflective writing was a new learning experience for 30% of the sample. Among these, the majority were health technicians and student social workers, and a few were medical students.

Eighty-three percent of participants had experience working in a primary care centre.

Reflections on communication in research

The participants in this study belonged to different professions and had varying levels of background information on research intricacies. Table 3 shows that in the FG, a majority (87%) enjoyed contributing to inter-professional relationships by providing constructive feedback (83%) or through interaction on social and physical health problems (79%). On the other hand, community teamwork skills in focus areas were acquired by most of the students (90%) and by a nearly equal percentage (83%) in the faculty group.

Table 3

Reflections of faculty members and students regarding communication competencies (n = 96).

Learning outcomes	Learned to greater extent n (%)		Learned to lesser extent n (%)
	FG	SG	FG	SG
Interact effectively on social and physical health problems	19 (79)	34 (47.2)	5 (20.8)	38 (52.7)
Communicate information with patients, families, and healthcare team members	7 (29.1)	57 (79)	17 (70.8)	15 (20.8)
Express one's knowledge and opinions to team members	13 (54.1)	20 (27.7)	11 (45.8)	52 (72.2)
Listen actively and encourage others	16 (66.6)	16 (22.2)	8 (33.3)	56 (77.8)
Give constructive feedback to others	20 (83.3)	36 (50)	4 (16.6)	36 (50)
Use respectful language appropriate for a given difficult situation	15 (62.5)	46 (63.8)	9 (37.5)	26 (36.1)
Contribute to positive inter-professional working relationships	21 (87.5)	60 (83.3)	3 (12.5)	12 (16.6)
Importance of teamwork in community-focused care	18 (75)	65 (90.2)	6 (25)	7 (9.7)

Moreover, a majority (78%) of the SG identified active listening and encouraging others as an ability acquired through the course, followed by competency in ‘expressing their opinion’ (72%). Additionally, 53% and 50% of students, respectively, cited ‘interaction on social and physical health problems’ and ‘giving constructive feedback to others’ as skills in which they improved as a result of the course.

Among faculty, ‘communicating information’ with patients, families and health care team members was cited to a lesser extent, by 70% of the FG, and ‘disbursing knowledge to other team members’ was cited by just 45% of the FG.

Reflection on strengths and weaknesses of the program

Most of the participants in the FG identified the design of the course and coaching abilities as strengths of the training program, whereas few suggested that more field activities should be included as a means of improving one's participatory learning abilities. The consensus view was that continuity of the programme was a weakness.

The SG group identified coaching and the fact that it was challenging as strengths of the program, while weaknesses were found in a lack of communication and continuity.

Respondents mentioned that materials could be made more user-friendly and interactive to be well understood [leprosy technician].

Respondents said it was enjoyable to discuss a wide spectrum of health problems with participants who had a variety of experiences [clinical faculty].

Students also showed a keen interest and admitted that, although they had thought research methodology would be a dry subject, they thoroughly enjoyed tutorials and field training, and it helped them to apply robust research methods in primary care practice [medical student].

All said they would encourage inter-professional education and felt that working in a diverse group gave them the opportunity to better understand the importance of health workers at all levels [Public Health PG].

The course was viewed as challenging, and some felt it might have been better if a few activities from basic sciences, such as case studies of drug reactions, etc., were added [non-clinical faculty].

Students' enthusiasm and cooperation was evident throughout the exercise. “I hope to see the same sharing and cooperation among us when we actually work in a primary health care centre in the near future” [food inspector].

Discussion

We found an obvious disparity between FG and SG regarding the variety of learning. Majorities of faculty participants exhibited strong learning with respect to contributing to inter-professional relationships (87%), giving constructive feedback (83%) and interaction on social and physical health problems (79%). Similarly, communication skills have been reported to be most effectively learned in studies of experiential learning by psychiatrists and by faculty training in the health profession education programme.10, 13 In our study, half of the students identified interactive competencies with regard to health problems as having been learned to a greater or lesser extent. This finding is understandable in our study, as more than two-thirds of the participants in SG were not adequately acquainted with or trained in medicine and were relatively young. The finding can be further explained by the fact that 17% of the participants had no experience working in primary care settings and consisted of medical students who had not completed their rotations in primary health care centres at the time.

Among students, developing and implementing teamwork in community-focused areas were found to be learned to a greater extent by 90% of the sample. Similarly, in an American study, communication skills through inter-professional education while using simulation were found to be improved among more than 90% of pharmacy students. This was also observed in a trial conducted in New Zealand, in which attitudes towards teamwork were much improved among students who were trained through IPE. However, active listening and expressing one's opinion were learned to a lesser degree by more than two-thirds of students, in contrast to communicating information with families, which was learned by a majority of the FG. This finding might also be explained by participants' respective roles and responsibilities in health care settings and also by experience in participants' respective fields. Surprisingly, a tertile of the FG also identified active listening to a lesser extent. This result may be due to encounters of FG participants with a variety of experts, such as gynaecologists, endocrinologists, dermatologists, pathologists, health educationists and social workers.

The analysis of reflections involves the use of participatory methods to evaluate the thought processes of a highly diverse group of participants. In the literature, there is sufficient evidence that combining normative thinking and participatory methods to actively foster change in implementation settings would help refine theory.15, 16

One would expect to see changes in the behaviour of the full health care team because psychosocial theory-driven methods have been shown to improve 'buy in' among the intended audience.

A study evaluating the first training session to use clinical research methodology, in Chile, was partly in agreement with our findings in that the majority of students reported that the programme had contributed to their professional development and that they had shared some of the knowledge acquired with colleagues in the workplace. Among the teachers, the area of greatest interest was communication strategy.

In another study, not only professional development but also aspects of personal development, such as self-confidence and understanding of personalities, were found to be important topics of learning.

Quantitative analysis shows that the research course was well received, with 87% of students rating its overall quality excellent, good, or satisfactory. The course offered educators a model to teach graduate students the skills that are essential to becoming effective CTS (clinical translation science) researchers. The findings in this study were measured on a scale of 3 responses, with key terms in reflective notes extracted and found to best fit into two categories of learning, namely, learning to a ‘larger extent’ and learning to a ‘lesser extent’. In our study, respectively, for 70% and 30% of the participants, it was research course and writing reflective notes was a new experience, that in itself determined many inter-group differences.

Limitation of study

Varying levels of intellect and differing responsibilities of the participants in field exercises could not be fully controlled in this study, even though the classroom environment was ideal. Content evaluation of the course was not done at that point and therefore not reported here.

Conclusions

Among faculty, learning was found to be maximal with respect to contributions to inter-professional relationships, whereas among students, learning was found to be maximal with respect to teamwork education, an area highly appreciated by students. Moreover, it was evident that, although active listening was learned to a lesser extent, information was better communicated to families by students than by faculty. This difference in maximal and minimal learning of communication skills between faculty and students relates well to their differences in responsibilities and intellect. Their deliberations on strengths and weaknesses of the research methodology course additionally explain the disparity in areas of core learning.

Furthermore, barriers in the form of a lack of user-friendly materials and a lack of continuity in a primary health care setting were identified at the student and faculty levels, respectively.

Although communication in research education programmes was the focus of this study, a number of other issues were brought out that also impacted the experiences of health professionals. These included the context in which the programme was delivered, the diversity of health care teams, cultural barriers of seniority, and levels of confidence and motivation of learners to put their learning into practice.

The findings in this study necessitate research into other domains of IPE to ensure continuance of IPE practice in the future.

Authors' contribution

FAM conceived of this longitudinal study, facilitated the course, and contributed to writing the introduction and discussion. LAB, an eminent educationist and expert in public health, facilitated the course, observed the findings, helped with the qualitative analysis and wrote the results. WAS compiled the data, helped summarize the reflective notes and helped write the results. TAB & SSS observed learning activities in the primary care centre and compiled information. NH, an authority on educational research, guided the methods and procedures. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Conflict of interest

The authors have no conflict of interest to declare.