Certificate Course in Occupational Safety and Health: A Capacity Building Program for Primary Care Physicians based on Adult Learning Model.

Context: The need for physicians qualified in the field of occupational safety and health (OSH) is growing with the growth of manufacturing and service sectors where maximum number of work-related morbidity and mortality occur. Aims: This article aims to assess the effectiveness and feasibility of the certificate course in occupational safety and health for training and capacity building of primary care physicians in OSH. Methods and Material: Guideline for reporting evidence-based practice educational interventions and teaching (GREET) was used for describing educational interventions. The outcome was assessed by comparing the mean scores. t test with P < 0.005 was considered a level of significance.
Results: The result showed significant improvement in the cumulative pre- and post-test scores after each module. The certificate course is suitable for adult learning as there was no intergroup difference in knowledge after the program. Consistent with the findings, the improvement scores indicate that training has made a difference in the knowledge and learning of the trained physicians. Conclusions: This customized training intervention has high potential for scaling up while optimally addressing the scarcity of trained physicians in the OSH in high population density settings like India where a high number of vulnerable workforces work in the informal economy. Copyright:

INTRODUCTION

Occupational diseases and injuries are major contributing factors to the global burden of diseases.[1] People in developing countries bear more than 80 per cent of global burden of occupational disease and injury.[2] Annually, 12.2 million people, mostly in developing countries, die from occupational diseases while in active working age.[3] As more than half of the world's labor force resides in Asia and the Pacific region,[4] occupational diseases and injuries cause great human suffering and socioeconomic loss.[5]

India has the second-largest labor force (461 million) in the world after China;[6] therefore, 17 per cent of the world's cases are contributed by India.[7] Lately, rapid industrialization with limited knowledge and awareness of hazards has made the situation grimmer in the country.[8] Still, occupational health is considered a secondary issue in India.[9] This results in huge socio-economic burden on individuals, their families, communities, societies, and the nation at large.

Hence, a strong and responsive occupational health system is of paramount importance in India. However, the current system has various lacunae, and most profound is the lack of trained occupational health professionals.[91011] A huge number of undiagnosed and unreported occupational illnesses are indicative of a scarcity of trained occupational health professionals.[12] Capacitating primary care physicians (PCPs) in occupational disease management is one of the strategies to overcome this challenge.[913] Such an initiative can improve access to promotive, preventive, and curative occupational health services.[14]

Therefore, the certificate course in occupational safety and health (CCOSH) was envisaged to build the capacity of PCPs in the field of occupational safety and health. This article aimed to describe the CCOSH program and to assess its outcome in terms of change in knowledge of trained participants and satisfaction level after undergoing the capacity-building program.

METHODOLOGY

There are inconsistencies in describing educational interventions and to make these replicable and comparable, improvement in the reporting of educational interventions is required.[15] Therefore, a Delphi survey was utilized in determining and identifying 39 items for describing an educational intervention.[16] From these 39 items, a checklist of guidelines for reporting evidence-based practice educational interventions and teaching (GREET) was developed using a three-stage development process.[17]

The GREET checklist included items recommended for reporting educational interventions where an educational intervention is defined as “any learning activity where the intent is to facilitate the learning of skills or knowledge”. This paper employed GREET checklist to describe the CCOSH program in terms of 1) Intervention, 2) Theory, 3) Learning objectives, 4) Steps of evidence-based practice (EBP), 5) Materials, 6) Educational strategies, 7) Incentives, 8) Instructors, 9) Delivery, 10) Environment, 11) Schedule, 12) Face-to-face time, 13) Adaptations, 14) Modifications, 15) Attendance, 16) Actual delivery and 17) Actual schedule.

Outcome assessment of the program was done using a pre- and post-test study design. This study design measures the occurrence of an outcome of a particular intervention.[18] The pre/post-test is a common form of evaluating training programs on knowledge improvement of the participants where identical tests are used before and after the training.[19] The pre/post-test study design is one of the most reliable and widely used designs in training evaluations.[2021] Therefore, program-specific pre/post-test questionnaires were prepared and introduced before and after each training session. The outcome of the program was assessed by comparing the mean scores received by the participants. Additionally, participants’ feedback was also collected to assess the program delivery.

The data was analyzed using SPSS version 21. Continuous variables were shown as mean (± standard deviation) and categorical variables were reported as frequencies. Student t test, Mann–Whitney U test, and Kruskal Wallis test were used for comparative analyses where P < 0.005 was considered as level of significance.

RESULT

Program description

The application of adult learning principles in medical education settings is important for transforming learners into effective physicians.[2223] Therefore, CCOSH was conceptualized and developed based on assumptions and principles of Malcolm Knowles's adult learning theory.[24252627]

A group of experts brainstormed on academic content and program models to meet the expectations of the participants. Experts in the field of OSH developed the course curriculum and delivery methodology based on already existing scientific evidence and literature. The CCOSH curriculum was designed and developed based on existing evidence-based scientific guidelines. All five modules were developed by experts in their respective fields and consisted of theory, PowerPoint presentations, case studies, module-specific pretest, and post-test questions/quiz. The entire curriculum was divided into five thematic modules, namely,

Occupational Health & Safety - An Overview

Industrial hygiene - Industrial Safety-Hazard Risk Management and Stress & Adverse Psychological Factors at Work

Occupational Medicine – Occupational Health Services and Occupational Health for Women & Children

Occupational epidemiology – Health Surveillance & Data Management and Basics of Epidemiology & Biostatics in Occupational Health

Occupational Health and Safety – Information-Education-Communication (IEC) and Industry Emergency medical services (First Aid and Disaster management).

Faculty were identified based on their expertise, educational background, experience, and contribution in the field of OSH in the country. These faculty were deliberately selected and involved from the initial stages of designing and developing the academic content for the program. They were apprised of the participants’ profile so that content was developed meticulously, keeping into account the vision and objectives of the course, and expectations of the participants.

Considering the pandemic situation, the program adopted an online mode of delivery via Zoom platform to maximize its reach. The online sessions served two purposes: 1) the participants’ clinical practice would not be hampered by the program, and 2) participants would be able to attend the sessions at their convenience with greater motivation to learn. Participants were also given access to the recordings of online sessions for future reference and longer knowledge retention.

The CCOSH was spread over five consecutive days (except Sunday). The program used real-time online interactive sessions. Each session commenced with a pre-test followed by a didactic lecture delivered by an expert using standardized PowerPoint presentations, and concluded with post-test and discussion on the respective module. The study material was shared with the participants beforehand to make sessions more interactive and enriching. Although, participants joined voluntarily to learn and acquire knowledge in the OSH field, certificate of completion was awarded only to successful participants meeting the following eligibility criteria: 1) attendance in all online sessions 2) participation in pre-test and post-test, and 3) obtain minimum 50% marks in exit-examination.

Participant profile

A batch size limited to 50 participants was finalized to ensure adherence to adult learning principles during the virtual sessions.[28] Therefore, 50 PCPs (78% male and 22% female) enrolled in the program. A majority (43%) of participants were in the age group of 31–40 years. Most of them (66%) were graduates while 34% were postgraduates. More than half (56%) were practicing in rural areas and 44% in urban areas. The mean clinical experience was 16.8 (min. 4, max. 44, SD 8.67) years. Among all, 82% were engaged in private practices while remaining (18%) were in government affiliates.

Program outcome

All participants attended and participated in online sessions. The mean pre- and post-test scores of the participants were 6.07 (min. 2.8 and max. 8.0, SD 1.19) and 7.12 (min. 3 and max. 10, SD 1.19) respectively. The analysis showed a significant improvement in the knowledge of PCPs post training. The program improved the participants’ knowledge equally despite the differences in socio-demographic indicators. The average pre-test, post-test, and improvement scores in respective modules are shown in Tables 1 and 2. The mean score received by the participants in the exit-examination was 14.2 (min. 10 and max. 19, SD 2.45) [Table 3].

Table 1

Average pre-test, post-test, and improvement scores

Module No.	Average Pre-test Score	Average Post-test Score	Improvement Score	P
Module 1	6.6	7.6	1.0	<0.000
Module 2	4.6	5.8	1.2	<0.000
Module 3	6.6	7.4	0.8	<0.005
Module 4	4.9	7.0	2.1	<0.000
Module 5	7.4	8.2	0.8	<0.005

Table 2

Demographic indicator–wise pre-test and post-test scores

Descriptive characteristic	Pre-test Score (mean, SD)	P	Post-test Score (mean, SD)	P
Gender
Male (n=39)	6.13 (1.27)	0.405*	7.07 (1.18)	0.990*
Female (n=11)	5.86 (0.84)		7.30 (1.28)
Qualification
Graduate (n=33)	6.04 (1.24)	0.973*	7.10 (1.24)	0.748*
Postgraduate (n=17)	6.12 (1.12)		7.14 (1.12)
Area of practice
Rural (n=28)	5.97 (1.29)	0.613*	6.93 (1.39)	0.164*
Urban (n=22)	6.20 (1.05)		7.38 (0.80)
Experience (years)
0-10 (n=11)	5.70 (1.73)	0.649#	6.36 (1.79)	0.660#
`11-20 (n=23)	6.01 (1.08)		7.28 (1.12)
21-30 (n=13)	6.42 (0.93)		7.34 (6.88)
31-50 (n=3)	6.30 (1.32)		7.23 (0.21)
Affiliation
Government (n=9)	6.50 (0.82)	0.203*	7.29 (0.88)	0.905*
Private (n=41)	5.97 (1.25)		7.07 (1.26)

* Mann–Whitney U Test, # Kruskal Wallis Test

Table 3

Demographic indicator–wise exit examination score

Descriptive characteristic	Exit Examination Score (mean, SD)	P
Gender
Male (n=39)	14.21 (2.35)	0.906*
Female (n=11)	14.18 (2.92)
Qualification
Graduate (n=33)	13.76 (2.12)	0.091*
Postgraduate (n=17)	15.06 (2.88)
Area of practice
Rural (n=28)	14.00 (2.54)	0.489*
Urban (n=22)	14.45 (2.38)
Experience (years)
0-10 (n=11)	14.73 (2.72)	0.418#
11-20 (n=23)	13.74 (2.24)
21-30 (n=13)	14.08 (2.43)
31-50 (n=3)	16.33 (3.05)
Affiliation
Government (n=9)	14.22 (2.38)	0.882*
Private (n=41)	14.20 (2.50)

* Mann–Whitney U Test, # Kruskal Wallis Test

Participant feedback

Analysis of the participants’ feedback revealed that almost all participants were satisfied with the program modality like teaching methods, interaction, time allocation, and use of examples. All participants were satisfied with the trainers’ expertise. Consequently, 99% of the participants agreed that post training, their knowledge about OSH improved significantly and the program met its objectives. However, 3% were not satisfied with the virtual training platform because of the connectivity and internet issue. Details of the participants’ feedback are shown in Figure 1.

Figure 1

Participants’ feedback (%)

DISCUSSION

The above results showed significant improvement in the cumulative pre- and post-test scores after each module. The highest improvement was recorded in the fourth and second modules covering topics relevant to occupational epidemiology and industrial hygiene respectively. The other topics which showed improvement in scores were basics of OSH followed by occupational medicine. These results are in congruence with similar studies done in assessing training programs on OSH.[2930]

Table 2 highlights that all PCPs were suitable for adult learning as there was no intergroup difference in knowledge before and after the OSH program. Findings from the participants’ feedback suggest that almost every enrolled participant was satisfied with the various program implementation and management parameters which were designed and developed on the adult learning theory like teaching methods, session interactions, time allocation to sessions, and use of case studies and examples. The study found that 99% of the participants believed that their knowledge about the OSH field enhanced post training.

Consistent with the findings, the improvement scores indicate that training has made a difference in the knowledge and learning of the trained physicians, and it is vital to sensitize and train practicing PCPs with continued customized and standardized medical education to tackle the increasing number of fatalities and disabilities due to occupational hazards.[31] This customized training intervention has high potential for scaling up while optimally addressing the scarcity of trained physicians in the OSH in high population density settings like India where a high number of vulnerable workforces work in the informal economy. This can prove to be a sustainable model while strengthening the linkages between community and existing government programs (which demands full-time commitment and time, making it difficult for physicians to enroll in such training).[31] The training had a large impact on the participant's acceptance of the online training.

CONCLUSION

This study evaluated the feasibility of a training program to facilitate primary care physicians’ holistic knowledge and learning in the field of OSH. The results of the study showed that participants considered the training program to be feasible and a catalyst in their learning about the subject. Thus, the program can serve as a viable approach to facilitate the physicians’ knowledge and skills in the field of OSH. The learning from this training program can be used in the development and implementation of similar programs in other low-income and middle-income countries that face an alarming burden of occupational health injuries and disorders, and a shortage of trained physicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.