Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 3  |  Page : 116--121

Flipped classroom – An innovative teaching model to train undergraduate medical students in community medicine


Rupali Vishal Sabale1, Padmaja Chowdary2,  
1 Department of Community Medicine, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
2 Department of Community Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Krishna, Andhra Pradesh, India

Correspondence Address:
Rupali Vishal Sabale
Department of Community Medicine, Seth G S Medical College and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
India

Abstract

Background: Second-year MBBS students need to be trained in applying theoretical knowledge into practice so that they can give appropriate advice during family visits in the community. For this, it is necessary to utilize the classroom timing for discussion and facilitation. In “flipped classrooms,” what is normally done in class and what is normally done as homework is switched or flipped. Thus, a study was planned to train the students to apply theory into practice by using flipped classroom methodology. Methods: After ethical committee approval and informed consent, 48 second year MBBS students were enrolled in the study. Selected topics (i.e., “nutrition in under-five children”) was taught through the “flipped classroom”model after a pretest assessment. Students were allotted a family case in the urban slums having at least one under-five child so that they can apply theory into practice. The formal assessment was done through structured case viva and spot examination. After 3 months, a posttest was conducted in the classroom to assess retention in knowledge. Feedback of the students was taken on the flipped classroom model. Results: The average marks scored in structured case viva with spot examination was 8.28 ± 2.4 marks. There was a statistically significant association of scores in the structured case viva with spot examination with participation in all pre- and in-class activities (P < 0.05). There was a statistically significant difference in pre- and posttest marks (10.03 ± 2.17 vs. 18.84 ± 3.8). The class average normalized gain was 44%. Overall, there was positive feedback for “flipped classroom teaching.” Most of the students felt that this was a practical approach to the topic. Discussion: Students can apply theory into practice and knowledge gained is also retained through the use of the flipped classroom teaching method.



How to cite this article:
Sabale RV, Chowdary P. Flipped classroom – An innovative teaching model to train undergraduate medical students in community medicine.Educ Health 2019;32:116-121


How to cite this URL:
Sabale RV, Chowdary P. Flipped classroom – An innovative teaching model to train undergraduate medical students in community medicine. Educ Health [serial online] 2019 [cited 2020 Jun 1 ];32:116-121
Available from: http://www.educationforhealth.net/text.asp?2019/32/3/116/282872


Full Text



 Background



Undergraduate medical students learn community medicine in the 1st, 2nd, and 3rd year of the MBBS curriculum.[1] The summative assessment is in the 3rd year (part I). In the current curriculum, students have exposure to the community, especially urban slums through a family case study. It is a very unique concept in community medicine where students have to visit families in the community.[2] This is scheduled in the 2nd year. During family visits, students are expected to effectively apply theoretical knowledge into practice by advising family members. Bringing community medicine teaching from the classroom to the community helps to provide a realistic picture to the students and acts as a stimulus to learning and active involvement in its application and implementation.[3] Moreover, family visits are the opportunity to create awareness regarding various health issues in the community. However, in spite of receiving orientation to family visits; students are not able to advise allotted family members satisfactorily during a family visit. To train 2nd-year students, to be able to give appropriate advice, it is necessary to utilize the classroom timing (in clinical posting) for discussion and facilitation. There is a need to free up time for interactive engagement between students and the teacher. Thus, it was felt that use of the flipped classroom model would improve engagement. Using this model, what is normally done in class and what is normally done as homework is switched or flipped.[4] Currently, theoretical teaching on a particular topic and family case orientation is covered in clinical postings. Students are then instructed to read books to come prepared for a family case study. However, this methodology is not serving the purpose since 2nd-year students lack the applied skills. They are not able to correlate the theory with practice when they are in the community. They lack competence in advising the allotted family members on health issues. By implementing a flipped classroom, we want to utilize the classroom time for developing skills so that they can apply theory into practice. However, for this, students should be aware of the aspects of theory that will be delivered before class. Han and Klein[5] drafted a list of “best practices” to approach pre-class learning materials for flipped classroom approaches. These are as follows: align pre-class learning materials with learning objectives, avoid replicating material from pre-class learning during in-class learning, provide specific guidance for pre-class learning materials, be conscientious of preparation time and other demands on students' time, include assessments within pre-class learning materials, allow time at the beginning of class for students' questions and summary of key concepts, hold students accountable for pre-class preparation, and provide access to pre-class learning materials in a timely fashion. Flipped classroom methodology is an educational innovation that shows promise for use in medical education.[6] However, the systematic review done on the effectiveness of flipped classroom in medical education by Chen et al.[7] mentioned that out of 46 articles reviewed, 25 were focused in the USA, 5 in the UK, 3 in Canada, 2 in Hong Kong, and 2 in India. There is a paucity of information on the applicability of flipped classroom in an Indian setting. Moreover, among those articles, much of the changes in knowledge have examined knowledge acquisition. To better inform educational practices, studies examining long-term impact of the flipped classroom with regard to knowledge retention and transfer of knowledge to professional practice and patient care are warranted. In this study, the effectiveness of the flipped classroom model in community medicine to train undergraduate medical students with a focus on retention on knowledge and ability to transfer knowledge in the community setting was evaluated.

 Methods



This interventional study was conducted in a private medical college in Mumbai, affiliated to Maharashtra University of Health Sciences and recognized by the Medical Council of India. Ethical committee approval and informed consent of the study participants were obtained. The intake capacity of the medical students for each year is 50 seats. In the present year, there were 48 medical students in the 2nd year. All those 48 students were oriented to the “flipped classroom model.” The topic on “nutrition in under-five children” was divided into two subtopics, namely day 1 – breastfeeding, complementary feeding, and dietary assessment and day 2 – anthropometric assessment and interpretation of growth chart. Second-year students were posted in the community medicine in the third semester, in two batches of 24 students each, in the period of December–January and January–February 2016. Teaching using flipped classroom methodology was implemented twice for Batch A and B separately. Two subtopics were taught on two separate days in the clinical posting with the gap of 1 day.

Gmail addresses provided by college authorities to all students were utilized for sharing the Google Form links. A WhatsApp group was also created and used to share the links since some students faced technical difficulties in logging in. Google slides – an e-learning tool was used to make an effective presentation of the topic.

Flipped classroom model

Pre-class activity

Google Forms were used as a tool for pre-class activity. The Google Form consisted of three sections. In the first section, PowerPoint presentation slides was shared. Slide content was based on the topic (e.g., breastfeeding, complementary feeding, and dietary assessment) and was aligned with learning objectives. It was a guided reading for students. Students had to read the presentation thoroughly. Replication of materials from both pre-class and in-class was avoided. The PowerPoint slides were shared so that students were knowledgeable regarding the topic before coming to class. After going through the PowerPoint slides, the students took a quiz which was the second section of the Google Form. Questions were of image-based, single best response and open-ended. The Quiz was incorporated as a method of self-assessment. The third section was an open-ended question to allow students to ask any query after reviewing the slides and completing the quiz. The Google Form gave immediate feedback scores to the students. It took almost 20–30 min to go through all three sections. Two such different Google Forms were made for 2 days in-class session topics. Links for Google Forms were shared via e-mail and WhatsApp 2 days before the in-class session. Through this pre-class activity, it was ensured that students had a fair knowledge about the topic which is one of the main principles of the “flipped classroom model.”

In-class activity

Two in-class sessions were planned on two separate days to teach two subtopics. Each classroom session was 150 minutes. Typically, a teaching session began with a short introduction. The topic was briefly discussed for 40–50 min. During this briefing, all queries asked in the Google Form were addressed. The wrong concepts identified from the Google Form analysis were also addressed. After this, students were put to work. Facilitation was done to build their analytical thinking. For this, various group activities were planned for the next 40–50 min. Group activities such as planning a balanced diet, case-based discussion on identifying socioenvironmental factors influencing nutritional status of under-five children, plotting a weight on growth chart and interpretation of the growth curve, and playing an agree-disagree game to understand various myths and misconceptions related to child's nutrition were properly planned out in two classroom sessions. In agree and disagree game, statements were read loudly and each student took their stand whether they agree or disagree with a particular statement. Then, a short debate was conducted between the two groups. The last one-third of teaching time, i.e., 40–50 min was utilized to demonstrate nutritional counseling to mothers. Role-plays were done to learn how to advise the mother/primary caretaker about the nutrition of under-five child.

Thus, each classroom session of 150 min was divided into three parts. The first, one-third was on briefing the topic to build their concepts, next one-third on group activities to build their analytical skills, and last one-third on building their communication skills to advise the mother/primary caretaker during family visits in the urban slum community.

Family case study

After a few days, family visits were conducted. Students were allotted family cases in the urban field practice area of the department of community medicine. Each student was allotted a family having at least one under-five child. Students were provided with a growth chart. They assessed the nutritional status of the child and advised accordingly regarding nutritional status, breastfeeding advice, and diet of the allotted under-five child. Each faculty member supervised almost 5–6 students on their various skills such as dietary history taking, anthropometric measurements, the correct way of plotting weight on a growth chart, and giving appropriate nutritional advice to the mother or primary caretaker.

Method of assessment

To measure the learning amongst students, 30 marks question paper was set. It consisted of seven MCQ type questions, six true/false statements, one match the column type questions, five short answer questions, and three fill in the blanks questions. This test was given to the students as a pretest. A posttest was done after 3 months of teaching to assess their retention of knowledge. To assess the analytical thinking and ability to give appropriate nutritional advice, a practical examination was conducted consisting of structured case viva and spot examinations of 8 marks and 5 marks, respectively. Spot examination questions were of an applied type such as interpretation of growth curve or nutritional status, etc.

After posttest, student feedback was taken on the “flipped classroom model” using 18 item 5 point Likert scale (grading as: 5 – strongly agree, 4 – agree, 3 – neutral, 2 – disagree, and 1 – strongly disagree). Open-ended questions, namely “how the model helped in understanding the topic, in the retention of knowledge and gaining interest in the Community Medicine subject,” were incorporated to explore students' views on the learning through the flipped classroom model.

Data were analyzed using SPSS version 21, IBM Corporation, SouthAsia, India. Descriptive statistics were presented by the mean, standard deviation (SD), and proportion. The difference between the marks was analyzed using an appropriate paired t-test or unpaired t-test. The average learning gain score for the class was calculated. Nominal data were analyzed using the Chi-square test.

 Results



All 48 2nd-year MBBS students were enrolled for the study. Two Google Forms were used for two pre-class activities. Participation in the first and second pre-class activity was 60.4% (29 out 48 students) and 64.6% (31 out 48 students), respectively. Two in-classroom sessions were conducted. Attendances for both the days were 91.7% (44 out of 48 students). The proportions of students attending both the classroom sessions were 89.6% (43 out of 48 students). The proportions of students completing two pre-class activities and attending two classroom sessions were 54.2% (26 out of 48 students). There was a statistically significant association of participation in both the pre-class activities with attendance for both the two in-classroom sessions (P < 0.05). Five students showed nil participation for both pre-class activities and in-class sessions.

There was a statistically significant difference in the marks obtained by students who participated in all pre-class and in-class activities versus those who did not participate, as shown in [Table 1]. Grading of students was divided as failed (≤6.5 marks), passed (>6.5–<10 marks), and high achievers (≥10 marks) based on the total marks (13 marks) obtained in the practical examination. There was a statistically significant association of high scores with participation in all the pre-class and in-class activities (P < 0.05), as shown in [Table 2].{Table 1}{Table 2}

The average pretest mark was 10.0 (SD = 2.2) marks. The average posttest mark was 18.8 (SD = 3.8). There was a statistically significant difference in pre- and posttest marks (P < 0.05). The normalized gain score for the class was 44%. The mean pretest score in students participating in all activities was 10.35 ± 2.22 marks. The mean pretest score in students not participating in all activities was 9.7 ± 2.07 marks. There was no statistically significant difference in the pretest marks between the students who actively participated in flipped classroom teaching (all in-class and pre-class activities) and not actively participated. However, there was a statistically significant difference (P < 0.05) in the posttest scores between these two groups (20.13 ± 3.08 vs. 16.80 ± 3.88).

Feedback was taken from 26 students who participated in all pre-class and in-class activities because only these students could provide appropriate feedback on overall “flipped classroom model.” From the rest of the students, reasons for nonparticipation in any of the activities were lack of time, their term ending examination was due, and one student had taken a transfer from another college so he had missed earlier classes.

Cronbach's alpha was 0.8 for the feedback questionnaire. [Table 3] shows the proportion of students responding to each statement of the Likert item. Overall, there was positive feedback for “flipped classroom model.” However, there were mixed responses on providing of lecture presentation prior to class. Almost 45% wanted lecture presentation, while 31% did not felt it necessary and 23% were neutral. Ninety-two percent of the students felt that it was time consuming to learn through this model. Examples of the open-ended responses given by students were “The online quiz was highly implemental in helping me remember important points.” “Learning about the topic beforehand, helped me concentrate more in class.” “Due to the flipped classroom, there were multiple revisions of the important points. Learning became very easy and interesting.” “This flipped classroom is better than the 2 h lecture in the classroom during clerkship which causes loss of interest in the topic and subject as after 1 h the person can't concentrate. All classes should be done by this flipped classroom to create interest in the subject.”{Table 3}

 Discussion



Although flipped classroom can be implemented in various ways, many who use it are motivated by a desire to increase students' time for problem-solving.[7] We too used the flipped classroom model with one of the objectives to utilize classroom time for facilitation. The preclass activity provided, students with a fair knowledge of the topic. Thus, ample of time could be utilized for discussion and group activities. Through the flipped classroom model, there is a scope to make classroom sessions interactive. Furthermore, student–student and student–teacher interactions increase through this model. Carini et al.[8] concluded that student engagement is generally considered to be among the better predictors of learning and personal development. The more students study or practice a subject, the more they tend to learn about it.[8] This was observed in the present study. Students who actively participated and were engaged performed better in practical examination.

Han and Klein.[5] reviewed the studies on types of pre-class learning modalities in the flipped classroom. According to their findings, the types of pre-class learning used by various researchers were as follows: (1) online (modules, simulation, and learning resources), (2) reading assignment (textbook, instructor-created text, handouts, guided readings, primary literature, and guidelines), and (3) video lecture (lecture recordings, PowerPoint slides with voiceover, and podcasts). In the present study, we utilized the “Google Form App” as a tool for pre-class activity. The Google form App is a tool, which is primarily used to conduct quizzes. However, there are features in the Google Form, wherein the form can be broken into sections depending on the creator's need. Thus, we utilized reading assignments (PowerPoint presentation slides with quiz) as a preclass activity.

Google Forms and slides are part of the Google online apps suite of tools. They are freely available. It is compatible with almost all commonly used browsers such as Google Chrome, Firefox, and Windows – Internet Explorer 11 and Safari. It works on Android and IOS smartphones as well. We experienced that some students could not access through Google Form link because their electronic devices were unavailable or incorrect contact information was on record. In spite of these technical difficulties, their friends shared their mobiles so that they could go through the Google Form and attempt the quiz. On average, 63% participated in pre-class activities in the present study. The rest of the students (37%) did not participate. The reason could be it was completely voluntary to participate in the online activity. There were no incentives in terms of attendance or marks for participation. In contrast, some students overcame the technical difficulties and found out the way to access Google Form. This is a challenging issue while implementing the flipped classroom model.

In the present study, the class average normalized gain score was 44%. Colt et al.[9] considered a predefined target of a normalized gain of 30% to define the minimum value at which the educational intervention could be regarded as effective. Considering the same cutoff level, the flipped classroom model was effective to teach undergraduate medical students in community medicine.

The attendance rate for the classroom session was almost 90%. It was observed that over the past few years, the attendance rate was 50% for community medicine posting in our college. Students neglect postings of community medicine in the 2nd year because its final assessment is in the 3rd year. We observed that due to the flipped classroom model, students' attendance rate was high. This can be considered as an advantage of the use of a flipped classroom model. Thus, this model can be replicated for other topics in community medicine to raise the interest of the students.

In today's era, there cannot be one size fits all strategy to make students understand a particular concept. Learning styles, namely visual, aural, read/write, and kinesthetic, have been shown to vary widely among students.[10] The flipped classroom model allows the teacher to incorporate different strategies to teach a topic. Through this, all types of learners learn and understand a topic.

Our one of the objectives to use the flipped classroom model was to utilize classroom time for facilitation skills so that students were able to apply theoretical knowledge into practice during their family visits. It was evident that students who participated in all activities scored higher in practical examination. This is also reflected from the feedback, 96% of the students felt that it helped them to apply their knowledge into practice.

As mentioned in AMEE Guide,[11] advantages of the flipped classroom include an increase in interaction between students and teachers; a shift in the responsibility for learning onto students; and the ability for students to prepare at a time that suits them. Other advantages includes, collaborative working between students; an increase in student engagement; and a shift from passive listening to active learning. Possible disadvantages include the need to invest time and resources to develop courses; the possible need for technological investment; and time for both teachers and students to adapt and acquire the new skills required for this more active and self-directed approach to learning. The key to the success of this approach is that students take responsibility for their learning and come to class prepared. In the present study, we too got similar results. All students agreed that this model encouraged communication between the students and teacher, model encouraged the active participation of students, and they could learn through group activities conducted in class. Almost 85% agreed that they were well prepared for the class. Regarding disadvantage, 92% of the students felt that this model to be time consuming. From a teacher's point of view, once he/she gets expertise in making Google Form, it is not time consuming. Furthermore, skills need to be developed to make effective presentations. For students, they need not learn any technical skills. Google Form is a user-friendly app.

The present study was limited to 2nd-year undergraduate students at one institution. Similar studies for different academic years and in different medical colleges can be undertaken. This was a limitation of the study.

Students were able to apply theory into practice and knowledge gained is retained through the flipped classroom model of teaching. This model can be used to create interest among 2nd-year medical students for community medicine so that they attend clinical postings.

Acknowledgments

This educational research was a part of FAIMER project. The authors acknowledge FAIMER faculties, especially Dr. Ashwini, Dr. Santosh, and Dr. Sujata, for providing inputs in shaping the project. Mrs, Megha (Medical Social Worker) supported in finding under-five cases in the community and support of Dr. Kowli (ex-HOD) and Dr. Padmavathi (HOD), Department of Community Medicine in implementation of the projectMs. Sejal, Nutritionist, for providing technical input in the content of the topic

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Curriculum Phase3-Third MBBS. Available from: http://www.muhs.ac.in/upload/syllabus/Phase3_180609_new_16082012_1235.pdf. [Last accessed on 2019 Dec 29].
2Bogam RR. Twelve tips to facilitate learning in community medicine. Educ Med 2015;7:56-61.
3Nath A, Ingle G. From classroom to community – Teaching community medicine in India. South East Asian J Med Educ 2008;2:5-8.
4Naccarato E, Karakok G. Expectations and implementations of the flipped classroom model in undergraduate mathematics courses. Int J Math Educ Sci Technol 2015;46:968-78.
5Han E, Klein KC. Pre-class learning methods for flipped classrooms. Am J Pharm Educ 2019;83:6922.
6Moffett J. Twelve tips for “flipping” the classroom. Med Teach 2015;37:331-6.
7Chen F, Lui AM, Martinelli SM. A systematic review of the effectiveness of flipped classrooms in medical education. Med Educ 2017;51:585-97.
8Carini RM, Kuh GD, Klein SP. Student engagement and student learning: Testing the linkages. Res High Educ 2006;47:1-32.
9Colt HG, Davoudi M, Murgu S, Zamanian Rohani N. Measuring learning gain during a one-day introductory bronchoscopy course. Surg Endosc 2011;25:207-16.
10Samarkoon L, Fernando F, Chaturaka R. Learning styles and approaches to learning among medical undergraduates and post graduates. BMC Med Edu 2013;13:42.
11Kennedy C. Update on the Flipped Classroom. Available from: https://www.amee.org/getattachment/AMEE-Initiatives/MedEdWorld/Flipped-Classroom-leaflet-v3.pdf. [Last accessed on 2019 Dec 29].