|ORIGINAL RESEARCH PAPER
|Year : 2008 | Volume
| Issue : 2 | Page : 83
Community-Based Education in Nigerian Medical Schools: Students' Perspectives
DE Heestand Skinner1, CA Onoka2, EN Ofoebgu2
1 University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
2 University of Nigeria College of Medicine, Enugu, Nigeria
|Date of Submission||15-Jul-2007|
|Date of Acceptance||06-Apr-2008|
|Date of Web Publication||05-Sep-2008|
D E Heestand Skinner
#595 4301 W. Markham St., Little Rock, AR 72205
Source of Support: None, Conflict of Interest: None
Context: Community-based education (CBE) was developed thirty years ago in response to the maldistribution of physicians and subsequent inequity of health care services across geographical areas in developed and developing countries. Several medical schools in Nigeria report adopting CBE. This study seeks to identify and describe the CBE programs in accredited Nigerian medical schools and to report students' assessments of the knowledge and skills gained during their community-based educational experience.
Methods: Researchers developed a questionnaire that was distributed to student representatives at 19 of the 20 accredited medical schools. Student representatives distributed the questionnaire to 20 final year medical students and returned the completed questionnaires to the researchers. Quantitative data were entered into SPSS 14.
Results: Most students from CBE schools participated in CBE experiences of 4 to 8 weeks duration during their fifth or sixth year and paid for their food and transportation costs. Medical school personnel supervised the students who were also often assisted by community personnel. Students' rated highest their learning about environmental-related health risks and how to identify community health problems. They rated lowest what they learned about how to train health workers and how to implement and analyze results of community health interventions.
Discussion and Conclusion: CBE teaches future physicians how to function as health care providers in underserved communities. CBE curricula in Nigeria are addressing most, but not all, of the validated CBE generic objectives. Most notably, the curricula are not providing adequate education in the implementation and analysis of results of a community health intervention.
Keywords: Community-based Education, Medical Education, Medical Curriculum
|How to cite this article:|
Heestand Skinner D E, Onoka C A, Ofoebgu E N. Community-Based Education in Nigerian Medical Schools: Students' Perspectives. Educ Health 2008;21:83
Community-based education (CBE) is a vital component of the broader educational orientation called community-oriented medical education (COME). COME describes the focus of the entire medical school curriculum, one that addresses the population and individual health needs of a community (Hamad, 1999). It developed more than thirty years ago in response to the recognition of the maldistribution of physicians in developed and developing countries and the subsequent inequity of healthcare service across geographical areas, particularly in rural communities (Bennett, 1997). CBE describes those “learning activities that use the community extensively as a learning environment, in which not only students but also teachers, members of the community, and representatives of other sectors are actively engaged throughout the educational experience” (World Health Organization, WHO, 1987). CBE is an educational method that directly addresses two significant barriers to adequate distribution of physicians in medically underserved communities. It teaches future physicians how to function as a health care provider in an underserved community, and it educates medical students, faculty, and the general population about the health care needs of underserved communities (Schmidt, Magzoub, Feletti, Nooman, & Vluggen, 2000; Hamad, 2000).
There is evidence that CBE can meet some of the expectations of its early developers. Magnus and Tollan (1993) describe the success of the University of Tromso Medical School, using an innovative curriculum including CBE, in educating physicians who preferred to practice in the underserved rural areas of northern Norway. Authors of a recent Best Evidence Medical Education review of research from 1992-2001 on the effect of preclinical experience in clinical and community settings note that, in the thirty-eight studies that were sufficiently rigorous and yielded significant findings, early experience in a community setting “can have a lasting impact on students’ learning which can influence career choices” (Dornan, Littlewood, Margolis, Scherpbier, Spencer & Ypinazar, 2006). There is also evidence that early CBE can promote the empathy of students towards ill people, increase students’ understanding of how living conditions influence health and disease, and improve students’ communications skills (Dornan, 2006).
A recent study by Tamblyn et al. (2005) compares the care provided by graduates of a community-oriented medical school that includes CBE, with the care provided by graduates from three traditional medical schools. Graduates of the community-oriented school were found to provide significantly better preventive care and continuity of care. It is important to point out that there appears to be no difference on measures of summative performance between students who have early experience in a community and those who do not (Dornan, 2006).
While CBE has been adopted by medical schools in developed countries, the need for effective CBE is greater in developing countries where the supply of trained health care professionals is grossly inadequate and the migration patterns of these professionals mirror that of other professions, namely, from poorer rural areas to wealthier urban areas, and from poorer nations to richer nations (Narasimhan, et al., 2004). Bennett (1997) estimates that in many developing countries less than 30% of rural residents have access to health services.
Nigeria is the most populous nation in Africa, with over 131 million people, and has the highest population growth rate (2.4%) among the world’s 10 most populous nations (van der Heyden, 2006). Approximately 53% of its population live in rural communities (UNDP, 2006). The World Health Organization estimates that Nigeria’s physician to population ratio is 28:100,000 (WHO, 2006). While there are 20 accredited medical colleges in Nigeria and several more under development, the exodus of physicians is significant. It is estimated that over 600 physicians each year leave Nigeria, in a country that produces only 1500 per year (World Health Organization Regional Office for Africa, 2002).
It is known that some Nigerian medical schools have adopted CBE, including: the University of Ibadan (Brieger, 1997), Obafemi Awolowo College of Health Sciences, Bayero University Faculty of Medicne, the College of Health Sciences at Obafemi Awolowo University, the College of Medical Sciences at the University of Maiduguri, and the University of Ilorin Faculty of Health Sciences (Jinadu, Ojofeitimmi, & Oribabor, 2002; Magzoub & Schmidt, 2000). Efforts to evaluate some of these programs disclosed that the level of acceptance of CBE by the communities is a factor of how the medical schools gained entry into the communities, the explicitness of the objectives, and the level of education and urbanization of the communities (Jinadu, 2002). With a good entry into the community and a well administered educational program, the community’s attitude toward the students and the program can change from one of uncertainty to increased appreciation for house-to-house visits, disease prevention measures, and good clinical skills (Omotara, Padonu, & Kok, 2004). Moreover, most community residents perceive that the students’ visits improved peoples’ health (Omotara, Yahya, Shehu, Bello, & Bassi, 2006).
A literature search revealed no reports of a systematic survey of CBE programs in Nigerian medical colleges. While some of the Nigerian CBE programs have been described in the literature, this study seeks to identify more of those schools that have CBE programs and to describe their programs. The study also includes self-assessments by medical students who participated in CBE programs of the knowledge and skills they gained specific to generic objectives for CBE programs in developing countries, using the objectives defined and validated by Kristina and colleagues (Kristina, Majoor, & van der Vleuten, 2004; Kristina, Majoor, & van der Vleuten, 2006). These CBE objectives include gaining the knowledge and skills to provide health education to the community, to work with the community to improve its health, and to reduce the inequality of access to health service within the community .
The researchers developed a survey, to be completed by medical students in their final year, that sought information about the students and their schools, general descriptive information about CBE postings (defined as postings in which the students lived in a community) and information about the students’ perception of their increase in knowledge and skills as outlined by Kristina’s 21 generic objectives. The instructions to the students read, “No community-based posting provides the opportunity to learn everything listed. Please tick only the appropriate knowledge and skills that you learned while in the community. Please rate your increase in knowledge and skill…” The research protocol, questionnaire, and accompanying general cover letter were reviewed and approved by the University of Nigeria Teaching Hospital Ethics Committee and the University of Arkansas for Medical Sciences Institutional Review Board.
The researchers worked through the Nigerian Conference of Christian Medical and Dental Students, for one of the researchers (CO) was a recent national past president of this group and could personally contact student representatives at many of the medical schools. The researchers distributed copies of the questionnaire and general cover letter addressed to “student participants” by surface mail or e-mail to the student representatives at 19 of the 20 medical schools. One of the medical schools did not have a chapter of the Nigerian Conference of Christian Medical and Dental Students, thus no student representative was available to help with the study. The cover letter explained the purpose of the survey and stated that all responses would be anonymous. The researchers asked student representatives to distribute the questionnaire to a convenience sample of the first 20 final year students they encountered. The student representatives collected the completed questionnaires and returned them to the researchers.
Quantitative data from the convenience sample of students were entered into SPSS 14. Based on the responses to the question, “Does your college require students to participate in a community-based posting?” schools were identified as offering CBE if all of their students responded “yes” or none of their students responded “no”. Several students failed to complete the item. Schools were identified as not offering CBE when students responded “no” to the question and at least 80% of the students from the school did not complete the portion of the questionnaire specific to their CBE experience. Descriptive statistics of central tendency and frequency counts were run on all responses from students at CBE schools. Students’ responses on the self-assessment portion of the questionnaire were from 1 (poor) to 5 (excellent), with responses of not applicable coded as 0. Data were separated by school and descriptive statistics of central tendency and frequency counts were run for students of each school. A Spearman’s rho correlation coefficient was calculated with the length of CBE experience and the mean of the ratings on the 21 generic objectives by student response.
Students from 15 of the 19 schools completed questionnaires. Each student representative was asked to distribute and collect 20 questionnaires. The response rates from individual schools ranged from 70% to 100% with a mean of 89%. The response rates from the ten schools found to offer CBE ranged from 70% to 100%, with a mean of 86%; the range for non-CBE schools was 90% to 100%, with a mean of 95%. A total of 269 responses were received for a total response rate of 89.7%; 172 of these were from CBE schools and 97 were from non-CBE schools. The 10 CBE schools represented all three regions of Nigeria with three from the East, two from the North, and five from the West. The non-CBE schools were also distributed across the country with two from the East, two from the North, and one from the West.
Students’ demographic information and their responses on descriptors of their CBE experience are summarized in Tables 1 and 2.
Table 1. Student Responses from CBE Schools
Table 2. Student Responses from CBE Schools Describing CBE Experience
The general profile of those completing the survey from CBE schools is that of a student in his/her final year, intending to enter a primary care specialty, and attending a school of medicine that offers a residency in community medicine and a master’s degree in public health. In most instances the CBE experience occurs in either the fifth or sixth year and is between 4 and 8 weeks in duration. While in the community, most students pay for their food expenses and a little more than half pay transportation costs. University faculty supervise the CBE experiences for most students, but some students were supervised by community professionals or residents.
Table 3. Student Responses from all CBE Schools on Ratings of Knowledge and Skills Gained During CBE Experience Frequency Counts and Percentages
Table 4. Student Responses from Individual CBE Schools on Ratings of Knowledge and Skills Gained During CBE Experience: School Means and Total Means and Standard Deviations of all Student Responses
Students’ ratings of their increase in knowledge and skills on the 21 generic objectives of CBE are reported in Tables 3 and 4. Students reported that the greatest gains were in knowledge of environmental-related health risks, skills to identify health problems in the community barriers to health care utilization by the community, and to work in a variety of community health care settings. Students indicated that they gained the least knowledge about evaluation of health education efforts and the training of health workers in health education. They gained the least in skills related to implementing a health intervention in the community and analyzing the results, developing realistic strategies to improve community access to health services, and managing a primary care unit.
The variation in the design and implementation of CBE among the schools would appear to be considerable, as experiences range from one to eight weeks.. The correlation between the length of CBE experience and self-ratings of knowledge and skills on the objectives is positive, significant but low (r=.212, p<.01). . The two schools with CBE experiences of less than two weeks register overall means of 2.2 and 2.5; the schools with experiences of over seven weeks register overall means of 2.4 and 3.1. Generally, there is little difference among the mean of all ratings on the objectives by school. However, when the individual school means falling below the 25th percentile are identified (bold type) in Table 4, the presenting pattern suggests that curriculum review is needed by several schools.
The goal of this study is to identify and describe CBE programs in Nigerian medical schools through medical students’ questionnaire responses and self-assessments of the knowledge and skills they gained in their CBE experience. The study provides a “snapshot” of the diverse implementation of CBE in Nigeria. ranging from one to eight weeks and costing students an average of 7,141 Naira ($56). Regardless of the duration of the CBE, students reported overall increases in knowledge and skills at the fair to good level. While 10 of 15 schools are identified as using CBE, the true number is probably greater. We were not able to distribute questionnaires to Bayero University, an institution that reportedly uses CBE. We received no questionnaires from students at the University of Illorin, another school reported to have CBE (Jinadu, 2002). It is possible that 60% or more of Nigerian medical schools have a type of CBE for medical students.
The composite scores on the attainment of program objectives provide a useful overview of CBE in Nigeria, showing reasonable variation. Those objectives on which students rate their knowledge or skill gain to be the greatest are those that feature the strengths of a community-based experience, such as environmental-related health risks, identifying health problems of the community, identifying barriers to health care utilization by the community, and working in a variety of community health care settings. Those objectives on which students rate their gain in skills lowest reflect more complicated and time-consuming learning tasks. Training community health workers in health education is the lowest rated objective in terms of skills gained. We suspect that learning how to train health workers is not a goal for most, or perhaps any, of the CBE programs, because implementing a health education intervention in the community and evaluating its effectiveness probably requires more time than most students had in the community. Developing realistic strategies to improve community access to health services is a challenge to health care professionals in the field already; it must be even more so to students. Finally, it is doubtful that CBE programs stress management of a primary care unit as a learning goal. In fact, the authors of the generic objectives eliminated this objective as a result of their validation study (Kristina, 2006).
The cohort scores of students of individual schools may be useful to faculty at their schools in assessing their own CBE curriculum. For example, two schools were consistently below the 25th percentile in knowledge gained related to health education. Another two schools, with relatively short CBE experiences of less than 4 weeks, were below the 25th percentile in development of most skills related to working with the community and reducing inequality in access to health services.
There are limitations in this study’s methodology. The responses came from samples of convenience. The students who distributed and collected the questionnaires at their schools were told to distribute questionnaires to the first 20 final year students they encountered. But the students who distributed the questionnaires were selected for their leadership in the Nigerian Conference of Christian Medical and Dental Students and they may have distributed questionnaires to student colleagues with similar leadership interests or otherwise not fully representative of all students of their schools. Nevertheless, if sampling bias was present, it may have been present throughout the sampling from all schools.
Students’ self-assessments of their knowledge and skills are subjective and can be inaccurate. Further, self-assessment does not measure actual knowledge or skills gained. Students with a one-week CBE experience may perceive that they have improved their knowledge and skills at a high level; however, it is unlikely that they have improved their knowledge and skills to the same extent that students who experience four or eight weeks of CBE. However, what students believe about their learning is still important information and the pattern of their responses provides useful information about their school’s curriculum and their self-efficacy.
This study provides a “snapshot” view of CBE that may stimulate discussion of CBE in Nigeria as a means of addressing the maldistribution of physicians and inequality of health care access. At least half of the accredited medical schools in Nigeria provide a CBE experience for their students, ranging from one to eight weeks. Faculty from the schools generally supervise the experience, but there is significant involvement by community professionals and residents in over one third of the CBE experiences. During the CBE experience most students pay for their food and a little more than half pay for their transportation costs and few students pay for their accommodation. The cost to the students is significant but not prohibitive.
This study supports the findings of Schmidt (2000) and Hamad (2000) that CBE teaches future physicians how to function as health care providers in underserved communities. The self-assessment mean scores on 19 of the 21 objectives were between a fair and a very good rating. These objectives directly address the knowledge and skills needed to function in an underserved community. The remaining 2 objectives on which the students rated their gains as between poor and fair addressed more advanced skills of training community health workers in the areas of health education and implementing a health intervention in the community and analyzing outcomes.
CBE is a relatively new curriculum innovation, developed in the past thirty years, yet its prevalence in Nigerian medical schools is quite high, probably over 60%. Many unanswered questions remain. Why is CBE embraced by so many schools? What are the individual curriculum designs? How are the programs implemented? How are they evaluated? How and why may some schools have retained CBE while others have eliminated it?
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