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      Lessons learnt from comprehensive evaluation of community-based education in Uganda: a proposal for an ideal model community-based education for health professional training institutions

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          Abstract

          Background

          Community-based education (CBE) can provide contextual learning that addresses manpower scarcity by enabling trainees acquire requisite experiences, competence, confidence and values. In Uganda, many health professional training institutions conduct some form of community-based education (CBE). However, there is scanty information on the nature of the training: whether a curriculum exists (objectives, intended outcomes, content, implementation strategy), administration and constraints faced. The objective was to make a comprehensive assessment of CBE as implemented by Ugandan health professional training institutions to document the nature of CBE conducted and propose an ideal model with minimum requirements for health professional training institutions in Uganda.

          Methods

          We employed several methods: documentary review of curricula of 22 institutions, so as to assess the nature, purpose, outcomes, and methods of instruction and assessment; s ite visits to these institutions and their CBE sites, to assess the learning environment (infrastructure and resources); in-depth interviews with key people involved in running CBE at the institutions and community, to evaluate CBE implementation, challenges experienced and perceived solutions.

          Results

          CBE was perceived differently ranging from a subject, a course, a program or a project. Despite having similar curricula, institutions differ in the administration, implementation and assessment of CBE. Objectives of CBE, the curricula content and implementation strategies differ in similar institutions. On collaborative and social learning, most trainees do not reside in the community, though they work on group projects and write group reports. Lectures and skills demonstrations were the main instruction methods. Assessment involved mainly continuous assessment, oral or written reports and summative examination.

          Conclusion

          This assessment identified deficiencies in the design and implementation of CBE at several health professional training institutions, with major flaws identified in curriculum content, supervision of trainees, inappropriate assessment, trainee welfare, and underutilization of opportunities for contextual and collaborative learning. Since CBE showed potential to benefit the trainees, community and institutions, we propose a model that delivers a minimum package of CBE and overcomes the wide variation in the concept, conduct and implementation of CBE.

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          Most cited references 28

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          Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

          Background Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making. Methods This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review. Results The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies. Conclusion There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.
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            Does community-based experience alter career preference? New evidence from a prospective longitudinal cohort study of undergraduate medical students.

             A. Howe,  G Ives (2001)
            Previous studies have shown that most medical students want a hospital-based career, but the protagonists of community-based teaching predict that increased community exposure within undergraduate curricula will alter subsequent career preferences. To evaluate the impact on career preference and other attitudes of a year with substantial community exposure, compared with a year of hospital-based learning. Questionnaire to student cohort before and after two consecutive levels of the course, one with, and the other prior to, substantial community placement. Sheffield Medical School. Total of 260 students in the third and fourth year of the MBChB degree. There were significant differences in career preference and attitude to primary care after the year with a community placement, with more students expressing a preference for a community-based career. This was particularly true for women, and less true for non-European students. Conversely, the hospital-based students, especially men, showed a significant change toward hospital-based careers. The findings support the hypothetical advantages of shifting medical education to primary care settings, both in encouraging a career in general practice and in the retention of appropriate professional attitudes.
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              AMEE Medical Education Guide No. 24: Portfolios as a method of student assessment.

              This guide is intended to inform medical teachers about the use of portfolios for student assessment. It provides a background to the topic, reviews the range of assessment purposes for which portfolios have been used, identifies possible portfolio contents and outlines the advantages of portfolio assessment with particular focus on assessing professionalism. The experience of one medical school, the University of Dundee, is presented as a case study. The current state of understanding of the technical, psychometric issues relating to portfolio assessment is clarified. The final part of the paper provides a practical guide for those wishing to design and implement portfolio assessment in their own institutions. Five steps in the portfolio assessment process are identified: documentation, reflection, evaluation, defence and decision. It is concluded that portfolio assessment is an important addition to the assessor's toolkit. Reasons for using portfolios for assessment purposes include the impact that they have in driving student learning and their ability to measure outcomes such as professionalism that are difficult to assess using traditional methods.
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                Author and article information

                Journal
                BMC Med Educ
                BMC Medical Education
                BioMed Central
                1472-6920
                2011
                1 March 2011
                : 11
                : 7
                Affiliations
                [1 ]Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [2 ]Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [3 ]Office of the Dean, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [4 ]Department of Nursing, School of Health Sciences, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [5 ]Department of Dentistry, School of Health Sciences, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [6 ]Department of Pharmacy, School of Health Sciences, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [7 ]Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
                [8 ]Department of Nursing, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
                [9 ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
                Article
                1472-6920-11-7
                10.1186/1472-6920-11-7
                3056836
                21362181
                Copyright ©2011 Kaye et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Education

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