Engaging Universities and Ministry of Health in Evaluation of Reformed Community Medicine Training Program

Background: Reform of the community medicine training program (CMTP) for the undergraduate medical students is crucial for successful medical education and community development. Objective To evaluate the practical component of the reformed CMTP by: 1) reviewing the students' performance, 2) exploring the perspectives of the public health department (PHD) staff at Cairo and Ain-Shams Universities towards the program 3) exploring the views of the managers of the Ministry of Health (MOH) Primary Health Care (PHC) centers where medical students receive their PHC training towards the program. Methods: Quantitative data were obtained by reviewing the performance scores of 1492 students. Qualitative data were obtained by focus group discussions with PHD staff and MOH PHC managers. Results: It was found that the total students' mean score was 94.2%. About 91% of students scored >85% of the total marks. PHD staff from both universities expressed appreciation to the introduction of generic skills in the CMTP. They referred the success in management of CMTP to small-group teaching. The community-oriented and service-learning approaches also added more points to the CMTP. The MOH PHC managers acknowledged the CMTP which would contribute to preparing future physicians to have vital role in the dynamic health system.


INTRODUCTION
Future physicians are expected not only to be skillful clinicians but also to understand and work within the community through the health system.
) Therefore, the role of the public health motivate the teachers to implement the curriculum.The latter approach is especially relevant if health problems are becoming increasingly complex and changing rapidly.However, involving and motivating the different stakeholders is also costly and complicated in practice.
Consequently achievements of many initiatives have been limited.It is thus important to identify the strategies and activities that will stimulate and encourage the involvement of wide range of stakeholders to ensure that the final product i.e. "the training program" is appropriate to the needs of the society and the health system. (2,4,5) Egypt, the Supreme Council of  Bull High Inst Public Health Vol.39 No.4 [2009]   centers of MOH where the PHC training was conducted.

Study setting:
The • Third module included understanding the PHC within the MOH system through seminars and visits to the PHC centers.The students used a "Checklist for Quality PHC services" adapted from the MOH guidelines (6,7) .
It included 541 items to evaluate the performance of the PHC centre.The

Study tools and data collection:
The study used quantitative and qualitative techniques of data collection.

Quantitative data collection:
This included the review of the  Bull High Inst Public Health Vol.39 No.4 [2009]   student to protect student confidentiality.

Qualitative data collection:
A total of 7 focus group discussions (FGD) were carried out in accordance with the recommendations of Barbour. (8)th PHD staff of Cairo University and the

Data Analysis Plan:
Quantitative data obtained by review of the students' performance was done using SPSS version 15.For the qualitative data obtained by FGD, the audio-files were transcribed in verbatim.
The analysis followed a procedure for thematic content analysis. (9)by 1) reading all the material to obtain an overall impression; 2) identifying units of meaning, representing different aspects of the theme and coding for these; 3) condensing and summarizing the contents of each of the coded groups to generalize descriptions and concepts about the specific theme.

Ethical considerations:
The study protocol was ethically reviewed and approved by the ethical committee at the Community Medicine Department, Faculty of Medicine, Cairo University.Verbal consent was obtained from the study participants.The performance score for the generic skills was highest for the student-staff interaction.

Assessment
Females achieved significantly higher score in the teamwork and staff-student interaction components.

Perspectives towards CMTP:
Views towards the CMTP were obtained from all PHD staff categories at Cairo University (professors, assistant professors, lectures and instructors), some members from PHD of Ain Shams  Bull High Inst Public Health Vol.39 No.4 [2009]   University, as well as the MOH PHC mangers in order to abstract the evidence-based experience and learned lessons after implementing the reformed CMTP.
The following themes were abstracted from the FGD:

The reform initiative and the triggering action:
There was a general consensus that the reformed program was greatly successful.
One of the Cairo University staff members said: "Our reformed program is one of the success stories of the faculty of medicine, Cairo University" Study particiapnts referred this success to four overarching factors: • The political support from the head of the department who was willing to make a difference, • The presence of an active group of junior staff members who played a great role to make the program successful, •

Management of the reformed CMTP:
There The system used to evaluate the performance of the students in the reformed CMTP was perceived by almost all the staff as a good system.More than one staff member is involved in the evaluation of the student's performance which is done on daily basis and is task oriented.

Management of the reformed CMTP:
The PHD staff from Cairo University The process of reforming the CMTP had countersigned new approach in the assessment of students' performance, where close observation and interaction is required.This method of training assessment had been adopted by other public health programs. (11,16)In such programs small group education is managed by complex organization and adequate guidance for standardization of the process of teaching across different education teams.The staff assessing the students give grades to each individual student reflecting the student's participation during the group discussions and field activities. (11,17)e current study showed a significant difference in the final scores achieved by male and female students.
approach is to set up a process of interactions among the different stakeholders and the medical schools for both the design and the implementation of the curriculum.These interactions are needed to produce a balance between the training capacities of the schools and the social needs, thus university staff at the PHD and other faculty departments, as well as the Ministry of Health (MOH) staff in the urban and rural primary health care (PHC) facilities.After implementing the reformed CMTP during 2006/2007 and before rolling out the CMTP in the coming academic years, it was necessary to subject it to extensive evaluation by all parties engaged in this training and to exchange experience with those having similar programs to further improve the quality of the program.Thus, the aim of this study was to: 1) examine the profile of student's performance assessment; 2) explore the views towards the reformed CMTP by the PHD staff of the 2 biggest Universities in Egypt; Cairo University and Ain Shams University; as well as the managers PHC

•
study was conducted at the PHD, Faculty of Medicine, Cairo University.It is an evaluation study for reformed practical component of the CMTP applied during the academic year 2006/2007.Second module included servicelearning and hands-on problem solving in the rural community through seminars and visits to rural families aiming at: a) risk assessment for the visited families in the rural area, b) draft plan for problem analysis and health education messages according to needs of the visited families, c) action plans to be completed during the subsequent visit to the target families in the village.
students were also taught to calculate the vital indices for the catchment area of the PHC and used a questionnaire form to assess clients' satisfaction in the visited PHC centre.The practical component of the CMTP contributed to 20% of the total marks of the community medicine course.The reformed practical CMTP included a new system for the assessment of the students' performance which entails a day-to-day assessment of attendance and active participation in the workshops, seminars and field visits.The total marks of the practical program were distributed on the 3 CMTP modules, so that module 1 contributed to 20% of the total practical marks (5% for each of the leadership, team work, student-

Figure
Figure(1) displays the final performance assessment scores for 1492 was almost a general agreement of all the staff who participated in the FGD that the new training program was successful in introducing cooperative learning in the CMTP: "Finally we had a golden opportunity to allow our students to develop and practice leadership, teamwork, communication and problem solving while serving the rural community and understanding MOH system in PHC centers".PHD staff found that the design of the practical course allowed the application of leadership and teamwork through exposure of the students to group tasks and challenges.The leadership exercise allowed the students to discover their capabilities and develop self-confidence, while the teamwork allowed students to know each other and to work together towards specific objectives e.g. the design of health education messages for the rural families.Ain Shams PHD staff was very impressed with the community-based activities in the rural area.They said: "This type of activity would allow for involvement of the students in real life problem-solving activities" All the study participants found that the rural visit was followed by critical thinking of the rural families and analysis of the health risks that the family was facing, this was followed by developing of health messages tailored to the family needs.One staff member said: "Students felt responsible for the rural family they visited and tried to think how to help them, they tried to be innovative in giving them counseling and health education, they even discovered some silent health problems that need medical consultation" MOH PHC managers also acknowledged the reformed program and said that "The reformed CMTP has created a great momentum for building a better doctor who could effectively serve the community through MOH system."PHD staff from Cairo and Ain Shams universities also found that using the checklist for quality PHC would greatly enhance the training of PHC component in the practical training and would allow for the standardization of the education process for all the students' groups.Such approach would raise the awareness of the students about the updated MOH health system regarding the reform, family medicine and accreditation.MOH PHC managers also added that the use of the checklist to record observations of the students during their visit ensured that the visit was organized and directed towards specific objectives.They also emphasized the importance of PHC training activities in the MOH centers.Bull High Inst Public Health Vol.39 No.4 [2009] One manager said: "In many countries all over the world, medical students have active role in service delivery.In Egypt we suffer from the education which converts the student into a tank to be filled with information without practical training".A manager of the rural PHC unit also pointed to the benefits of the training: "Home visiting activities conducted by students could be invested to raise awareness of families about different MOH programs as family medicine" Staff from both universities praised the active contribution and support of MOH PHC managers to the successful training in the PHC centers, and the MOH PHC managers greatly appreciated their active involvement in the education process.The Cairo University PHD staff agreed that the reformed program was also of great benefit for the junior staff.They thought that the field training added experience to the junior staff in management and field studies.Some of the instructors had conducted the practical component of their master degree thesis in the village where the students conduct their field visits.One of the staff members said that "Most of the staff members and students have demonstrated their capacity for leadership, creativity and educational management" fund given to the PHD to allow for the efficient management of the training.In fact, having training activities outside the PHD necessitated the recruitment of paid manpower to facilitate the field activities e.g. the community workers in the target village.Thus the problem of sustainability of the reformed CMTP was mentioned by the Cairo University staff.Staffs from both universities also raised the issue of the limited clinical background of the undergraduate medical students by the time they start their CMTP.One staff member said: "When we start talking about the maternal and child health services provided at the PHC, students feel a little bit lost, because they don't have any Another issue that was raised is that the practical component of the CMTP contributes to only 20% of total score of the community medicine course, while the rest of the score depends only on the theoretical part of the course.Staff from both universities expressed their concerns that this might negatively impact the students' activity, some Bull High Inst Public Health Vol.39 No.4 [2009] students will just prefer to study the theoretical parts of the curriculum which is worth 80% of the total score, rather than giving much attention to the practical part of the program.PHD staff from both universities was very impressed by the active contribution of the junior staff members, yet they raised the issue that the teaching activities are not given considerable attention in the staff promotion policy.The main activities considered in the promotion is having publications, thus this might have a negative impact on the enthusiasm of junior staff and affect their active contribution to upgrade the CMTP.They recommended giving some sort of credit to the distinguished junior staff members to encourage them to spend more time on the upgrading of the CMTP.DISCUSSION: The study provided an evaluation of a reformed model of CMTP.The student's performance scores that were set by the staff on daily basis throughout the CMTP could be used as a proxy for the efficiency of the training as well as for the assessment of the interaction between the PHD staff and the students while implementing the CMTP.The views of PHD staff of Cairo University towards CMTP represent self-assessment and internal evaluation, the views of PHD staff from Ain Shams University represent an external or peer-to-peer evaluation, while the views PHC managers of MOH could be considered as a mixture of internal and external evaluation due to their contribution and facilitatory role in the implementation of the PHC component of the CMTP.This comprehensive evaluation highlighted many aspects of the training program at the national and local (university) levels.The views of the PHDs in both universities and MOH PHC managers provided critical evaluation for the CMTP according to the "logic model".This model was also embraced in different studies.(10)This "logic model" includes input (staff, students, classrooms, .The method used by CMTP in PBL or service learning is highly compatible with similar training programs elsewhere.(4,14)PBL is a method of knowledge acquisition where small groups of students are guided by tutors to develop their own learning objectives based on real-world case scenarios.PBL is adopted by many medical schools that reformed their medical course from a traditional lecture-based course to integrated PBL.This PBL is community based and integrated curriculum, under the domain of "Tomorrow's Doctors".(15) Figure (1) Percent distribution of the undergraduate medical students by their performance score in the practical component of the reformed community medicine training program

Table (
(p=0.001).The rural health module showed the highest mean performance score with no statistically significant difference between males and females.