AJHPE Vol 9, No 2 (2017) by HMPG

African Journal of Health

Professions Education June 2017, Vol. 9 No. 2

Scholarship of Africa for Africa

ISSN 2078 - 5127

AJHPE African Journal of Health Professions Education June 2017, Vol. 9, No. 2

EDITORIAL

50 Authorship: Lone wolf or wolf pack? J E Wolvaardt

SHORT RESEARCH REPORTS

EDITORIAL BOARD

EDITOR-IN-CHIEF Vanessa Burch University of Cape Town INTERNATIONAL ADVISORS Michelle McLean Bond University, QL, Australia Deborah Murdoch-Eaton Sheffield University, UK DEPUTY EDITORS Julia Blitz Stellenbosch University

51 Use of role-play and community engagement to teach parasitic diseases F Haffejee, J van Wyk, V Hira

Jose Frantz University of the Western Cape

54 ‘He has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: The role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement H Myezwa, D Maleka, P McInerney, J Potterton, B Watt

ASSOCIATE EDITORS Francois Cilliers University of Cape Town

RESEARCH

57 The health system benefits of attending an HIV/AIDS conference A Bosman, J E Wolvaardt 62 A learning development module to support academically unsuccessful 1st-year medical students C A Kridiotis, S Swart

Jacqueline van Wyk University of KwaZulu-Natal

Rhena Delport University of Pretoria Patricia McInerney University of the Witwatersrand Ntombifikile Mtshali University of KwaZulu-Natal Anthea Rhoda University of the Western Cape Michael Rowe University of the Western Cape

67 Depression, anxiety, stress and substance use in medical students in a 5-year curriculum P M van Zyl, G Joubert, E Bowen, F du Plooy, C Francis, S Jadhunandan, F Fredericks, L Metz

Marietjie van Rooyen University of Pretoria

73 Developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings M van Rooyen, A Reinbrech-Schütte, J F M Hugo, T S Marcus

Elizabeth Wasserman Stellenbosch University

78 Reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education H Pandya, W Slemming, H Saloojee 83 Dental undergraduate students’ knowledge, attitudes and practices in oral health self-care: A survey from a South African university S Singh, S Pottapinjara

Susan van Schalkwyk Stellenbosch University

Elizabeth Wolvaardt University of Pretoria

HMPG

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CPD questionnaire

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Editorial

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Authorship: Lone wolf or wolf pack? Publications are essential for promotion and for establishing the professional profile of academics, who can then in turn build national and international collaborations and secure research funding.[1-5] These publications are often equated with subsidy income for universities and improved prestige in the various university ranking systems. Therefore, ‘publish or perish’ is an unofficial hashtag in academia. No surprise then that the trend is one of increasing numbers of authors on manuscripts. A review of four prestigious medical journals saw a substantive increase over all four journals in the 20-year period reviewed: from 4.5 authors in 1980 to 6.9 authors in 2000.[6] A partial explanation is that the number of manuscripts authored by study groups is also on the increase.[7] In 1991, only 6% of the 172 research articles published in the Journal of the American Medi cal Association involved a study group. Ten years later, 22% of the 185 research articles were published by study groups.[7] Study groups are common in large clinical or observational studies and the number of authors can be substantial, with the highest number recorded at 5 154 authors.[8] With the increase in the number of authors per manuscript, disputes about authorship follow the same trajectory. Little is written about the magnitude of such disputes, but one article reports that from a single faculty the disputes that were referred to the ombudsman increased from 2.3% (1991 - 1992) to 10.7% (1996 - 1997). Also worth noting is not only the percentage increase, but an overall increase in the number of issues referred to the office of the ombudsman – from 355 to 551 for the same 2-year period.[5] Some of the reasons for articles having multiple authors are the complexity, the inherent collaborative nature of research and the emergence of research questions, such as global or multisite questions, which need multidisciplinary or interdisciplinary participation.[1,6] However, when authorship holds academic benefits other than the expansion of knowledge, questions are raised whether multiple-authored articles reflect true collaboration or if they are artefacts of institutional pressure or gaming of the system.[4] Editors caution against three particular types of authorship: ghost, guest and gift authors. The ghost author, often a student, who although having contributed substantially, is excluded.[2] Guest authors are those who are listed with the hope of increasing the chance of publication. Finally, there is the gift author, whose affiliation with the study is symbolic and whose addition is often due to institutional pressure.[4] Factors such as power relations (gender, race and sexual orientation) and power differentials in low- and high-income country collaborations have been cited as contributing to these problematic exclusions or inclusions of authorship.[3] This trend of increasing numbers of authors has resulted in guidelines being developed for the allocation of authorship credit. Some examples are the International Committee of Medical Journal Editors (ICMJE), the World Association of Medical Educators (WAME), and the Committee on Publication Ethics (COPE), which have all published comprehensive guidelines. Even though these are useful when applied, the guidelines do not assist in guiding authors on the order in which authors’ names are listed. The interpretation of the position also varies: some may interpret the last author as the most senior, but to others the decreasing position is a reflection of a decrease in contribution and the risk of becoming an et al.[1,2] Despite all the challenges surrounding multiple authorship, single authorship has almost disappeared in medical journals.[6] However, is it any different in medical education journals? A cursory review of the latest editions (May or June 2017) of three prestigious international medical

June 2017, Vol. 9, No. 2 AJHPE

education journals revealed that none of the original articles was a singleauthored manuscript; this edition of AJHPE is no different. The manuscripts by Kridiotis and Swart;[9] Pandya, Slemming and Saloojee;[10] Van Rooyen, Reinbrech-Schütte, Hugo and Marcus;[11] and Singh and Pottapinjara[12] are all prime examples of the benefit of collaborative – sometimes interdisciplinary – research done within a single department. The manuscript ‘Use of role-play and community engagement to teach parasitic diseases’ by Haffejee, van Wyk and Hira,[13] demonstrates the benefits of interdepartmental collaboration within a single institution. The short report by Myezwa, Malek, McInerney, Potterton and Watt[14] is also an interdepartmental contribution, and another manuscript (Bosman and Wolvaardt[15]) is a reflection of interinstitutional authorship. A particularly exciting inclusion in this edition is the manuscript by Van Zyl, Joubert, Bowen, du Plooy, Francis, Jadhunandan, Fredericks and Metz.[16] Their article, ‘Depression, anxiety, stress and substance use in medical students in a 5-year curriculum’, is co-authored by six medical students. If researching and writing for publication – i.e. authorship – is a learning experience, then no better examples can be found than in this edition of AJHPE. However, if we want to solve the problems of Africa, should we not lead the pack for multisite or multinational collaborations?

J E Wolvaardt School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, South Africa liz.wolvaardt@up.ac.za

1. Smith E, Williams-Jones B. Authorship and responsibility in health sciences research: A review of procedures for fairly allocating authorship in multi-author studies. Sci Eng Ethics 2012;18:199-212. https://doi.org/10.1007/ s11948-011-9263-5 2. Marusic A, Bosnjak L, Jeroncic A. A systematic review of research on the meaning, ethics and practices of authorship across scholarly disciplines. PLoS ONE 2011;6(9):e23477. https://doi.org/10.1371/journal.pone.0023477 3. Smith E, Hunt M, Master Z. Authorship ethics in global health research partnerships between researchers from low or middle income countries and high income countries. BMC Med Ethics 2014;15:42. https://doi. org/10.1186/1472-6939-15-42 4. Street JM, Rogers WA, Israel M, Braunack-Mayer AJ. Credit where credit is due? Regulation, research integrity and the attribution of authorship in the health sciences. Soc Sci Med 2010;70(9):1458-1465. https://doi. org/10.1016/j.socscimed.2010.01.013 5. Wilcox LJ. Authorship. The coin of the realm, the source of complaints. JAMA 1998;280(3):216-217. 6. Weeks WB, Wallace AE, Kimberley BCS. Changes in authorship patterns in prestigious US medical journals. Soc Sci Med 2004;59:1949-1954. https://doi.org/10.1016/j.socscimed.2004.02.029 7. Flanagin A, Fontanarosa PB, deAngelis CD. Authorship for research groups. JAMA 2002;288(24):3166-3168. https://doi.org/10.1001/jama.288.24.3166 8. ATLAS and CMS Collaborations. Combined measurement of the Higgs Boson Mass in pp collisions at s√=7 and 8 TeV with the ATLAS and CMS experiments. Phys Rev Lett 2015; 114:191803. https://doi.org/10.1103/ PhysRevLett.114.191803 9. Kridiotis CA, Swart S. A learning development module to support academically unsuccessful 1st-year medical students. Afr J Health Professions Educ 2017;9(2):62-66. https://doi.org/10.7196/AJHPE.2017.v9i2.694 10. Pandya H, Slemming W, Saloojee H. Reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education. Afr J Health Professions Educ 2017;9(2):78-82. https://doi. org/10.7196/AJHPE.2017.v9i2.796 11. Van Rooyen M, Reinbrech-Schütte A, Hugo JFM, Marcus TS. Developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings. Afr J Health Professions Educ 2017;9(2):73-77. https://doi.org/10.7196/AJHPE.2017.v9i2.723 12. Singh S, Pottapinjara S. Dental undergraduate students’ knowledge, attitudes and practices in oral health selfcare: A survey from a South African university. Afr J Health Professions Educ 2017;9(2):83-87. https://doi. org/10.7196/AJHPE.2017.v9i2.800 13. Haffejee F, van Wyk J, Hira V. Use of role-play and community engagement to teach parasitic diseases. Afr J Health Professions Educ 2017;9(2):51-53. https://doi.org/10.7196/AJHPE.2017.v9i2.673 14. Myezwa H, Malek D, McInerney P, Potterton J, Watt B. He has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: The role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement. Afr J Health Professions Educ 2017;9(2):54-56. https://doi.org/10.7196/ AJHPE.2017.v9i2.888. 15. Bosman A, Wolvaardt JE. The health system benefits of attending an HIV/AIDS conference. Afr J Health Professions Educ 2017;9(2):57-61. https://doi.org/10.7196/AJHPE.2017.v9i2.693 16. Van Zyl PM, Joubert G, Bowen E, et al. Depression, anxiety, stress and substance use in medical students in a 5-year curriculum. Afr J Health Professions Educ 2017;9(2):67-72. https://doi.org/10.7196/AJHPE.2017.v9i2.705

Afr J Health Professions Educ 2017;9(2):50. DOI:10.7196/AJHPE.2017.v9i2.985

Short Research Report

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Use of role-play and community engagement to teach parasitic diseases F Haffejee,1 PhD; J van Wyk,2 PhD; V Hira,1 BSc 1

Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, South Africa

Department of Clinical and Professional Practice, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: F Haffejee (firozah@dut.ac.za)

Background. Role-play can enhance students’ learning, improve communication and serve as an effective tool for team building. When combined with community engagement projects (CEPs), it can enhance empathy in challenges relating to the community. The benefits of role-play in medical education have been reported, but the impact of the strategy is unknown in the allied health sciences at universities of technology, where there is a need to improve pass rates. Objective. To ascertain the benefits of role-play and CEPs in the context of understanding parasitic diseases by students enrolled for programmes in the allied health professions. Method. Role-play and CEPs were used to facilitate students’ learning of parasitic diseases. Students’ perceptions of the influence of these strategies on their learning were determined through the use of a semi-structured questionnaire. Test scores of the students before and after the assignment were compared. Results. The majority of students reported becoming more enthusiastic about their studies. They indicated that role-play with regard to the clinical features of the parasitic diseases added to their improved understanding of the disorders. Role-play also made the learning entertaining and informative, and enhanced class camaraderie. An improvement in the students’ test marks and pass rates relating to this section was also observed. Students valued the opportunity to teach people in the community, which linked their learning to a community engagement initiative. Conclusion. Learning through role-play and using a CEP to teach about parasites enhanced the quality of student learning in the allied health sciences. Afr J Health Professions Educ 2017;9(2):51-53. DOI:10.7196/AJHPE.2017.v9i2.673

Role-play, as a teaching technique, can greatly enhance students’ learning by asking them to enact a specific role that relates to their learning outcomes.[1] It draws on students’ creativity, improves their communication, serves as an effective tool for team building and increases analytical skills.[2] Benefits of role-play in medical education have been reported,[3] but the impact of the strategy is yet unreported in the allied health sciences at universities of technology, where there is a need to improve pass rates. Role-play, when combined with community engagement, can greatly enhance empathy in issues and challenges relating to the community.[4] The objective of this study was for 2nd-year students enrolled for programmes in the allied health professions at the Durban University of Technology (DUT), South Africa (SA), to ascertain the benefits of role-play and community engagement projects (CEPs) in the context of understanding the parasitic diseases. This study also explored the benefits of interventions on students’ learning.

flies, ticks, bedbugs, mosquitoes, lice, fleas, mites, rats and mice. The groups conducted research in relation to the parasite, including the parasitic life cycle, diseases caused, and prevention and control measures. Topics were allocated by a ballot method. Student groups prepared a research report that was made available to their peers on the online forum. After delivery and assessment of the assignment, all students were invited to participate in the study; however, participation was voluntary and those who agreed to participate (n=56) signed informed consent prior to answering the research questionnaire, which was adapted from a study by Higgins-Opitz and Tufts.[3] Responses required yes/no or degrees of agreement on a Likert scale. Additional comments were offered in an open-ended section. Questionnaires were administered by an independent research assistant. Test scores of the students before and after the assignment were compared. Data were analysed on SPSS version 21 (IBM Corp., USA).

Methods

Respondents were mainly English (60%) and isiZulu (22%) first-language speakers. The majority (85%) found the topics interesting and relevant. They reported that the topics helped them to understand the parasites’ life cycles (82%) and diseases (84%). The majority of respondents experienced the role-play as beneficial to their learning. They thought that it encouraged and supported further selfstudy. They became more enthusiastic because of the creativity required during the project (73%) and it helped them to understand the relevance of their studies (77%). The majority of respondents (78%) indicated that they learnt more when preparing for the role-play. In addition, participation in

Ethical clearance was obtained from the DUT Research Ethics Committee (ref. no. IREC 030/14). Chiropractic and Homoeopathy students who registered in 2014 for the parasitology module in their 2nd year of study (n=58) were given an assignment on arthropod and mammalian parasites. The assignment was presented as a role-play in class and subsequently in a school or children’s home as part of a CEP. The assignment required students to work in self-selected groups of 6 - 8 members. Each group performed a play on a different arthropod/ mammalian parasite, which included common community pests such as

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Results

Short Research Report the play caused students to engage in additional reading and research of the parasites and parasitic diseases (74% and 78%, respectively; Table 1). The respondents agreed that role-play made the presentations more entertaining (82%) and that it helped them to gain an easier and better understanding of the disorder being studied (77%). Those who were hesitant to speak in front of a large group indicated that the activity had helped them to overcome their fear of public speaking (58%). The role-play of other groups was equally informative (85%) and easy to follow (63%). Students valued the feedback from their peers, which helped them to identify deficiencies in their presentations (64%). Some students (34%) were, however, still reluctant to ask questions during the discussion time (Table 1). The role-play enhanced class camaraderie (82%). The presentations allowed the majority to integrate new material with previously taught content (76%). Despite a small group (44%) indicating that the presentations were more informative than lectures, 78% thought that role-play should be continued in the future. While 71% found the exercise useful, only 56% wanted role-play extended to other parts of the curriculum (Table 1). Most respondents were pleased to present as part of a CEP (80%). The CEP component increased their awareness of how education can help others (85%). The majority planned to become more involved in CEP in the future (84%). The students obtained a significantly higher mean on their test scores (77.7 (standard deviation 10.9)%; range 53 - 95%) after the role-play intervention, when their marks were compared with the pre-intervention test (55.2 (17.0)%; range 11 - 91%; p=0.005). The pre-intervention and postintervention pass rates were 72.4% and 100%, respectively.

Discussion

The intervention promoted active involvement of students in the learning process. It allowed them to be creative and to develop new skills. It had a positive impact on the students’ learning, with the majority becoming more enthusiastic and active in the learning process. Students found the topics stimulating and relevant to the course; it also helped in understanding both parasitic lifestyles and diseases. Students were very creative in their approach to and presentation of the task. The role-play took the form of short plays, which ranged from patient consultation with health practitioners, school scenarios, such as was seen in a lice presentation, to SA real-life situations, mimicking housing conditions of low-income workers through to taxi drivers. The plays generated a great deal of interest and humour among students and staff. The students indicated that the presentations were informative, enhancing class camaraderie. Role-play of clinical features of the parasitic diseases was perceived to improve students’ understanding of the disorders. Other studies have similarly found that roleplay increased learning and retention.[3] Role-play can serve as an extra strategy to assist weaker students, who generally struggle with abstract concepts.[5] We also noted an improvement in mean test marks and pass rates after the role-play exercise, indicating that weak students, particularly, benefited from the intervention. As higher education institutions are striving to increase higher pass rates, the introduction of this type of intervention will be beneficial to both the students and the institutions. Interestingly, only 44% of respondents found role-play more informative than lectures. It is possible that this finding stems from our students’ past, where they relied heavily on teacher-directed instruction, and that these students still need to become confident in their ability to research their own topics.

Table 1. Benefits of role-play and responses to a community engagement project Benefits of role-play in the classroom, % Role-play by the other groups were informative

Role-play made the presentations more entertaining

ole-play contributed to a more friendly camaraderie atmosphere 82 R in the class Role-play encouraged further reading on parasitic diseases

Learn more when having to prepare for the role-play

This method of teaching should continue in future

Role-play helped in understanding the relevance of the study

Gained an easier and better understanding of the disorder

ole-play helped to integrate material covered in other parts of R the curriculum

Role-play encouraged further reading on parasites

Role-play caused more than usual enthusiasm about studying

Found the exercise useful

Audience feedback was helpful in identifying deficiencies

It was easy to follow the subject matter presented by other groups 63 ole-play helped in overcoming the fear of addressing a large R group of people

ould like role-play extended to other courses offered in the W 2nd-year programme

Generally reluctant to speak in front of a large group

Role-play is more informative than lectures

Hesitant to ask questions during discussion time

Responses related to community engagement, % roject created awareness of the need to be engaged in P communities that need help with education

lan to become more involved in community engagement P projects in the future

Happy to present the work as part of a CEP

The students could easily follow and understand the peer presentations, indicating that they were able to learn from researching, role-playing and their role as a peer observer and assessor. Furthermore, our study indicates that students who were previously hesitant to speak in front of large groups of people now overcame their fear of public speaking. This is supported by a previous study, where role-play was used in the teaching of foreign language education.[1] It has been suggested that role-play boosts self-confidence and raises self-education capabilities.[2] Our study was novel in that the students were required to present the role-play at an educational facility, such as a school or a children’s home, as part of a CEP. Feedback indicated that this part of the project was favourably experienced and enjoyed. The majority intended to maintain their involvement in the community setting. Soon after the class activity, two groups of students returned to the respective children’s homes to spend additional time with the children. The activity thus not only created sympathy for those afflicted by parasitic diseases, but created empathy for those less fortunate than themselves. Consequently, our students have taken steps to alleviate the plight of disadvantaged individuals. The majority of students wanted the exercise to continue during the course. However, only 58% felt that such an exercise should be extended

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Short Research Report to other sections of the curriculum. Similarly, a study conducted among SA medical students indicated that students did not want the exercise to continue in other parts of the curriculum, possibly owing to the large volume of work comprising the 2nd-year curriculum and the substantial amount of time required in the preparation of a good role-play.[3] Nevertheless, the positive feedback received indicates that the exercise should be continued in future years for this part of the course, as the benefits would outweigh the extra time spent in preparing for the presentation.

Conclusion

This study indicated that the innovative method of teaching through roleplay and a CEP was beneficial to students in the allied health sciences. The students felt good about directing their own learning. It allowed them to

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read around related topics, in addition to the topic of their own presentation. Presentation of their work as part of a CEP was enjoyable and has made them more aware of issues surrounding those less fortunate than themselves. It was perceived as a positive learning experience and also improved pass rates. 1. Haruyama J. Effective practice of role play and dramatization in foreign language education. Komaba J Engl Educ 2010;1:31-58. https://doi.org/10.1016/0346-251x(85)90037-5 2. Wang J, Hu X, Xi J. Cooperative learning with role play in Chinese pharmacology education. Ind J Pharmacol 2012;44(2):253. https://doi.org/10.4103/0253-7613.93862 3. Higgins-Opitz SB, Tufts M. Student perceptions of the use of presentations as a method of learning endocrine and gastrointestinal pathophysiology. Adv Physiol Educ 2010;34(2):75-85. https://doi.org/10.1152/advan.00105.2009 4. Illich I. To hell with good intentions. In: Kendall J, ed. Combining Service and Learning: A Resource Book for Community and Public Service. Vol. 1. Raleigh, NC, USA: National Society for Internships and Experiential Education, 1990:314-320. 5. Littlefield JH, Hahn HB, Meyer AS. Evaluation of a role-play learning exercise in an ambulatory clinic setting. Adv Health Sci Educ 1999;4(2):167-173. https://doi.org/10.1023/A:1009789110719

Short Research Report

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

‘He has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: The role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement H Myezwa,1 PhD; D Maleka,1 PhD; P McInerney,2 PhD; J Potterton,2 PhD; B Watt,1 BSc 1

Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Centre for Health Sciences Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: H Myezwa (hellen.myezwa@wits.ac.za)

Background. The Department of Physiotherapy at the University of the Witwatersrand, Johannesburg, South Africa has a programme that allows 4th-year physiotherapy students to experience learning about public health in a rural setting. This experience is assessed using a portfolio. To date, the portfolios have only been assessed in terms of the students achieving the learning objectives. The process has not been evaluated for its effectiveness in promoting a reflective learner. A reflective learner is considered as one who will develop critical thinking and better accountability for their own learning. Objective. To analyse the level of reflective practice attained by the students. Methods. A qualitative approach was used to analyse evidence of reflective practice in student reflective diaries. Guided content analysis, using a framework compiled from the literature, was used to code the data. The coding framework outlined the levels of reflective practice – from the lowest level, identifying learning outcomes, to the highest level, i.e. abstract concept formation. Results. Forty-eight portfolios with reflective diaries were available for analysis. Data saturation was obtained after eight reflective diaries were analysed. The majority of the student diaries (6 of 8) reflected a low level of reflective practice, with only a few attaining a high level. Conclusion. This study showed that physiotherapy students who experienced learning in a rural setting achieved low levels of reflective practice. A minority of students were able to progress in their reflection to reveal elements of critical thought, reflective thinking and, further still, abstract concept formation. Afr J Health Professions Educ 2017;9(2):54-56. DOI:10.7196/AJHPE.2017.v9i2.888

Professional development is a process entered into by professional practition ers to maintain, enhance and broaden professional and reflective practice. Reflective portfolios in physiotherapy have predominantly been used as part of professional practice and to a lesser extent in undergraduate training.[1] There is considerable variation in the definitions of reflection and the criteria used to assess it. Definitions have common threads of experience, a process of introspection, analysing knowledge and taking action on the learning or practice needs of the learner.[2,3] Recognition of experiential learning in the curriculum is acknowledged if learning is clearly demonstrated in a written form.[4,5] The use of the written portfolio as an alternative form of assessment provides a means to evaluate students’ growth, maturity and achievement over time. Final-year students at the University of the Witwatersrand, Johannesburg, South Africa are exposed to knowledge and skills that prepare them for the practice of physiotherapy in a public health and rural community setting prior to embarking on this clinical experience. A reflective diary, as part of a portfolio, is used to assess the level of reflection undertaken by students during their rural experience. Students write their reflective diaries daily during their 3-week rural community placement. The aim of this study was to analyse the level of reflective practice attained by final-year physiotherapy students.

integration of Brookfield’s work on reflective practice that makes use of primary work by Mann et al.,[3] Schön,[6] Mezirow,[7] Johns,[8] Gibbs[9] and Kolb.[10] Our study followed the vertical dimension model of reflective practice (Table 1). A framework was derived from the literature on the process of reflection. Forty-eight portfolios with reflective diaries were available for analysis. Each researcher was initially allocated two randomly selected diaries to read and code. Further allocation of diaries was planned until data saturation was attained. Codes were identified from the students’ write-up and a constant comparison method was applied. On completion of the first iteration of coding, the portfolios were exchanged. Then the second coder checked and read the diary, and looked for alignment of codes to the specific reflective category and possible fitting of reflective statements that may have been overlooked. After the second iteration of coding, the diaries were exchanged between coders. This provided a means of verification, conformability and peer debriefing.[12] A fifth category was added to the framework, i.e. level 5, which ‘shows evidence of reflective practice’. After the coding of eight portfolios, saturation of data was achieved. Ethical approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (ref. no. M120360). Permission was obtained from students to use their portfolios for research purposes.

Methods

Results

This study used a qualitative approach and directed content analysis to evaluate the reflective diaries. The definitions used are based on an

June 2017, Vol. 9, No. 2 AJHPE

In the eight diaries reviewed, the full range of levels of reflective practice was found. Three of the eight diaries showed growth in reflective practice over

Short Research Report Table 1. Coding framework[6-11] Level of reflection

Description

The student refers to a particular activity/task

The student demonstrates the process of acquiring an understanding of the task

The student refers to achievements experienced

The student has applied a methodical approach using a standard procedure to complete the task, and the detail of the description should be to the level provided in the rubric for the entire portfolio

The student demonstrates an accurate and deep understanding

The student demonstrates insight into his/her own learning process

Acknowledgement of limitations of: 3ci

Self

3cii

Others

3ciii

System

Identifies and challenges assumptions

Understands the importance of context

Explores and imagines alternatives

Reflective scepticism

Direct experience, reflection on action and reflection with abstract concept formation

the 3-week period, with levels 4 and 5 being more evident in the second half of the students’ clinical rotation. The majority (108 of 283) of the entries were categorised as level 1a. Twelve examples could be classified as level 1b. The example in Table 2 reflects one student referring to a forgotten consideration of ensuring that a screening tool was reliable and valid. There were fewer reflections (n=27) at level 2. The majority of the entries were at level 2a, where students referred to actual achievements experienced. There were only four entries at level 2b. At level 3a, students (n=16) demonstrated a deep understanding of the learning outcome. There were a greater number of entries at level 3b (n=42), where students demonstrated insight into their own learning processes. The reflections at level 3 were in the limitations of self, others and the system. Problems related to communication and language barriers were often mentioned in relation to the self. In reflecting on others in level 3, students frequently mentioned the role of family members. Sometimes students described an incident in which self, others and the system were linked. Level 4 reflections demonstrated students’ experience of growth. There were a total of 74 reflections across the four sub-levels. Four out of the eight diaries showed a greater progression to levels 4 and 5. The importance of context (level 4b) was recognised frequently as an important factor in healthcare. Students (n=2) recounted events with reflective scepticism, as reflected in the quote in level 4b. Not all diaries (2 of 5) displayed evidence of level 5 reflections. Students often reflected on what they had seen and how they would have managed a situation.

Discussion

The results of this study revealed that all student entries demonstrated a low level of reflection. There were not many self-examination entries showing insight, self-awareness and recognition of own and others’ limitations. A higher level of reflection (level 4) was evident in 50% of the diaries, with 2 of 8 diaries progressing to abstract formation (level 5). Similar findings have been reported in the literature, where low levels of reflective practice have been attained when student journals were assessed.[13,14] Learning and practice issues, such as ethical concerns, questioning one’s profession and questioning student supervisor behaviours, emerged from the results of the analysis. These findings may have been influenced by confounding factors such as trust between student and educator, clarity of instruction, type of feedback, grading, number of entries and training. The rural block is unique in our physiotherapy curriculum. Reflection occurs when a situation does not suit normal practice. Hallett[15] found that the practical element and exposure to a community setting were crucial for developing critical thought. Students should be encouraged to interrogate limitations of themselves, others and the system. No gold standard on how best to assess the levels of reflection exists.[6] The knowledge that the reflective journals would be read by examiners and assigned a mark may have affected the levels of reflection. The study used eight reflective diaries and attained saturation. This may be owing to the study being in a single institution; future studies may include diaries from other institutions.

Conclusion

Our study demonstrated that physiotherapy students in a rural placement achieve low levels of reflection involving factual, cognitive and competencyrelated thinking. A minority were able to expand this to reflection that involved elements of critical thought, reflective thinking and reflective practice. Strategies need to be developed to enhance the quality of reflective practice among students. Acknowledgements. The authors acknowledge the final-year students of 2011 for giving permission to use their written portfolios, including their reflective diaries, in this study. We further acknowledge the staff and patients at the clinical placement sites, whose participation made this experience possible. 1. Buckley S, Coleman J, Davison I, et al. The educational effects of portfolios on undergraduate student learning: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Med Teach 2009;31(4):282298. http://dx.doi.org/10.1080/01421590902889897 2. Boud D, Walker D. Promoting reflection in professional courses: The challenge of context. Stud Higher Educ 1998;23(2):191-206. http://dx.doi.org/10.1080/03075079812331380384 3. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ 2009;14(4):595-621. http://dx.doi.org/10.1007/s10459-007-9090-2 4. Cross V. The professional development diary: A case study of one cohort of physiotherapy students. Physiotherapy 1997;83(7):375-383. http://dx.doi.org/10.1016/S0031-9406(05)65791-4 5. Alsop A. Competence unfurled: Developing portfolio practice. Occup Ther Int 2001;8(2):126-131. http://dx.doi. org/10.1002/oti.139 6. Schön DA. The Reflective Practitioner: How Professionals Think in Action. 6th ed. New York: Basic Books, 1983:1-8. 7. Mezirow J. Learning as Transformation: Critical Perspectives on a Theory in Progress. San Francisco, CA: JosseyBass, 2000:1-300. 8. Johns C. Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. J Adv Nurs 1995;22(2):226-234. http://dx.doi.org/10.1046/j.1365-2648.1995.22020226.x 9. Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Brookes University, 1988:27-30. 10. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Vol. 1. Englewood Cliffs: Prentice‐Hall, 1984:20-38. 11. Brookfield S. Developing Critical Thinkers. Milton Keynes: Open University Press, 1987:1-67. 12. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills: Sage, 1985:1-416. 13. Williams RM, Wessel J. Reflective journal writing to obtain student feedback about their learning during the study of chronic musculoskeletal conditions. J Allied Health 2004;33(1):17-23. 14. Kember D. Determining the level of reflective thinking from students’ written journals using a coding scheme based on the work of Mezirow. Int J Lifelong Educ 1999;18(1):18-30. http://dx.doi.org/10.1080/026013799293928 15. Hallett CE. Learning through reflection in the community: The relevance of Schön’s theories of coaching to nursing education. Int J Nurs Stud 1997;34(2):103-110. http://dx.doi.org/10.1016/S0020-7489(97)00001-1

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Short Research Report Table 2. Results of level of reflection Level of reflection

Entries, n

Quotes illustrating level of reflective practice

1a: The student refers to a particular activity/task 1b: The student demonstrates the process of acquiring an understanding of the task

1a: 108

‘I really should have checked, and this is so basic, how could I have forgotten?’ (PF 7)

1b: 12

‘Of all the questions covered in the Denver Screening Tool, our chosen outcome measure, the children here seemed to struggle the most with colours, adjectives and opposites.’ (PF 1)

2a and b: Achievements and methods used in the task

2a: 23

‘We finally had a meeting with the manager of the sewing room. I am overjoyed at the response – he agreed with all our suggestions and it would seem that he is willing to implement the necessary changes to help improve the working environment of the seamstresses. I have a deep feeling of satisfaction – at last, something is making a difference.’ (PF 8)

2b: 4

‘I walked away from the home visit feeling proud of the work I do and the potential impact we can have on community such as this one.’ (PF 3)

3a:16

‘These figures showed the need for an intervention to impede the increasing prevalence of hypertension and arising complication(s) among the health staff as well as to intervene in empowering those who are already hypertensive to take control and improve their lifestyles.’ (PF 3)

3b: 42

‘The best I could do was be compassionate and educate him on his condition and what he has the potential to become if he continues with rehabilitation.’ (PF 2)

3c: 22

‘This is when I realised that sometimes this job is not about what you do for the patient alone but also for the people around them.’ (PF 1) ‘With so many patients to see I must admit that short cuts were taken, which I didn’t feel comfortable with.’ (PF 8) ‘When we went to [a particular] clinic, there were no patients booked for us. This happens so often that [it] really annoys me how the few resources that are available to the clinic are not utilised!’ (PF 4) Sometimes students described an incident in which self, other and the system were linked.’ (PF 7) ‘Throughout the morning, I was increasingly aware of a sub-standard level of treatment given to the patients and was also told that I should not try to learn from what I was seeing because this is community – and things are done differently in community compared to theory. I did not pursue that as I wanted to avoid any conflict (it’s only my second day!!!) but felt very disappointed that patients are receiving such poor rehabilitation. I hope that this is not a true reflection of the care being given at the hospital and that today was just a once off!’ (PF 7)

4a: 27

‘Home-based care seems to bring back the sensitivity to healthcare, he is no longer a cerebrovascular accident covered by sheets. He is a man, who has a family and a community who bear him on their shoulders. He has a life, a soul, a meaning that extends far deeper than his medical assessment. And it is only in this setting that these things come together.’ (PF 8)

4b: 22

‘… it is important to them, the patients travel so far just for the treatment they seek and it’s our responsibility to make the most of the time we have with them!’ (PF 1)

4c: 16

‘Although we wanted to help him for his painful hand, there was a possibility there was an undiagnosed fracture. Therefore we advised him to go to Siloam Hospital for X-ray.’ (PF 1)

4d: 18

‘When the children have to write, they have to kneel on the cold and dirty concrete floor and write on their benches. How can this still be happening in a country that is striving to promote equality among its citizens!?’ (PF 3)

5: 4

‘I don’t think that my siblings, or myself, would give up our dreams in order to look after a parent after a stroke.’ (PF 4) ‘I learned again how courtesy goes so far. Just simple greeting in your patients’ mother tongue, ensures, that they will try to co-operate as much as possible.’ (PF 4)

3a, b and c: Insight, understanding and acknowledgement of limitation of self, others and the system

4a, b, c and d: Identifying challenges, importance of context and exploring alternatives

5: Reflection and abstract formation

PF = portfolio.

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Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

The health system benefits of attending an HIV/AIDS conference A Bosman,1 BCom (Fin Man), HED, BCom Hons (Acc), ACHM; J E Wolvaardt,2 BCur, MPH, PGCHE, PhD 1

Foundation for Professional Development, Pretoria, South Africa

School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, South Africa

Corresponding author: A Bosman (aletb@foundation.co.za)

Background. Although abstract-driven scientific conferences are expensive, little has been written about their benefits and whether attendance influences delegates’ actions. Objective. To explore possible benefits of conference attendance among 97 scholarship recipients at the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) 2013. Methods. A cross-sectional study was conducted. Data were collected via an online survey before the start and on the last day of the conference, and 5 months after the conference. Results. Scholarship recipients represented 27 countries and were between 20 and >60 years of age. The majority of respondents were between 26 and 40 years old, were male, and were researchers/scientists or advocates/activists. Respondents reported that they attended ICASA 2013 to learn more about tuberculosis/HIV/AIDS/sexually transmitted infections and networking opportunities. The majority reported that they gained professionally from attending ICASA 2013 and made ‘new contacts and opportunities for partnership and collaboration’ and ‘new ideas/directions for new project(s)’. Respondents identified ways in which they intended to use what they had learnt at the conference. Five months later respondents reported that they, their colleagues, managers and/or partners were motivated with regard to their HIV work and had shared information, best practices and/or skills gained. The majority had implemented best practices or innovations and retained professional contact with someone they met at ICASA 2013. Conclusion. Conference scholarship programmes provide opportunities for learning and networking and may translate into partnerships or joint ventures, which may result in the implementation of innovations and best practices. Such programmes may also lead to skills transfer, which could strengthen workforce capacity and health systems. Afr J Health Professions Educ 2017;9(2):57-61. DOI:10.7196/AJHPE.2017.v9i2.693

Abstract-driven scientific conferences are expensive and little has been written on their benefits – if any – beyond the possible improvement in the knowledge of the participants. Articles that report on health conferences focus on the clinical advancements,[1-3] the ethical issues surrounding HIV,[1] or the political arena of HIV in South Africa (SA).[4] One article focused on the benefits (including improved knowledge) experienced by the participants.[5] Healthcare conferences in developing countries have an additional obligation of ensuring societal benefit beyond the knowledge acquisition of delegates, as these conferences are often supported by donors who speculate whether the funding could not be better spent elsewhere. One area of donor funding is that of sponsoring scholarship programmes so that access to information presented at the conference is not a barrier for those without financial means. The question is whether scientific health conferences influence the actions of the delegates after the conference. Lalonde et al.[5] reported that the majority of survey respondents indicated that they would change their behaviour after attending the 15th International AIDS Conference, Bangkok, Thailand, 2004, and 80% of survey respondents who had attended one or more previous international AIDS conferences reported that they had changed their behaviour after attending. The International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) is the most important international AIDS conference in Africa and receives donor funding. Its current biennial hosting alternates between Anglophone and Francophone African countries and draws together African scientists, leaders, communities, organisations and individuals who share experiences and update their responses to the HIV/AIDS epidemic.

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SA was selected to host the 17th ICASA – held in Cape Town from 7 to 11 December 2013 (ICASA 2013). The conference theme, ‘Now more than ever: Targeting zero’, highlighted the need to ‘now more than ever’ maintain the commitment to ensure access to treatment for everyone in Africa, irrespective of their ability to pay for such treatment. The hosting of this ICASA conference in SA was symbolic, as it was in our country that, during the 13th International AIDS Conference in 2000, a turning point was reached in breaking the silence around AIDS in Africa. This conference was a catalyst for the unprecedented commitment by donors, government and civil society to increase access to treatment in an attempt to turn the tide of this epidemic. ICASA 2013 was an opportunity to renew the global commitment by drawing the world’s attention to the legacy of AIDS 2000 being under threat as a result of the worldwide economic downturn. The conference was an opportunity for the world’s leading scientists, policy makers, acti vists, people living with HIV (PLHIV), and government leaders to promote intersectoral achievements in the AIDS response and to strengthen partnerships. The Swedish International Development Cooperation Agency (SIDA) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) made funding available for a scholarship programme, which enabled individuals to attend, participate or present at the conference. There were several categories for scholarship applicants, i.e. PLHIV, community-based organisations, women, youth, least-developed countries, media, students, and community influencers. SIDA provided funding for 97 full scholarships, which included travel, accommodation, per diems and conference registration fees. SIDA further funded 138 partial scholarships, which included conference registration fees

Research only. The PEPFAR scholarship was reserved for delegates ˂30 years of age. This article reports on the experience and effects of the conference on the SIDA fully-funded scholars.

Methods

This was a cross-sectional study of a cohort of scholarship recipients. A purposive sampling technique was used, and those who met the inclusion criteria (fully-funded SIDA scholarship) were invited to participate. Participation was voluntary and commenced after the scholarship was accepted and participants had arrived at the conference. Data were collected by means of three self-completed anonymous surveys, which were available in English and French. The survey questions were translated from English to French by a French mother-tongue speaker and checked by another French mother-tongue speaker. Data were collected at three points in time: • Pre-conference. Fully-funded scholarship recipients were requested to complete the pre-conference survey on arrival and registration at the conference. The survey comprised 10 questions, including closed- and open-ended questions focused on the planning and organisation of ICASA 2013 and the scholarship programme. A total of 97 pre-conference evaluation surveys were completed in hard-copy format (English, n=87; French, n=10). • Last day of conference. Fully-funded scholarship recipients were requested to complete a reaction evaluation survey on the last day of the conference. It consisted of 18 closed- and open-ended questions, which focused on the programme, what the attendees intended to do with what they gained at the conference, and the effects of having attended previous ICASA conferences. The surveys were completed either in hard copy or online on LimeSurvey (LimeSurvey GmbH, Germany). A total of 65 surveys were completed (English, n=44; French, n=21). • Five months after the conference. An online survey was e-mailed to all fully-funded scholarship recipients on 1 May 2014. The survey focused on the benefits of attending the conference. A total of 63 surveys were completed (English, n=45; French, n=18).

Fig. 1. African scholarship recipients’ nationality (n=97). Researcher/scientist

Clinician/physician

Advocate/activist

Other healthcare worker/social services provider

Programme/facility manager or administrator

Student

Other

Media representative

Policy/administration

Community/religious/traditional leader

Teacher/educator/trainer

Lawyer

All hard-copy questionnaires were captured on LimeSurvey by a volunteer who could speak both English and French. The captured data were checked for correctness by the evaluation project manager. The online data were exported to Microsoft Excel 2007 (USA), which was used for data cleaning, coding and analysis. Once exported, the data were cleaned. During the cleaning process duplicate responses were deleted and spelling errors were corrected to facilitate sorting. Permission to use the data was granted by the Society for AIDS in Africa. Scholarship recipients entered into an agreement between themselves and the ICASA 2013 organiser, whereby they agreed to participate in all three surveys.

Results

The response rate was 100% in round 1 of data collection, 67% in round 2 and 65% in round 3.

1 0

Occupation/profession, %

Fig. 2. Scholarship recipients’ main occupation/profession (n=96). I received a scholarship

I am a conference speaker, facilitator or presenter (abstract accepted) I want to learn more about TB/HIV/AIDS/STIs

22 21

Networking opportunities

I was recommend by a peer/colleague

Other

I have always wanted to visit Cape Town

I was required/recommended by my employer

2 0

Reasons for attending ICASA 2013, %

Demographic profile of the respondents

The scholarship recipients represented 27 countries, based on their nationality, and 29 countries, based on their country of residence/work (Fig. 1). Only 1% (n=1) of scholarship recipients was not originally from Africa and 3% (n=3) did not reside or work in Africa. The majority of respondents were from sub-Saharan Africa (92%, n=89). The minority (3%, n=3) of scholarship recipients were between 20 and 25 years old; 58% (n=56) were between 26 and 40 of age; 35% (n=34) were

Fig. 3. Scholarship recipients’ reasons for attending ICASA 2013 (n=267).

between 41 and 60 of age; and 3% (n=3) were >60 years old. One respondent did not answer the question with regard to age. Although the options of female, male, transgender and do not want to disclose were provided, all classified themselves as male (57%, n=55) or female (43%, n=42). When asked to select their occupation/profession from a list of 12 options,

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Research Table 1. Respondents’ intention to use what was gained and achieved from the conference Intention to use what was gained at end of conference, n (%) (N=480)

Self-reported effect of attendance 5 months after conference, n (%) (N=351)

Strengthen and expand efforts

203 (42.3)

115 (32.8)

Create new collaborations and projects

93 (19.4)

101 (28.8)

Influence and motivate others

91 (19.0)

83 (23.6)

Share information and raise awareness

88 (18.3)

52 (14.8)

I am unsure

2 (0.4)

I will not do anything differently

2 (0.4)

Other

1 (0.2)

Intentions/effect

22% (n=21) of the scholarship recipients selected researcher/scientist (Fig. 2). The second-largest groups of respondents were clinician/physi cians and advocate/activist, both at 20% (n=19) each.

Reasons for conference attendance

The reasons to attend the conference were explored; 267 responses were received from the 97 respondents (Fig. 3). The four most cited reasons were receiving a scholarship (29%, n=76), acceptance of an abstract (22%, n=58), wanting to learn more about tuberculosis (TB)/HIV/AIDS/sexually transmitted infections (STIs) (21%, n=55), and networking opportunities (18%, n=49).

Perceived value of attending the conference

The majority (95%, n=62) of respondents in the second round of data collection reported that they did gain professionally from attending the conference and identified their gains. The largest proportion (78%, n=51) reported that they had made ‘new contacts and opportunities for partnership and collaboration’, while 77% (n=50) reported that they developed ‘ideas/ directions for new project(s)’, and 75% (n=49) indicated that they ‘increased understanding of the challenges to achieving treatment access in Africa’. Almost all (98%, n=64) of the respondents in the second round reported that they had the opportunity to build a professional relationship with other delegates and speakers, which underlines the networking opportunities that conferences offer. At the end of the conference, scholarship recipients were asked how they intend to use what they had gained at the conference (from a list of 14 potential intentions). Sixty-five respondents reported a total of 480 intentions. The responses from the 14 potential intentions were combined after the analysis into seven thematic areas. Five months after attending the conference, respondents were asked to report on the effect of their conference attendance on their work and their organisation. Respondents could choose from a list of 10 items; 63 respondents selected a total of 351 effects. The responses from the 10 potential effects were combined post analysis into four thematic areas (Table 1).

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Attendance of previous ICASAs

Fewer than half (41%, n=26) of the respondents indicated they had attended previous ICASAs. The majority (77%, n=20) of those who had attended a previous conference reported that attendance had had an influence both on their work and their organisation. The most frequently cited influences were: • adjusted/changed work focus, direction or approach (77%, n=20) • improved/refined work practices and/or methodologies, including management (73%, n=19) • created new partnerships (69%, n=18) • motivated self, colleagues, managers, and/or partners with regard to HIV work (69%, n=18) • shared information with colleagues, peers and/or partner organisations (65%, n=17). Nearly all (92%, n=24) of the respondents who had attended previous ICASAs reported that they continue to have contact with someone they had met for the first time at a previous conference. A large percentage (69%, n=18) indicated that they had entered into a partnership or a joint venture with someone whom they had met for the first time at a previous ICASA conference.

Effects of conference attendance at 5 months

In addition to the self-reported effects at 5 months after the conference (Table 1), almost all of the respondents (98%, n=61) indicated that they still have contact with someone whom they met for the first time at ICASA 2013, and 68% (n=42) entered into a partnership or joint venture with someone they had met at ICASA 2013 for the first time. Respondents were asked how many media articles related to or inspired by ICASA 2013 they had published after attending the conference. Nonmedia scholarship respondents (n=34) had the option to indicate that they were not from the media. Nine respondents answered this question and 15 articles were published: 6 respondents published 1 article each, 2 respondents published 2 articles each, and 1 respondent published 5 articles. The target audiences of the articles varied, i.e. special interest groups, organisations with activities similar to those of the authors’ oganisations, scientists, policy makers and the general public. A large majority (84%, n=52) of respondents indicated that in the 5 months since attending ICASA 2013, they had implemented a ‘best practice’ or ‘innovation’ in their work, community and/or research environment. Respondents were also asked to summarise the action steps that they had undertaken and/or what they had done differently as a result of attending ICASA 2013. The descriptions of the best practices or innovations and the responses regarding action steps were analysed, and themes were allocated and combined according to the main themes. The following main themes were identified and are illustrated by some of the respondents’ quotes: Collaboration and fundraising ‘ After the ICASA conference I used the experience to write a combination prevention project and we received funding worth 250 000 dollars to implement combination HIV/AIDS.’ ‘We are conducting a study on HIV and disabilities, which is first of its kind in Nigeria. The idea sprang from ICASA 2013 experience and we hope the findings will stimulate donors towards this direction.’ Research ‘I have been able to redirect the focus of our organisation to start researching unique phenotypes of HIV infection.’

Research ‘ I have written three articles for conferences awaiting response. I am trying to ensure that partners were co-operating into responding to the global HIV response. I aim to support building the capacity of [Community Service Organisations] CSOs partners to write and present scientific papers based on evidence.’ ‘I have changed the methodology of my research based on the best practices that I learnt at the conference.’ Outreach/linkage to care ‘Commercial sex workers HIV outreaches.’ ‘I conducted a community dialogue with women in the church to discuss about issues of gender-based violence and intimate partner violence, which make women vulnerable to HIV and AIDS.’ ‘I have developed new strategies for tracing people who do not come back into care, based on models that have worked in other countries and in special populations, such as displaced people, people with a lot of stigma.’ ‘Created awareness on regular and consistent use of condoms and lubricants.’ Key populations ‘Condom promotion and integrating female condoms into our HIV prevention strategies. We have also established more male and female condom community outlets to increase access.’ ‘Gender sensitive advocacy on preventing discrimination against the mostat-risk population – [men having sex with men] MSM, [injecting drug users] IDUs.’ ‘New approaches in handling the key populations. Addressing gender issues in fighting against HIV.’ ‘Intervention strategies to close referral for targeting high-risk groups.’ Policy ‘Supported the [International Conference on Population and Development] ICPD process as part of a government delegation. Info from ICASA helped earmark priorities that ICPD should incorporate.’ ‘In implementing prevention program [minimum prevention package intervention] MPPI used.’ Service uptake ‘Forming a network for all [non-governmental organisations] NGOs working with [most at risk populations] MARPs in Egypt.’ ‘Using expert patient to strengthen linkage of HIV-positive to care and treatment.’ Improvement and innovation ‘Information sharing through restitution and monitoring for better implementation.’ ‘Systematic screening of TB patient[s]. I am determined to speak strongly in [favour of screening of] immunocompromised [patients].’ Strategy ‘Discussing experiences and new lessons learnt in SA with the three major networks on the need to involve [knowledge attitude and practices] KAP … in our implementation. This has led to redirecting our project through the involvement of two of the organisations in our pilot project.’ ‘I disseminated the key lessons and new innovations that I learnt from the conference that enabled my technical support unit to generate a new project that actually got funded. Hence developing a new partnership.’

Advocacy ‘I have created a mailing list where I have shared several abstracts that pertain to women and health presented at ICASA. I created a Whatsapp group where we continue to discuss issues that came from ICASA. I was on a radio programme where I spoke on the various issues that a diverse group of people spoke about at ICASA; in particular, issues around HIV prevention, treatment care and support.’ ‘Encouraging MSM/IDU to open up. Sensitising on the danger of sexual risky behaviour. Creating awareness on the regular and consistent use of condoms and lubricants.’

Discussion

The majority (59%, n=60) of the scholarship recipients were between the ages of 26 and 40 and two-thirds were a combination of researchers/ scientists, clinicians/physicians and advocates/activists. This demographic profile is characteristic of early- to mid-career health professionals. The three most-cited reasons for attending the conference were practical (receiving a scholarship) or educational (acceptance of abstract and wanting to learn more about TB/HIV/AIDS/STIs). The fourth cited reason – networking opportunities – proved to be durable, as these new contacts and opportunities for partnership and collaboration were the most cited in terms of perceived value of the conference. Also, almost all of the respondents reported that they had the opportunity to build a professional relationship with other delegates and speakers during the conference. This level of networking can be considered to be sustainable after the conference, as nearly all (92%, n=24) of the respondents who had attended previous ICASA conferences reported that they still had contact with somebody they had met for the first time at a previous ICASA conference. This finding held true, as 5 months after the ICASA 2013 conference almost all (98%, n=61) of the respondents still had contact with somebody they had met for the first time at ICASA 2013. The networking opportunity also translated into concrete partnerships or joint ventures with somebody they had met at ICASA 2013 for the first time for more than two-thirds (68%, n=42) of the respondents. This finding is consistent with that of 69% (n=18) of respondents from the second round of data collection, who reported that they had entered into a partnership or a joint venture with somebody they had met for the first time at a previous ICASA conference. The findings regarding the network opportunities support the findings of Wiessner et al.,[6] who reported that the focus of conferences extend beyond opportunities for learning, as the delegates have other expectations and needs that include making contacts and building relationships. The stimulation of ideas for new projects and an increased understanding of the challenges to achieving treatment access in Africa were also cited as being perceived of value as a result of conference attendance, and 31 new projects were listed by the respondents 5 months after the conference. At the conclusion of the conference, the respondents committed to strengthen and expand efforts within their organisations/networks, create new collaborations and projects, influence and motivate colleagues, peers and/or partners, and share information and raise awareness when they returned to their workplaces. The third round of data collection at 5 months after the conference suggested that the respondents did indeed strengthen and expand their efforts, create new collaborations and partnerships, influence and motivate their colleagues, managers and/or partners, share information, and raise awareness. This finding is supported by the theory of reasoned action described by Fishbein and Middlestadt.[7] Capacity was built by

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Research sharing the information, best practices and/or skills gained with colleagues, managers and/or partners. This skills transfer included improved/refined work practices and/or methodologies, including management practices. The majority of the activities described by the participants after the conference are health-system strengthening activities. This vigorous post-conference activity is not surprising, as Lalonde et al.[5] reported that ‘significantly more delegates from developing versus developed countries reported an intended behaviour change’ after the conference. The survey 5 months after the conference may have been too soon to determine with absolute certainty the impact of attending the conference. In particular, creating new collaborations and projects and influencing and motivating others would need more time to take full effect. In contrast, strengthening and expanding efforts and sharing and raising awareness could be more rapidly achieved. This post-conference survey was, however, an opportunity for participants to reflect on conference experiences that could have an impact on their scholarship and practice.[6] The post-conference survey did give a good indication of some of the outcomes. Ninety-eight percent (n=61) of the respondents in round 3 of data collection indicated that they still have contact with somebody they had met for the first time at ICASA 2013, and 68% (n=42) reported that they had entered into a partnership or joint venture with someone they had met for the first time at ICASA 2013, suggesting the value of conferences for networking and possible partnerships. According to Wiessner et al.,[6] this kind of reflective learning is a return on a conference investment. The conference also served as an impetus for the implementation of best practices or innovations in the workplace, community and research environment. These improvement and innovation activities included research reports, outreach, work with key populations, policy work and improving service uptake. What is now needed is confirmation of this impact through another study.

Study limitations

The timing of the questionnaire 5 months after the conference is a limitation, as it is likely that some of the effects (such as developing new projects) might require more time. Also, the use of anecdotal data is not sufficiently strong evidence of the impact of the conference. Finally, the use of self-reported data is a limitation, as participants might have provided socially desirable responses as scholarship recipients.

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Conclusion

From the respondents’ reports 5 months after the conference it is clear that the scholarship programme contributed to the strengthening of health systems. In the case of ICASA 2013, the benefits are retained in Africa, as the majority of scholarship recipients work in Africa. As the majority (59%) of scholarship recipients were between 26 and 40 years old, it implies that they will be able to continue to strengthen health systems for several decades to come. Conference scholarship programmes, therefore, arguably provide the opportunities to create partnerships and strengthen health systems in Africa, and answer the question whether this kind of activity is worthy of donor support. The finding by Lalonde et al.[5] suggests, however, that the maximum benefit would be achieved by ensuring that scholarships are awarded to those who are new to the conference, as respondents who had attended only one previous international AIDS conference were ‘[statistically] significantly more likely to report making a change in their HIV/AIDS work as a result of attending a past [AIDS conference] than those who attended more than one’. Funding. This study was made possible by ICASA and the professional conference organisers, Dira Sengwe Conferences. The ICASA scholarship project was funded by SIDA. According to the agreement with SIDA, it was not necessary to obtain approval from SIDA to write this article. SIDA did not contribute to the writing of this article and does not vouch for the content. Conflict of interest. Ms A Bosman is a technical advisor in evaluation in the Programme Evaluation Unit of the Foundation for Professional Development and the Company Secretary of Dira Sengwe Conferences.

1. Fuller J, Keenan JF. The International AIDS Conference in Bangkok: Two views. America (NY) 2004;191(5):13-15. 2. Mukherjee JS. The international AIDS conferences from Vancouver to Bangkok: How far have we come in eight years? Pan Am J Public Health 2004;16(2):75-77. http://dx.doi.org/10.1590/S1020-49892004000800001 3. Brannon PM, Yetley EA, Bailey RL, Picciano MF. Vitamin D and health in the 21st century: An update. Am J Clin Nutr 2008;88(Suppl 2):S483-S490. 4. Horton R. Politicisation of debate on HIV care in South Africa. Lancet 2000;355(9214):1473. http://dx.doi. org/10.1016/S0140-6736(00)02154-1 5. Lalonde B, Wolvaardt JE, Webb EM, et al. A process and outcomes evaluation of the International AIDS Conference: Who attends? Who benefits most? J Int AIDS Soc 2007;9:6. http://dx.doi.org/10.1186/1758-2652-9-1 6. Wiessner CA, Hatcher T, Chapman D, et al. Creating new learning at professional conferences: An innovative approach to conference learning, knowledge construction and programme evaluation. Hum Res Dev Int 2008;11(4):367-383. http://dx.doi.org/10.1080/13678860802261488 7. Fishbein M, Middlestadt SE. Using the theory of reasoned action as a framework for understanding and changing AIDS-related behaviours. In: Mays VM, Albee GW, Schneider SF, eds. Primary Prevention of AIDS: Psychological Approaches. Newbury Park, CA: Sage, 1989.

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

A learning development module to support academically unsuccessful 1st-year medical students C A Kridiotis, MA (Health Professions Education), BTech, BCom; S Swart, PhD (Health Professions Education), MA (Industrial Psychology) Division of Health Sciences Education, Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: C A Kridiotis (c.kridiotis@intekom.co.za)

Background. Students who fail the first semester in an undergraduate medical programme at the University of the Free State may join a Learning Development Programme (LDP) in the second semester. A new generic skills module, Lifelong Learning Skills (LLLS), was added to the curriculum in 2013. Objective. To ascertain whether the LLLS module helped to improve the generic learning skills of LDP students. Methods. Student reflections and a self-administered questionnaire with open-ended questions were used to obtain feedback. Results. Students believed that the LLLS module enhanced their generic skills, and that it was beneficial to them. Aspects such as motivation, time management and critical thinking improved. Furthermore, they indicated that the skills mastered during the module continued to be useful in the subsequent academic year. Conclusion. The students’ reflections made a valuable contribution to understanding ways in which they can be supported. Through student insights, future presentation of the LLLS module can be enhanced. Afr J Health Professions Educ 2017;9(2):62-66. DOI:10.7196/AJHPE.2017.v9i2.694

Not all 1st-year students who enter the medical programme in the Faculty of Health Sciences at the University of the Free State (UFS) in Bloemfontein, South Africa, are successful, despite the application of strict selection and admission criteria. Selection criteria include high academic scores in school-leaving examinations and achievement according to National Benchmark Tests (NBTs). Furthermore, applicants may have held secondary school leadership roles, as well as achieving in both sport and cultural activities, for which additional admission points are allocated. Across all institutional faculties, research has shown that student success is ‘a complex phenomenon with many influencing factors’,[1] which include cognitive, motivational, dispositional, sociocultural and economic variables.[2] While acknowledging that complex factors contribute to entry-level student unpreparedness for higher education, institutional support is considered vital for students struggling academically in their 1st year of study. International research has shown that faculties can contribute to student support by using strategies to enhance self-efficacy in students in all disciplines.[3] In the UFS undergraduate medical programme, early monitoring of assessment results and student academic support and development are in place.[4] The identification of effective strategies for medical student remediation has been investigated, which include providing at-risk students with an alternative learning environment, teaching to smaller groups of students and improving students’ generic skills.[5,6] Results show that mandatory remedial courses offered to small groups of medical students have proved successful.[6,7] In line with the international trend of providing remediation programmes,[6,7] UFS medical students who fail one or more of their first-semester modules for the first time, are given the opportunity to join a 6-month Learning Development Programme (LDP) during the second semester. Academic success in the LDP allows students a second opportunity to re-enter the mainstream medical programme at the start of the following academic year. Theoretical underpinnings of a remediation

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course include mindful design of the syllabus to include aspects of active learning and carefully selected course content, with the aim to promote student self-regulation and self-reflection.[7] The theory behind successful remediation includes the three key steps of diagnosis, use of remedial activi ties, and subsequent re-testing.[8] Additionally, according to Hommes et al.,[9] collaboration between students benefits their performance and influences their learning, Over a number of years, the focus of the LDP for UFS medical students has been on modules providing additional content knowledge, i.e. medical terminology, language skills, medical physics, basic biochemistry and physiology, and integrated anatomy and physiology. Since 2013, the LDP curriculum also includes a new generic skills module – Lifelong Learning Skills (LLLS). The rationale behind this revised curriculum was that recent international research has indicated that key generic learning skills were contributing factors in the academic success of medical students.[5,7] These generic skills include information literacy, data handling, information and computer technology, problem-solving, self-management and teamwork.[5] Critical thinking skills are also considered to be a key generic skill, specifically for medical education.[7] According to Murdoch-Eaton and Whittle,[5] the challenge for medical educators is to train healthcare professionals to recognise ‘unstated assumptions, values or prejudices, to evaluate evidence, interpret data and inspect arguments using discrimination, accuracy and judgement’. The focus of the LLLS module is on developing generic skills in students, and introducing them to professional conduct, ethics, and critical thinking in healthcare. Motivation, learning styles and study techniques, time management, communication skills, problem-solving and professional behaviour in the health sciences are all key learning areas in the module. International research has shown that curricula for medical education may undervalue student motivation, and ways to stimulate intrinsic motivation may improve the manner in which future medical education is planned and

Research delivered.[10] When studying students’ wellbeing, motivational strategies and ‘approaches to learning and their perception of their learning environment’, it was found that the same learning environment may not be perceived in the same way by all students.[11] The LDP provides unsuccessful students with an alternative learning environment. In a large-scale study conducted in the USA across various institutions, Booth et al.[12] researched factors that students thought had supported their educational success, in an attempt to understand how institutions could deliver support to students, both inside and outside the classroom. Feedback from the study showed that students regarded ‘being directed’ and working towards a goal as important, and that being focused and aiming to succeed were equally important. It was also reported that if students felt that they were nurtured and valued, and that there was someone who encouraged them to succeed, it had a positive impact on their studies. When students were actively engaged, and when they participated in lectures and felt that they were connected with the institutional community, these factors contributed to student success.[13] International results highlight that collecting data on self-regulated learning among medical students and on student participation in learning activities, may ‘help medical schools to identify students who are at risk for poor performance early in their training’.[13] Students’ confidence in their individual academic-related skills plays a role in their motivation to achieve, and although student perceptions may be self-reported, there is an association between level of practice of a skill and confidence to use the skill.[14] The newly developed LLLS module in the LDP at the Faculty of Health Sciences, UFS, is aligned with the abovementioned research findings, and aims to help students to address their goals, function in a small and nurtured environment, and overcome their academic shortcomings in positive ways. The current research sought to gauge student perceptions regarding the new LLLS module. The objectives of the study were: • to ascertain whether there was a student perception that the introduction of the LLLS module within the LDP of the Faculty of Health Sciences, UFS, helped to improve their generic learning skills • to ascertain whether there was a student perception that the LLLS module made a difference to the way they approached their studies, and whether the module could be improved in future • to determine whether the module was perceived by students to have had an ongoing impact not only on their generic skills, but also on their attitudes, professional conduct, group skills, and overall academic success.

Methods

The study used a qualitative methodology, with some quantitative elements. Student academic statistics were used as an overview to determine the number of students who passed and failed. The qualitative methodology included student reflections on the LLLS module. These reflections were documented and reviewed by the researchers over a period of two years. Ten medical students were in the LDP in 2013, and 15 in 2014. In the second part of the research, a self-administered questionnaire with open-ended questions was used to gain information from the first group of students (n=7), who had successfully progressed through the LDP in 2013, re-entered the second-opportunity mainstream programme and successfully completed semesters 1 and 2 in the mainstream. Students were asked to reflect on the benefits of the LLLS module in particular and the LDP in general, a year after completion of the programme, and subsequent

academic success in the mainstream programme. By analysing academic achievements and student self-reflection, triangulation was used as a validity process. The data were edited, categorised and summarised by both researchers, and thematical analysis was used to identify common themes in the responses. Ethical approval to conduct the study was obtained from the Ethics Committee of the Faculty of Health Sciences, UFS (Ecufs ref. no. 112/2014). Permission was obtained from the Dean of the Faculty of Health Sciences, Head of the School of Medicine and Vice-Rector: Teaching and Learning, UFS.

Results

During 2013, 158 1st-year students enrolled in the first semester of the medical programme at the Faculty of Health Sciences at UFS. Of these students, 144 (91.1%) passed the first semester, 12 (7.6%) failed the first semester and 2 (1.2%) voluntarily discontinued their studies. Of the 12 students who failed the first semester, 10 (6.3%) were placed in the LDP for the second semester. One of the students had already obtained a qualification before being selected for the medical programme and, according to regulations, was not allowed into the LDP. At the end of the second semester LDP, 7 of the medical students in the LDP achieved an overall average mark of 75% for all the modules in the programme and were readmitted to the first semester of the mainstream medical programme in 2014. Two students were unsuccessful in the LDP, as shown in Table 1. One student discontinued his studies. In 2014, 149 1st-year medical students were enrolled for the first semester of the medical programme. Of the total group, 131 (87.9%) passed the first semester, 17 (11.4%) failed the first semester and 1 student (0.7%) voluntarily discontinued his/her studies. Fifteen students (10.1%) were admitted to the LDP for the second semester, of whom 12 obtained the required minimum of 75% average for all modules and were readmitted to the first semester of the mainstream medical programme for 2015. Three students were unsuccessful in the LDP (Table 1). Key reflections of the 2013 LDP students included that many expressed the feeling that they had lost a degree of self-confidence after failing the first semester. Most students viewed their experience of the LLLS module as very beneficial, and the small size of the group promoted mutual support among the group members. During the LLLS module they were given the opportunity to express their opinions and interact with each other. The facilitators of the LLLS module positively reinforced the students, further ensuring that they felt connected and nurtured. The facilitators also ascertained that the students were made aware that, with the right Table 1. Statistics of 1st-year medical students at the end of the first semester of 2013 and 2014 2013, n (%) 2014, n (%) (N=158) (N=149)

Outcome Successful (passed first or second examination opportunity)

144 (91.1)

131 (87.9)

Unsuccessful (no admission to write examination, 12 (7.6) or failed examination)

17 (11.4)

Dropped out of the medical programme

2 (1.3)

1 (0.7)

Admitted to LPD

10 (6.3)

15 (10.1)

Successful in LPD

7 (4.4)

12 (8.1)

Unsuccessful in LPD

2 (1.3)

3 (2.0)

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Research Table 2. Most beneficial aspects of the key generic skills taught in the LLLS module, 2013 Learning unit

Students’ reflection on beneficial aspects

Motivation and selfmanagement

‘Helped build up confidence after failing first semester.’ ‘Helped build a constructive, positive attitude.’ ‘Discovered other students faced the same challenges as I did.’

Learning styles and study techniques

‘Discovered how best to study using my personal learning style.’ ‘Helped me study large amounts of work.’ ‘Assisted with becoming more effective while studying.’

Time management

‘Helped to discover how to make an effective study timetable.’ ‘Helped to avoid procrastination by using a study timetable.’ ‘Managing study time by writing it down in the form of a schedule made a huge difference.’

Communication skills and critical thinking skills

‘The oral presentation was a very good exercise.’ ‘I was apprehensive about giving the oral presentation, but felt confident afterwards.’ ‘Built confidence and helped the group to bond.’

Group work, problem-solving and conflict management

‘Helped me realise I must take the view points of others into consideration.’ ‘Made it easier to function in a group.’ ‘Helpful – being more considerate and mindful of the opinions of others.’

Stress management

‘Helped me identify my stressors and helped me cope better with stress.’ ‘Discovered techniques to help me deal with stress.’ ‘Helped, I had been very stressed out when I failed.’ ‘Realised I could ask for help.’

Test and examination management

‘Was useful to discover techniques to approach tests and examinations.’ ‘Learning key action words to identify what examiner is asking for was useful.’ ‘Helpful, we could have spent even more time on this.’

approach to their studies, academic success was within their reach. Essential reflections of students regarding the most beneficial aspects of the generic skills learned in the LLLS module during 2013 are shown in Table 2. Some students indicated that they would like more information on applying new learning styles, and also that more help was needed in applying study techniques, and test and examination management. These shortcomings, having been identified, were addressed in subsequent facilitation of the LLLS module. The comments of the 15 medical students in the LDP during the second semester of 2014 included reflections, e.g. that they found the module

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insightful and beneficial, as they reassessed the way in which they learnt and applied knowledge. The LLLS module encouraged the students and made them approach the future positively, despite the fact that they had failed. They reported having acquired skills in writing scientific reports, presenting and critical reflection, which they did not have before. The module also brought about an improvement in attitudes and perspectives, preparing students to become academically and socially better prepared for the challenges of medical education. Further reflections of the 2014 LDP students included comments that although some of the module content was similar to what they were taught in semester 1 in the mainstream, the attention to foundational knowledge in this module made the understanding and retention of the study material more manageable. The underlying support provided to the students in the LDP course enabled them to grasp concepts they had previously found challenging. The module was considered by one student ‘to have made a huge impact on my studies and the way I look at university life’. One effective and beneficial skill acquired by students was improved time management. Their reflections regarding the generic skills learned in the LLLS module are shown in Table 3. Quantitative data were used to track the academic progress of the students in the year following the LDP, to ascertain whether students maintained their level of academic success. The students who had passed the LDP in 2013 and re-entered the mainstream medical programme (n=7) had all been academically successful. These students indicated that they had learnt better time management during their LLLS module, which was very beneficial. The students also indicated that the LDP in general had motivated them to study consistently and consequently and to prepare ahead of their classes in the mainstream programme. Students were asked a year after completing the LDP which module(s) they considered to have been the most beneficial during the programme. Student perceptions on the efficacy of the LDP in general, as well as the contributing factors to their initial academic failure and subsequent academic success, were documented by the researchers. The students cited the modules of integrated anatomy and physiology, medical terminology, and basic biochemistry and physiology as being the most helpful. The consolidation of core knowledge during ‘the slower pace’ of the LDP modules was cited as very beneficial to the students after they had re-entered and were successful in the mainstream programme. When asked to comment on factors that contributed to their subsequent success in the mainstream programme, students indicated that during the second opportunity, they were more aware of the way in which they would be assessed. By being familiar with the assessment methods, they could adjust their learning. In the mainstream, integrated assessment methods are used, which require deep learning and challenge students to apply critical thinking. The LLLS module had informed students of assessment principles and key action words, as well as giving them the opportunity to practise the use of study techniques, learning skills such as effective summarising and ways to maximise retention of study material. The students also indicated that timeous feedback on the results of assessment helped them to plan for the next test. When students were part of the LDP, their progress was carefully monitored and they became familiar with the support services at the Division of Health Sciences Education, which also played a role, as the students were comfortable with asking for assistance when they needed it. Additionally, the second-opportunity students indicated that the student mentors who had been appointed during 2014 to guide mainstream students also played an important supportive role, and that this contributed to their academic success.

Research Table 3. Beneficial aspects of the key generic skills taught in the LLLS module, 2014 Learning unit

Students’ reflection on beneficial aspects

Motivation and self-management

‘Learned about goal setting, to keep being motivated.’ ‘Helped benchmark my needs, identified lack of resources.’ ‘Made me realise what went wrong last semester.’

Learning styles and study techniques

‘Practical application methods of learning strategies extremely valuable.’ ‘I realised I have below average self-acceptance, and am critical of others – things I have to work on.’ ‘I learned to improve, implement deep learning, being more effective while studying.’ ‘I learned to summarise, formulate questions while learning.’ ‘Helped me understand the preparation-teaching-learning-assessment and reflection cycle.’ ‘I am more accommodative of people than I was previously.’

Time management

‘I organised my study space, used tips to study more effectively.’ ‘I realised how much I procrastinate and how to avoid this.’ ‘Managing my study time by planning a schedule.’ ‘I learnt that working continuously is better than cramming.’ ‘Making a weekly, daily and semester planner helped me to record and plan for tests and assignments, very helpful.’

Communication skills and critical thinking skills

‘I learned about written academic submissions, which was worthwhile.’ ‘The chance to give an oral presentation in front of a smaller audience was beneficial, and will prepare me for giving a presentation in front of a larger audience.’ ‘I benefited from having to write a scientific essay and reference it correctly.’ ‘I benefited by having some classes with other allied health professionals, such as nurses. This gave me understanding and insight.’

Group work, problem-solving and conflict management

‘This module’s focus was on the social aspects of ethical dilemmas.’ ‘The focus on group work is something I appreciated, I saw how my behaviour affects the other members of the group.’ ‘I do not enjoy group work, but because of this learning unit, I now know how to take part in group work and discussions in a responsible and accountable manner.’ ‘Helped me to think outside the box.’ ‘I realised that in the medical profession we will be faced with dilemmas, which will need critical thinking.’ ‘I found it hard to critically reflect on an article, which worries me. I need to improve this skill.’

Stress management

‘Stress is a constant and chronic problem throughout the medical field and I believe this unit approached it in the right way.’ ‘I was able to identify how my stress is manifested.’ ‘Although this learning unit did help me identify stressors and the symptoms of stress, I still do not know how to manage my stress.’

Test and examination management

‘I found that reflecting on a test helped me to prepare for the next test.’ ‘It was useful to learn about different kinds of questions and how to approach them.’ ‘Good techniques during the test, such as reading the question analytically and identifying the action words, is useful.’

Discussion

In the first part of the survey, students indicated that the skills they had learnt during the LLLS module helped them regain their confidence after a demoralising failure in semester 1. Students learnt to plan and apply time management and effective study techniques. They concluded that the following factors played a role in increased levels of confidence: (i) the small-group approach with supportive facilitators; (ii) interaction with peers; (iii) class discussions; and (iv) oral presentations within the small-group setting of the LLLS module. Stegers- Jager et al.[15] reported that participation by students in scheduled learning activities was strongly related to academic performance in the first year. A similar trend was found in the LLLS module. Students who were more conscientious regarding attendance outperformed those with poor session attendance. This trend was in line with a recent study among medical students in China, which showed that student engagement in lectures and recognition that effort needed to be put into studies, directly contributed to achievement.[16] In the second part of the survey, students indicated the generic skills development continued to be useful in the academic year that followed,

as they studied timeously and more effectively. The slower pace at which the academic modules within the LDP were presented, was perceived as beneficial to students, and they felt their core knowledge in modules such as anatomy and physiology had been consolidated during the LDP. Former LDP students reported that, once they were back in the mainstream programme, their core knowledge of anatomy and physiology compared favourably with the levels of knowledge demonstrated by their peers. This insight is a topic to be considered in further research, and would justify research into the short-, medium- and long-term effects of a short, integrated programme on study skills and learning development of 1st-year medical students. The LDP students of 2013, who were the first group to take the LLLS module, were positive about its benefits, and indicated that the skills they had learnt during the module had continued to be useful in the subsequent academic year. The group of students were aware of the academic challenges they had to face in their continued studies, but were more equipped on a personal level to deal with the challenges, as they had acquired techniques to deal with the academic workload and the accompanying stress. Using the

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Research goal-orientation theory to design an intervention to reinforce mastering goals as a successful outcome, ‘may enhance the effectiveness of medical student training’.[17] As indicated earlier by Hommes et al.,[9] collaboration between students benefits their performance and influences learning, which was also found in the current research, as frequent collaboration between the same group of students in the LLLS module strengthened the bond between them, and had a positive influence on their confidence and performance. After an unsuccessful first semester, students may also have had a better understanding of how to avoid pitfalls during assessment at university, which may also have played a role in their subsequent academic success.

Conclusion

The students noted the benefits of the remedial LDP, with support from facilitators and interaction with their peers within the small group. They considered that the slower pace at which the academic modules within the LDP were presented had helped them to consolidate core knowledge, which became apparent once they were back in the mainstream medical programme. The rationale behind the development and introduction of the new LLLS module was that recent research, both nationally and internationally, indicated that key generic learning skills were contributing factors in the academic success of health sciences students. The LLLS module was found to have addressed the need for enhanced key generic skills among 1st-year medical students who had initially been unsuccessful, in line with findings by Burch et al.,[6] who stress that ‘the importance of generic skills in underpinning effective learning is increasingly appreciated’.[6] The reflections of students made a valuable contribution to understanding how the key generic skills can be useful to medical students. The generic skills taught were found to supplement the core knowledge component of the LDP and promote lifelong learning skills in medical students in their subsequent years of study.

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Acknowledgements. Dr Daleen Struwig, Faculty of Health Sciences, UFS, for technical and editorial preparation of the manuscript.

1. Wilson-Strydom M. A framework for facilitating the transition from school to university in South Africa: A capabilities approach. PhD thesis. Bloemfontein, University of the Free State, 2012. http://scholar.ufs. ac.za:8080/xmlui/handle/11660/1935 (accessed 21 April 2017). 2. Cliff A, Ramaboa K, Pearce C. The assessment of entry-level students’ academic literacy: Does it matter? Ensovoort 2007;11(2):33-48. http://www.academia.edu/7958363/The_assessment_of_entry-level_students_academic_literacy_does_it_matter (accessed 11 April 2017). 3. Krumrei-Mancuso EJ, Newton FB, Kim E, Wilcox D. Psychosocial factors predicting first-year college student success. J Coll Stud Dev 2013;54(3):247-266. http://dx.doi.org/10.1353/csd.2013.0034 4. University of the Free State. Student Academic Support and Development. Bloemfontein: UFS, 2014. 5. Murdoch-Eaton D, Whittle S. Generic skills in medical education: Developing the tools for successful lifelong learning. Med Educ 2012;46(1):120-128. http://dx.doi.org/10.1111/j.1365-2923.2011.04065.x 6. Burch V, Sikakana CNT, Gunston GD, Shamley DR, Murdoch-Eaton D. Generic learning skills in academicallyat-risk medical students: A development programme bridges the gap. Med Teach 2013;35(8):671-677. http:// dx.doi.org/10.3109/0142159X.2013.801551 7. Winston KA, van der Vleuten CPM, Scherpbier AJ. The role of the teacher in remediating at-risk medical students. Med Teach 2012;34(11):e732-e742. http://dx.doi.org/10.3109/0142159X.2012.689447 8. Cleland J, Mackenzie RK, Ross S, Sinclair HK, Lee AJ. A remedial intervention linked to a formative assessment is effective in terms of improving student performance in subsequent degree examinations. Med Teach 2010;32(4):e185-e190. http://dx.doi.org/10.3109/01421591003657485 9. Hommes J, Rienties B, de Grave W, Bos G, Schuwirth L, Scherpbier A. Visualising the invisible: A network approach to reveal the informal side of student learning. Adv Health Sci Educ Theory Pract 2012;17(5):743-757. http://dx.doi.org/10.1007/s10459-012-9349-0 10. Kusurkar RA, Croiset G, Mann KV, Custers E, ten Cate O. Have motivation theories guided the development and reform of medical education curricula? A review of the literature. Acad Med 2012;87(6):735-742. http://dx.doi. org/10.1097/ACM.0b013e318253cc0e 11. Lonka K, Sharafi P, Karlgren K, et al. MED NORD – a tool for measuring medical students’ well-being and study orientations. Med Teach 2008;30(1):72-79. http://dx.doi.org/10.1080/01421590701769555 12. Booth K, Cooper D, Karandjeff K, Purnell R, Schiorring E, Willett T. Student support (re)defined: What students say they need to succeed. Key themes from a study of student support. http://archive.rpgroup.org/sites/default/ files/StudentPerspectivesResearchBriefJan2013.pdf (accessed 21 April, 2017). 13. Stegers-Jager KM, Cohen-Schotanus J, Themmen AP. Motivation, learning strategies, participation and medical school performance. Med Educ 2012;46(7):678-688. http://dx.doi.org/10.1111/j.1365-2923.2012.04284.x 14. Murdoch-Eaton D, Manning D, Kwizera E, Burch V, Pell G,Whittle S. Profiling undergraduates’ generic learning skills on entry to medical school; an international study. Med Teach 2012;34(12):1033-1046. http://dx.doi.org/10.3109/104 2159X.2012.706338 15. Stegers-Jager KM, Cohen-Schotanus J, Themmen AP. The effect of a short integrated study skills programme for first-year medical students at risk of failure: A randomised control trial. Med Teach 2013;35(2):120-126. http:// dx.doi.org/10.3109/0142159X.2012.733836 16. Zhou YX, Ou CQ, Zhao ZT, et al. The impact of self-concept and college involvement on the first-year success of medical students in China. Adv Health Sci Educ Theory Pract 2015;20(1):163-179. http://dx.doi.org/10.1007/ s10459-014-9515-7 17. Madjar N, Bachner YG, Kushni T. Can achievement goal theory provide a useful motivational perspective for explaining psychosocial attributes of medical students? BMC Med Educ 2012;12(1):4. http://dx.doi.org/10.1186/1472-6920-12-4

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Depression, anxiety, stress and substance use in medical students in a 5-year curriculum P M van Zyl,1 MB ChB, MMedSc, PhD; G Joubert,2 BA, MSc; E Bowen,3 MB ChB student; F du Plooy,3 MB ChB student; C Francis,3 MB ChB student; S Jadhunandan,3 MB ChB student; F Fredericks,3 MB ChB student; L Metz,3 MB ChB student 1

Department of Pharmacology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Corresponding author: P M van Zyl (vzylpm@ufs.ac.za)

Background. The mental health of medical students is a global concern, and medical training has been described by some as being detrimental to the health of medical students, affecting both their student experience and professional life. Objectives. To determine the prevalence of depression, anxiety, stress and substance use among preclinical students in a 5-year outcomes-based medical curriculum. The study also investigated the association of selected demographic factors with these outcomes. Methods. All University of the Free State medical students in semesters 3 (n=164) and 5 (n=131) during 2015 were included in this cross-sectional study. Depression, anxiety and stress levels were measured by means of the Depression Anxiety Stress Scales (DASS-21). Demographic questions were included in an anonymous self-administered questionnaire. Lifetime and past month substance use were determined. Results. A prevalence of 26.5% for moderate to extremely severe depression, 26.5% for moderate to extremely severe anxiety, and 29.5% for moderate to extremely severe stress was recorded. Female students had significantly higher stress levels, but not increased anxiety. Relationship status and accommodation were not associated with these outcomes. Lifetime use of methylphenidate, lifetime use of alcohol, and past month use of alcohol were associated with depression. Conclusion. The study revealed high levels of depression, anxiety and stress in 2nd- and 3rd-year medical students compared with the general population, but the levels were comparable to those of medical students elsewhere in the world. Past month substance use of alcohol and cannabis was lower than in international studies, but nicotine use was higher. Afr J Health Professions Educ 2017;9(2):67-72. DOI:10.7196/AJHPE.2017.v9i2.705

Psychological distress is prominent in medical students, and it has been shown that members of this group are more prone to depression, anxiety and stress than comparable populations.[1] Yet, some studies found that these indicators of psychological distress are not unique to medical students.[2,3] Being a student, irrespective of whether a medical student, is stressful and associated with depression and anxiety. Ibrahim et al.[4] reviewed articles published on the prevalence of depression among university students in all disciplines, using a variety of measuring instruments, and found a range of 10 - 85%, with a weighted prevalence of 30.6%. Medical students, however, consistently obtain higher scores for depression, anxiety and stress than the general population.[1] Dyrbye et al.[1] performed a systematic review of studies published between 1980 and 2005 reporting on depression, anxiety and other indicators of psychological distress among medical students. Two main schools of thought exist on the reason for medical students being so vulnerable. On the one hand, it is proposed that personality traits such as conscientiousness, that enhance academic performance and therefore a studentâ&#x20AC;&#x2122;s chances for selection, may also render them vulnerable to self-criticism in an environment of high academic or occupational demand. On the other hand, medical training itself has been described as a major psychological stressor. While the results on higher depression scores at entry into medical school are not

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consistent, there are numerous replications of the observation that medical students eventually have higher depression scores than comparable agematched groups.[1] Yusoff et al.[5] even expressed concern that medical training causes mental health problems in medical students. Students themselves perceive curricular factors, such as examinations, high volume of work and time constraints, as the major factors contributing to high levels of stress in medical school.[5] A prospective longitudinal study by Zoccolillo et al.[6] used the Diagnostic Interview Schedule (DIS) to screen for possible depression in 1st- and 2nd-year medical students, followed by an interview to confirm the diagnosis. They found an upward trend over time, and estimated a projected lifetime prevalence for depression in this cohort at three times that of their peers. The authors postulated that student selection seemed to contribute more to the findings than exposure to medical training. A particular concern is the risk of substance use and abuse as a possible consequence of high levels of depression, anxiety and stress in this population group.[1] Baldwin et al.[7] completed a large alcohol and drug use survey at 23 medical schools in the USA, and reported past month use of alcohol of 87.5%, marijuana use of 10.0%, and nicotine use of 10.0%, with the corresponding figures for cocaine at 2.8% and tranquillisers at 2.3%, among the 2 046 participants.

Research The University of the Free State (UFS) is situated in the province with the third highest occurrence of alcohol use disorders in South Africa (SA), where alcohol abuse causes extensive harm to the population as a whole.[8] A recent study involving hostel-dwelling students on the campus of UFS showed a combined prevalence of hazardous, harmful and dependent drinking of 25.3%.[9] The medical curriculum at the Faculty of Health Sciences, UFS, is unique in that it is the only 5-year (10 semester) medical curriculum in SA. Five semesters each are dedicated to preclinical and clinical training, respectively. The programme is outcomes based and accredited by the Health Professions Council of South Africa (HPCSA), which has recently commended the programme for its innovative integrated assessments, quality of teaching material, and resources to facilitate self-directed learning.[10] At the time of the study, students were selected for medical training at the institution primarily on academic merit, yet geographical origin and leadership qualities were also taken into account. All lectures are presented in Afrikaans and English. Academic support is provided according to the initiative of the module leader or session presenters, and may take the form of continuous assessment, revision sessions or individual counselling. Some modules make use of tutorials presented by student tutors. The Faculty of Health Sciences also hosts a formal academic development plan that identifies and supports students who lag academically.[10] A perception of common occurrence of psychiatric diagnoses among local medical students gave rise to the question to what extent students in this 5-year curriculum experience depression, anxiety and stress; and whether these are associated with substance use. The aim of the study was to assess the prevalence of depression, anxiety, stress and substance use among preclinical medical students. Associations between these outcomes and selected demographic factors were also investigated.

Methods

A group of 2nd-year students compiled the research proposal and questionnaire under the guidance of the supervisor and the Department of Biostatistics. The protocol was approved by the Ethics Committee of the Faculty of Health Sciences, UFS (ref. no. UFS-HSD 2014/0156). Permission was obtained from the relevant UFS authorities: the Head of the School of Medicine, the Dean of the Faculty of Health Sciences, the Vice-Rector: Research, and the Dean: Student Affairs. A quantitative cross-sectional study design was used, with convenience sampling. The inclusion criteria were medical students in semester 3 (n=164) and semester 5 (n=131), who were registered at the School of Medicine of the Faculty of Health Sciences, UFS, during the first half of 2015. These two groups were selected for inclusion in the study, as semester 3 students had not been exposed to clinical environments yet, whereas semester 5 students had been exposed. The date of the investigation was selected so that no major tests or examinations were scheduled to take place in that particular week. The questionnaire consisted of demographic questions, questions to determine depression, anxiety and stress levels according to the Depression Anxiety Stress Scales (DASS-21),[11] and questions on alcohol and drug use. DASS-21 distinguishes between depression, anxiety and stress as distinct manifestations of psychological distress, and assigns a value on a scale ranging from normal to severely affected. Depression is defined as a range of scores on DASS that indicates the presence of self-blame, pessimism and loss of enjoyment. Anxiety is defined as a range of scores that indicates a state of persistent apprehension and worry, accompanied by physical symptoms of

sympathetic activation. Stress is defined as a range of scores that indicates a state of over-arousal, tenseness and the inability to relax. The scales are purely for screening purposes and do not provide a definitive diagnosis. As described in the DASS guidelines, the categories moderate, severe and extremely severe are applied to indicate the degree of each of the respective conditions.[11] For purposes of this study, substance use is defined as medicinal or recreational use of selected psychoactive substances, as selected by the researchers. Substance use was determined for the periods lifetime (ever), past month and past week. Some questions of the Drug Abuse Screening Test (DAST)[12] were also included, which are not reported here. The questionnaire was tested in a pilot study that included six physio therapy students, equally representing the two language groups, to test the clarity of questions and practical aspects, such as the time to complete. Translation errors were corrected. Formal translation-back translation methods were not utilised, but it must be noted that the majority of the research team were fluent in both English and Afrikaans. The research was introduced by the student researchers to each class directly following a normally scheduled compulsory contact session. The voluntariness and anonymity of participation were explained before the questionnaires were handed out to all students present, excluding the researchers themselves. The anonymous self-administered questionnaire was available in Afrikaans or English and was accompanied by an information document. Non-respondents were students absent on the day of questionnaire distribution, and students who did not wish to complete the questionnaire. The students performing the research formed part of the study population, but were excluded from participation. To maintain anonymity, participants were requested to place the completed questionnaires in a box. Results are reported by frequencies and percentages. Subgroups were compared using χ2 or Fisher’s exact tests, as appropriate. A p-value <0.05 was considered statistically significant, and 95% confidence intervals (CIs) were calculated for differences between percentages. All analyses were performed using SAS version 9.2 (SAS Institute, USA).

Results

A total number of 295 students were registered in 2015 for semesters 3 and 5. A total of 257 questionnaires were returned, of which 14 were excluded owing to a number of incomplete items on the DASS-21 section. Another two questionnaires that contained inconsistent and erratic responses were excluded from the analysis. Therefore, 241 questionnaires could be analysed. The response rate was 81.7% (137/164 (83.5%) for semester 3, and 104/131 (79.4%) for semester 5). Semester 3 participants were mainly in the age group 18 - 20 years (75.9%) and semester 5 participants mainly in the age group 21 - 23 years (51.9%). Female students were in the majority in both semesters: 52.6% of semester 3 students and 56.7% of semester 5 students. The most common depression category, apart from normal/mild, in both semesters was moderate (Table 1), whereas for anxiety it was extremely severe in both semesters. For stress the most common categories, apart from normal/mild, were moderate for semester 3 and severe for semester 5. In both semesters seven students each reached severe or extremely severe for all three conditions. Table 2 shows a comparison between students of semesters 3 and 5. There was a statistically significant higher percentage of anxiety (p=0.01, 95% CI 3.8 25.5) and stress (p=0.03, 95% CI 1.6 - 24.2) in semester 3 students. Significantly more semester 5 students had none of the three conditions (p=0.05, 95% CI 0.4

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Research - 25.3). The most common combination of conditions in each semester, other than all three or none, was anxiety and stress in 10.3% of semester 3 students, and depression only in 9.7% of semes ter 5 students. An upward trend was seen for the diagnosis of depression and anxiety and current use of antidepressants progressing from semesters 3 to 5, yet the differences are not statistically significant (Table 3). Female students were statistically significantly more likely to report stress (Table 4, p<0.01, 95% CI for difference between female students and male students: 6.3 - 28.6), yet only marginally more likely to report anxiety or depression (p=0.32 and p=0.52, respectively). No significant associations were found between relationship status or housing arrangement and any of the conditions. The highest prevalence of past month substance use was found for alcohol (71.0%, Table 5), followed by nicotine (19.1%) and codeine (9.5%). Lifetime use of marijuana was relatively high at 22.8%, but past month use dropped to 5.4%. There were low numbers of lifetime use of cocaine, methcathinone (CAT), methylenedioxy-N-methyl amphe tamine (MDMA) (Ecstasy) and lysergic acid diethylamide (LSD), with no past month use of these substances reported. No lifetime use or past month use of crystal methamphetamine (tik) or heroin was reported. Table 6 shows a statistically significant asso ciation between lifetime methylphenidate use and depression when comparing lifetime users and never users (p<0.01, 95% CI 10.7 - 41.8). Likewise, a statistically significant association between lifetime methylphenidate use and stress was found when the same groups were compared (p<0.01, 95% CI 7.0 - 38.4). Past month use of methylphenidate was substantially less than lifetime use and no association was demonstrated with depression (p=0.11), anxiety (p=0.34) or stress (p=0.53), possibly owing to small numbers. Depression was significantly more common in lifetime alcohol users compared with never users (p=0.01, 95% CI 9.3 - 32.0), and past month alcohol users compared with non-users (p=0.01, 95% CI 5.4 - 27.2). Anxiety was statistically significantly more common in past month users of alcohol compared with non-users (p=0.04, 95% CI 1.7 - 24.6). Depression was also statistically significantly more likely in past month nicotine users compared with non-users (p=0.03, 95% CI 0.2 - 30.9). There were no significant associations between codeine or marijuana use and depression, anxiety or stress.

Table 1. Degree of depression, anxiety and stress (n=241) Degree of psychological distress

Normal, n (%)

Mild, n (%)

Moderate, n (%)

Severe, n (%)

Extremely severe, n (%)

Total

144 (59.8)

33 (13.7)

32 (13.3)

16 (6.6)

Semester 3

78 (56.9)

22 (16.1)

19 (13.9)

11 (8.0)

7 (5.1)

Semester 5

66 (63.4)

11 (10.6)

13 (12.5)

5 (4.8)

9 (8.7)

Total

130 (53.9)

45 (18.7)

21 (8.7)

15 (6.2)

28 (11.6)

Semester 3

70 (51.5)

21 (15.4)

16 (11.8)

10 (7.4)

19 (14.0)

Semester 5

60 (58.3)

24 (23.3)

5 (4.9)

9 (8.7)

Total

142 (58.9)

28 (11.6)

32 (13.3)

28 (11.6)

11 (4.6)

Semester 3

72 (52.6)

17 (12.4)

23 (16.8)

18 (13.1)

7 (5.1)

Semester 5

70 (67.3)

11 (10.6)

9 (8.7)

10 (9.6)

4 (3.9)

Depression

Anxiety*

Stress

*Semester 3: n=136; semester 5: n=103; total: N=239.

Table 2. Positive screening for depression, anxiety and stress Screening

Semester 3, n (%) (n=137)

Semester 5, n (%) (n=104)

p-value

Total, N (%) (N=241)

Depression (DASS-21 >6)

37 (27.0)

27 (26.0)

0.86

64 (26.6)

Anxiety (DASS-21 >5)*

45 (33.1)

19 (18.5)

0.01

64 (26.6)

Stress (DASS-21 >9)

48 (35.0)

23 (22.1)

0.03

71 (29.5)

Depression, anxiety and stress*

19 (14.0)

14 (13.6)

0.93

33 (13.8)

None of the abovementioned three*

71 (52.2)

67 (65.1)

0.05

138 (57.7)

*Semester 3: n=136; semester 5: n=103; total: N=239, as two participants did not complete the anxiety items fully.

Table 3. Previous diagnosis and current medication for depression and anxiety Diagnosis and medication

Semester 3, n (%) (n=137)

Semester 5, n (%) (n=104)

p-value

Total, N (%) (N=241)

Previously diagnosed with depression

16 (11.7)

15 (14.4)

0.53

31 (12.9)

Previously diagnosed with anxiety

14 (10.2)

14 (13.5)

0.44

28 (11.6)

Current medication for depression

8 (5.8)

8 (7.8)

0.55

16 (6.6)

Current medication for anxiety

11 (8.0)

8 (7.7)

0.92

19 (7.9)

Discussion

The current study is limited by its cross-sectional design and because a wide range of measuring instruments are used in reported studies. How ever, it provides a useful baseline for further investigations, e.g. the effect of major transitions in terms of implementation of the English-only language policy and demographic changes in selection criteria in the immediate future. The study showed a prevalence of 26.6% for depression, 26.6% for anxiety and 29.5% for stress, as defined by the DASS-21 screening tool, in the preclinical medical student cohort at

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UFS for 2015. It is important to note that 12.9% of the study cohort had a lifetime diagnosis of depression and 11.6% a lifetime diagnosis of an anxiety disorder. These findings should be interpreted against the background of the high levels of anxiety and depression in the general population of the Free State and findings among similar study populations done on similar populations using the same measuring instrument. The SA Stress and Health (SASH) study[8] reported a prevalence of lifetime diagnosis of mood disorders of 9.8% and anxiety of 15.8% for the Free State population

Research using the Composite International Diagnostic Interview (CIDI) as measuring instrument. Both these figures were statistically significantly higher than the corresponding figures for the country as a whole. Owing to the difference in the measuring instruments and definition of outcomes measured, the current study results cannot be directly related to these figures, yet the results seem high if one considers the relatively young age of the study population. With regard to comparability, findings of the studies mentioned below, which also used DASS-21 or DASS-42 and categorised the results in a similar manner, are of value. A study of 575 medical students at the Alfaisal University in Riyadh, Saudi Arabia,[13] using DASS21, showed a fluctuation of depression, anxiety and stress scores before and after examinations: between 43% and 30% for moderate or more severe depression, between 63% and 47% for moderate or more severe anxiety, and between 41% and 30% for moderate or more severe stress. The results of the current study therefore correspond with their postexamination measurements, with a notable lower level of moderate to extremely severe anxiety. Another study using DASS-21 in a group of 508 undergraduate college students at a univerÂ sity in the USA[14] reported a prevalence of 29% for depression, 27% for anxiety and 24% for stress. These results are closely comparable with the results of the current study. However, the authors did not explicitly indicate whether they grouped normal and mild categories together. It is therefore possible that the figures for positive cases appear higher than their actual value because they included mild cases, whereas in the current study mild cases were grouped together with the normal category. The instructions for DASS-21 indicate that the mild category refers to a group of individuals who experience symptoms that are not yet so severe as to prompt the person to seek treatment. A similar study was done in a population of 1 617 TurÂ kish undergraduate students using DASS-42, which is an extended version of DASS-21.[15] The authors found a prevalence of 27% for moderate or more severe depression, 47% for moderate or more severe anxiety, and 27% for moderate or more severe stress. Medical students did not attain higher scores in this particular group. The current study shows scores of stress and depression comparable to those found in studies on general student populations, performed with the same or similar test instruments, but the levels of anxiety measured tended to be lower.

Table 4. Influence of demographic factors on depression, anxiety and stress Depression (DASS-21 >6)

Anxiety (DASS-21 >5)

Stress (DASS-21 >9)

Female, n (%) (n=131)

37 (28.2)

38 (29.0)

49 (37.4)

Male, n (%) (n=110)

27 (24.6)

26 (24.1)

22 (20.0)

p-value

0.52

0.39

<0.01

Single, n (%) (n=148)

40 (27.0)

37 (25.0)

42 (28.4)

Married or in a relationship, n (%) (n=92)

23 (25.0)

26 (28.9)

28 (30.4)

p-value

0.73

0.51

0.73

With family, n (%) (n=40)

13 (32.5)

12 (30.0)

14 (35.0)

Hostel on campus, n (%) (n=66)

15 (22.7)

16 (24.2)

18 (27.3)

Private accommodation, n (%) (n=135)

36 (26.7)

36 (27.1)

39 (28.9)

p-value

0.54

0.81

0.68

Demographic factors Sex

Relationship status*

Housing arrangement

*Missing data: 1.

This trend coincides with a lower than expected level of anxiety in female students. According to the literature, female students are more likely to report anxiety and stress.[1,4,12-14] In the current study, female students showed a significantly higher tendency for stress (p<0.01) than male students, yet there were no significant differences with regard to depression or anxiety. In line with the reported literature,[1] semester 3 students showed statistically significant higher levels of anxiety and stress than semester 5 students. Nonetheless, the prevalence of depression did not differ significantly between the two year groups. Past month alcohol use in the study population (71.0%) compares favourably with that among US medical students, which ranges from 79% to 84%[16] and the 87% of alcohol use during the past two months reported among 1st-year psychology students from the University of Limpopo.[17] The SA Youth Risk Survey of 2011 reported past month alcohol use of 32.3% among high school learners in SA and 46.2% for the Free State.[18] The current study found past month cigarette smoking of 19.1% among the study population, while US studies showed figures of 10 - 12% for daily or regular use of nicotine.[16] The corresponding figures for SA schoolchildren were 17.6% for the country and 24.9% for the Free State.[18] While cigarette smoking was more common among the current study population compared with similar US populations, past month use of cannabis was found to be 5.4% compared with the corresponding figures for US studies ranging between 1% and 28%.[16] Past month use for school

learners in SA was 9.2% and 12.4% for the Free State.[18] The finding of 22.8% for lifetime use of cannabis was low compared with studies reporting lifetime use of cannabis among US medical students from 1973 to 2013, reporting figures between 47% and 74%.[16] The figure for lifetime use of cannabis among high school children in SA was 12.8% and for the Free State 13.5%.[18] Cannabis was the only illicit drug used during the 30 days preceding the current study. Low figures were recorded for lifetime exposure to other illicit drugs: cocaine (1.7%), CAT (1.2%), Ecstasy (3.3%) and LSD (1.2%). Lifetime use for cocaine in the US review ranged from 20% to 39%, and for stimulants between 20% and 27%.[16] There is no literature available on the use of illicit drugs among university students or medical students in SA. The SA Youth Risk Survey of 2011[18] reported the lifetime use of cocaine among high school learners as 4.9% nationally and 7.2% for the Free State. A recent survey by Jain et al.[19] showed that 11% of undergraduate medical students at UFS use methylphenidate. The lower figure of 5.3% found for past month use of methylphenidate in a proportion of the same population in the current study could reflect the timing of the investigation in relation to major assessments. No national figures are available for comparison in this regard. In a recent comprehensive meta-analysis of studies on methylphenidate use in medical students, Finger et al.[20] reported lifetime use of 8.3 - 9% and past year use of 3 - 16%. Most of these students used methylphenidate intermittently for performance enhancement.

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Research Table 5. Substance use Semester 3, n (%) (n=137)

Semester 5, n (%) (n=104)

p-value

Total, N (%) (N=241)

Lifetime use

26 (18.9)

20 (19.2)

0.96

46 (19.1)

Past month use

9 (6.6)

4 (3.9)

0.35

13 (5.3)

Lifetime use

116 (84.7)

91 (87.5)

0.53

207 (85.9)

Past month use

98 (72.6)

73 (70.2)

0.68

171 (71.0)

Lifetime use

33 (24.1)

33 (31.7)

0.19

66 (27.4)

Past month use

22 (16.1)

24 (23.1)

0.17

46 (19.1)

Lifetime use

30 (21.9)

25 (24.0)

0.69

55 (22.8)

Past month use

9 (6.6)

4 (3.9)

0.35

13 (5.4)

Lifetime use

9 (6.6)

33 (31.7)

<0.0001

42 (17.4)

Past month use

7 (5.1)

16 (15.4)

0.01

23 (9.5)

Lifetime use

5 (3.7)

11 (10.6)

0.03

16 (6.6)

Past month use

3 (2.2)

1 (1.0)

0.64

4 (1.7)

Lifetime use

3 (2.2)

1 (1.0)

0.64

4 (1.7)

Past month use

0 (0)

Lifetime use

0 (0)

3 (2.9)

0.08

3 (1.2)

Past month use

0 (0)

Lifetime use

3 (2.2)

5 (4.8)

0.30

8 (3.3)

Past month use

0 (0)

Lifetime use

1 (0.7)

2 (1.9)

0.58

3 (1.2)

Past month use

0 (0)

Substance Methylphenidate

Alcohol

Nicotine

Marijuana

Codeine

Benzodiazepine

Cocaine

CAT

MDMA (Ecstasy)

LSD

The current study also showed past month use of codeine of 9.5% and benzodiazepines of 1.7%. Interestingly, semester 5 students had a statistically significant higher lifetime use of benzodiazepines (p=0.03), lifetime use of codeine (p<0.0001), and past month use of codeine (p=0.01). The study found an association between lifetime use of methylphenidate and depression, lifetime use of nicotine and depression, and lifetime use of alcohol and depression. These results need to be explored in further studies. Medical students at UFS suffer near identical levels of depression and stress, and similar or lower levels of anxiety than their peers in institutions where comparable measuring instruments were used. The shorter 5-year medical curriculum at UFS, therefore, does not seem to contribute to

these conditions, yet shows a positive association with lower levels of anxiety, especially in female students. Several curriculum-specific factors may be responsible for this tendency, e.g. that expectations are well described in the outcomes-based model and the emphasis given to academic and psychological support in the curriculum. The authors recommend that aspiring medical students should be made aware of the potential risk to their mental health posed by their career choice. Likewise, academic institutions should take cognisance of the tendency of medical students to fall prey to psychological distress under academic pressure. The medical curriculum should also contain instruction on resilient behaviour and healthy responses to stress during the introductory phase. The associations between

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alcohol use and depression and anxiety, and nicotine use and depression, need to be incorporated in such instruction.

Conclusion

Medical curricula in general are challenging in terms of volume and complexity, which create an environment where stress vulnerability and resilience are tested. The current study supports a widely reported phenomenon of higher levels of depression, anxiety and stress in medical students compared with the surrounding population. Acknowledgement. We thank Ms T Mulder, medical editor, School of Medicine, UFS, for technical and editorial preparation of the manuscript.

1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med 2006;81(4):354-373. http://dx.doi. org/10.1097/00001888-200604000-00009 2. Bunevicius A, Katkute A, Bunevicius R. Symptoms of anxiety and depression in medical students and in humanities students: Relationship with big-five personality dimensions and vulnerability to stress. Int J Soc Psychiatry 2008;54(6):494-501. http://dx.doi. org/10.1177/0020764008090843 3. Mahajan AS. Stress in medical education: A global issue or much ado about nothing specific? Southeast Asian J Med Educ 2010;4(2):9-13. http://dx.doi.org/10.4103/0253-7176.122235 4. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res 2013;47(3):391-400. http://dx.doi.org/10.1016/j.jpsychires 5. Yusoff MS, Abdul Rahim AF, Yaacob MJ. Prevalence and sources of stress among Universiti Sains Malaysia medical students. Malays J Med Sci 2010;17(1):30-37. 6. Zoccolillo M, Murphy GE, Wetzel RD. Depression among medical students. J Affect Disord 1986;11(1):91-96. http://dx.doi. org/10.1016/0165-0327(86)90065-0 7. Baldwin DC Jr, Hughes PH, Conard SE, Storr CL, Sheehan DV. Substance use among senior medical students: A survey of 23 medical schools. JAMA 1991;265(16):2074-2078. http://dx.doi.org/10.1001/ jama.1991.03460160052028 8. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR. The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J 2009;99(5):339-344. 9. Van Zyl P, Botha J, van Wyk M, et al. Hazardous, harmful and dependent drinking in hostel-dwelling students at the University of the Free State, Bloemfontein: A cross-sectional study. J Child Adolesc Ment Health 2015;27(2):125-133. http://dx.doi.org/10.2989/17280583.2015.1084310 10. Health Professions Council of South Africa. Accreditation of Undergraduate Medical Education and Training, School of Medicine, Faculty of Health Sciences, University of the Free State. Pretoria: HPCSA, 2010. 11. Lovibond PF, Lovibond, SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995;33(3):335-343. http://dx.doi.org/10.1016/0005-7967(94)00075-U 12. Skinner HA. The drug abuse screening test. Addict Behav 1982;7(4):363371. http://dx.doi.org/10.1016/0306-4603(82)90005-3 13. Kulsoom B, Afsar NA. Stress, anxiety, and depression among medical students in a multiethnic setting. Neuropsychiatr Dis Treat 2015;11:17131722. http://dx.doi.org/10.2147/NDT.S83577 14. Mahmoud JS, Staten R, Hall LA, Lennie TA. The relationship among young adult college students’ depression, anxiety, stress, demographics, life satisfaction, and coping styles. Issues Ment Health Nurs 2012;33(3):149-156. http://dx.doi.org/0.3109/01612840.2011.632708 15. Bayram N, Bilgel N. The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. Soc Psychiatry Psychiatr Epidemiol 2008;43(8):667-672. http://dx.doi. org/10.1007/s00127-008-0345-x 16. Dumitrascu CI, Mannes PZ, Gamble LJ, Selzer JA. Substance use among physicians and medical students. Med Student Res J 2014;3:27-35. 17. Mogotsi M, Nel K, Basson W, Tebele C. Alcohol use by students at an emerging uni versity in South Africa. J Sociol Soc Anthropol 2014;5(2):187-195. 18. Reddy SP, James S, Sewpaul R, et al. Umthente Uhlaba Usamila: The 3rd South African National Youth Risk Behaviour Survey 2011. Cape Town: South African Medical Research Council, 2013. 19. Jain R, Chang C, Koto M, Geldenhuys A, Nichol R, Joubert G. Nonmedical use of methylphenidate among medical students of the University of the Free State. S Afr J Psychiatry 2016;22(1):a1006. http:// dx.doi.org/10.4102/sajpsychiatry 20. Finger G, Silva ER, Falavigna A. Use of methylphenidate among medical students: A systematic review. Rev Assoc Med Bras 2013;59(3):285-289. http://dx.doi.org/10.1016/j.ramb.2012.10.007

Research Table 6. Association between substance use and depression, anxiety and stress Substance

Substance use

Depression, n (%)

Anxiety, n (%)

Stress, n (%)

Yes (n=46)

22 (47.8)

17 (37.0)

22 (47.8)

No (n=195)

42 (21.5)

47 (24.4)

49 (25.1)

<0.01

0.08

<0.01

Yes (n=13)

6 (46.2)

5 (38.5)

No (n=227)

57 (25.1)

59 (26.2)

65 (28.6)

0.11

0.34

0.53

Yes (n=207)

61 (29.5)

58 (28.3)

65 (31.4)

No (n=34)

3 (8.8)

6 (17.7)

Methylphenidate Lifetime p-value Past month p-value Alcohol Lifetime p-value Past month

0.01

0.19

0.10

Yes (n=171)

53 (31.0)

52 (30.8)

54 (31.6)

No (n=68)

10 (14.7)

12 (17.7)

16 (23.5)

0.01

0.04

0.22

Yes (n=66)

23 (34.9)

21 (32.3)

22 (33.3)

No (n=175)

41 (23.4)

43 (24.7)

49 (28.0)

p-value Nicotine Lifetime p-value Past month

0.07

0.24

0.42

Yes (n=46)

18 (39.1)

15 (33.3)

16 (34.8)

No (n=195)

46 (23.6)

49 (25.3)

55 (28.2)

0.03

0.27

0.38

Yes (n=55)

14 (25.5)

15 (27.3)

17 (30.9)

No (n=186)

50 (26.9)

49 (26.6)

54 (29.0)

0.83

0.92

0.79

Yes (n=13)

1 (7.7)

2 (15.4)

3 (23.1)

No (n=228)

63 (27.6)

62 (27.4)

68 (29.8)

0.19

0.52

0.76

Yes (n=42)

14 (33.3)

11 (26.2)

13 (31.0)

No (n=199)

59 (25.1)

53 (26.9)

58 (29.2)

0.27

0.92

0.82

Yes (n=23)

6 (26.1)

7 (30.4)

No (n=218)

58 (26.6)

58 (26.9)

64 (29.4)

0.96

0.94

0.91

p-value Marijuana Lifetime p-value Past month p-value Codeine Lifetime p-value Past month p-value

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Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings M van Rooyen, MMed (FamMed), MB ChB; A Reinbrech-Schütte, MMed (FamMed), MB ChB; J F M Hugo, MB ChB, MPraxMed; T S Marcus, PhD Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa Corresponding author: M van Rooyen (marietjie.vanrooyen@up.ac.za)

Background. The Longitudinal Community Attachment programme for Students (L-CAS) is an activity by means of which each student is exposed to primary healthcare learning and practice in communities. Capability has been described as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively … but in response to new and changing circumstances’. Within this paradigm, peer-assisted learning (PAL) has been used to support the development of student capability during L-CAS activities. Objective. To evaluate the impact of PAL sessions on student and community health worker (CHW) capability development. Methods. Study participants comprised 4th-year medical students and CHWs. Student data were drawn from the rotation reflective reports (RRRs) and CHW data from semi-structured interviews. Results. The main themes that emerged from the RRRs and interviews were the impact on the personal and professional development of participants; the creation of awareness and understanding of the context of the communities; relationship building; and the impact of peer learning activities on the knowledge, skills and attitudes of participants. Conclusion. In the process of addressing the challenge of preparing capable professionals, PAL was found to be a very effective way of positioning peers in relation to each other as resources. PAL activities enhanced the abilities of students and CHWs to learn from experience and to achieve the goals of critical reflection and experiential learning. Afr J Health Professions Educ 2017;9(2):73-77. DOI:10.7196/AJHPE.2017.v9i2.723

The Longitudinal Community Attachment programme for Students (L-CAS) is an undergraduate education initiative of the School of Medicine, University of Pretoria (UP), South Africa (SA). By means of this programme each student is exposed to primary healthcare learning and practice. First initiated in 2008, L-CAS is a formal module (longitudinal community programme (LCP)) in the curriculum from years 1 to 4 across all MB ChB blocks. Through this programme students participate in ~13 000 community contacts per annum. In keeping with health education reform, advocated by the 2010 Lancet Commission on the Education of Health Professionals for the 21st century, L-CAS brings together three intersecting educational dimensions, i.e. the importance of the learning setting (curriculum context), a capability approach to learning (the process), and the production of expert generalists (the outcome) (Fig. 1). Together, these are designed to ensure that health professionals are ‘educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient- and population-centred health systems as members of locally responsive and globally connected teams’.[1] Communities are the primary context of health. There is, therefore, a need for students to learn and practise primary healthcare in communities rather than in hospitals. Over the years, L-CAS has been adjusted and refined in response to changes within the primary care setting and the university. It started as a clinic visit programme (2008 - 2010). Subsequently, it developed into a community-orientated primary care approach to support primary care re-engineering in Tshwane District, where students were linked to community health workers (CHWs) in community ward-based outreach

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teams (WBOTs), accompanying them to schools, crèches, shelters and oldage facilities, and into people’s homes.[2] In 2014, the School of Medicine, UP, discontinued home visits, restricting medical student community visits to clearly defined institutional learning platforms, such as health posts (where CHWs meet), paediatric institutions, district hospitals, old-age homes, interprofessional clinics, and shelters.

Context of the curriculum

Process of learning

Outcome Health Knowing Doing

Fig. 1. Intersection of educational dimensions.

People Students Staff

Research There is considerable literature on capability as an approach to human economic and social development, including education. In terms of the process of learning, Saunders and Hart[3] argue for the potential of the capability approach as ‘a creative way for changing and evaluating curricula’. For us, the project team, capability is relevant to both the what and the how of learning. Capability has been simply and precisely articulated by Stephenson and Weil,[4] as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively – not just in familiar and highly focused specialist contexts, but in response to new and changing circumstances’. Capability can be observed when ‘people with justified confidence in their ability [t]ake effective and appropriate action; [e]xplain what they are about; [l]ive and work effectively with others; and continue to learn from their experiences as individuals and in association with others, in a diverse and changing society’. Capability not only involves skills, but also qualities, such as judgement and the commitment to learn from experience, as well as ethics, including the virtue of moral excellence through practical wisdom. While capability incorporates notions of competence, the capability approach to learning makes competence a dynamic rather than a static state of being. Therefore, it combines the ability to perform effectively at any one point in time (competence) with an individual’s capacity to envisage and realise their own and others’ potential to do and be in the future (capability) (Fig. 2). It includes ongoing reflection and adaptation of action with the view to constant improvement.[5] Within this paradigm of learning, to be capable in the communityorientated primary care (COPC) context, peer-assisted learning (PAL) has been used to support the development of student capability during L-CAS (JFM ugo, T Mtoarcus and Honniball) activities.HPAL is known contribute to aN number of essential competencies, including communication, learning transfer, teamwork, self-confidence, and reciprocal and effective practice.[6-8] Research also shows that PAL provides a

safe and alternative way of learning, motivates ongoing learning and helps to prepare clinicians for their future roles as educators and mentors.[9] PAL is also an essential route to developing CHW competency. Given their current and potentially significant future contribution to primary health, it is a way of enhancing their ability to deliver quality communitybased primary healthcare.[10-12] Throughout the evolution of L-CAS practice, the focus of learning content has been on primary health, with special attention to health and disease prevention, early detection and management, and their relation to both the social determinants of health and best healthcare practice, as articulated in the principles of COPC.[13] Reflection is an essential part of capability that involves understanding the self, others and situations to prepare and plan future action.[14] As one of the L-CAS deliverables, medical students are required to submit a rotation reflective report (RRR) after each community visit. It is structured to guide students through a process of reflection that focuses on the assessment and plan for the person with whom they are interacting, their most significant learning experiences, the learning that still needs to take place, and the resources needed to accomplish the learning.

Objective

The objective of this study was to evaluate the impact of PAL sessions on student and CHW capability development. The article focuses specifically on students’ professional and personal development and their perceptions of behaviour change that resulted from new knowledge, skills and attitudes learnt during the PAL sessions.

The Capability Approach to learning

Methods

The study was conducted with two groups of participants: • the entire 2015 4th-year medical student cohort (N=242) • all CHWs (n=50) of three purposefully selected WBOTs. Two WBOTs

Fig. 2. The capability approach to learning.

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Research had minimal reported problems and were known to be student friendly, and one WBOT was known to have problems with student visits and organisation. All respondents in both groups agreed to participate in the study, with the exception of one CHW. Student data were drawn from the RRRs. CHW data were generated through semi-structured interviews conducted by trained independent interviewers from the same culture and language backgrounds as the CHWs. The researchers individually scrutinised the data for themes and then compared their findings until consensus and saturation were reached. Anonymised quotations were identified to support or substantiate each theme.

Results and discussion

The main themes that emerged from the RRRs and interviews are presented and discussed, and supported by quotes from the students and CHWs.

Impact of PAL on personal development

The strength of any activity lies in the development of the participants to become more capable. If one can challenge anyone to change, you have had an impact on the person. Both the medical students and the CHWs said they experienced personal growth through their interaction with each other. CHWs reported direct personal health benefits from PAL. CHWs felt their own lifestyles and habits improved and they could apply new knowledge to their own families and in the community: ‘To try to live a healthy lifestyle and to promote a healthy lifestyle to my friends and family.’ (CHW-S11) In some, illnesses and problems were discovered or diagnosed and could be addressed: ‘… I once felt sick and went to the clinic but the information I got regarding hypertension was not helpful but after the sessions I know what I need to reduce to get my blood pressure to the correct level.’ (CHW-D2) Some of the medical students also saw the value and impact of the principles of primary care.

Impact of PAL on professional development

Students presenting information to the CHWs, led to knowledge sharing with the community: ‘What we learn from the students we can teach the community so that they know how to prevent certain illnesses.’ (CHW-D7) CHWs described a perceived improvement in lifestyle, health promotion, screening and prevention of diseases in the community: ‘We take services to their door and they benefit from our health talks.’ (CHW-S22) This, however, was not always successful. CHWs reported that some community members did not trust CHW competency: ‘They didn’t benefit much from the sessions because they feel as though the information we give them is lies. They want us to be accompanied by the students.’ (CHW-S10) Most CHWs felt that their knowledge and various practical and communication skills improved as a result of the PAL sessions:

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‘ I know how to check diabetes and blood pressure. I can do pregnancy tests and screen TB and HIV.’ (CHW-S19) ‘I have more confidence when I do my work and I fear nothing.’ (CHW-S6) ‘… it gave me the ability to express myself easier because I had more skills.’ (CHW-D5) ‘My listening skill has improved a lot as a result of these sessions.’ (CHWP2) ‘The session expanded my vocabulary when it comes to health terms.’ (CHW-P5)

Creating awareness and understanding

As a health professional, greater understanding of the context of the person with whom you deal leads to greater capability, because it improves your understanding of where the person comes from and enables you to negotiate an appropriate management plan. Many of our students are far removed from the daily realities of the majority of our patients. It is very important for the learning programme that students gain understanding and knowledge of the patient context. As CHWs are from that community, they represent the patients that WBOTs and students serve. Students were able to recognise the value of this in their interactions with CHWs: ‘You get to really interact with the CHWs and they have so much to teach you about the people’s culture and why people do the things they do.’ (STD-32) From their responses, it was apparent that PAL created awareness of the social gap between the students and the people they are seeing: ‘I learned a lot about walking in the shoes of those that are less fortunate than me.’ (STD-22) They learnt about the importance of social issues in healthcare: ‘As medical practitioners we are very much focused on the discovery of pathology and disease. Sometimes it’s more a social thing than a medical thing.’ (STD-19) They were made acutely aware of the linguistic and conceptual issues of translating biomedical ideas into everyday intelligible language: ‘I think these visits have helped us to become aware of the fact that our patients will not always understand exactly what we are saying and will require us to be able to simplify concepts for their understanding.’ (STD-1) Language and culture form an integral part of the context of a person. Although all of the CHWs understand English, they felt that when students explained something in their language, they could understand better: ‘I liked that there is not only white students, because the black students used a language that we can understand better.’ (CHW-S1) They appreciated students’ efforts to speak and learn their language. It created a sense of being respected: ‘… they respect our culture. They were actually interested in learning our languages.’ (CHW-S5) They also felt they benefited from peer language learning: ‘… we sometimes teach each other words (medical terms) in differ ent languages. They teach us Afrikaans and we teach them Sepedi.’ (CHW-P8)

Research Interaction with a traditional healer was a culturally enriching experience for both sets of learners: ‘… it showed ways in which traditional and Western medicine can work together.’ (CHW-P3)

Building relationships to develop capability and enhance learning Relationships are one of the three essential components of learning in the capability model. As professionals, the backbone of our interactions with patients and colleagues is our interpersonal relationships. With enough time spent together, relationships and even friendships can be formed. Good relationships are also an integral part of developing capability and being an effective peer learner. PAL is a well-described tool to enhance self-development and relationship building. With PAL, the curriculum extends beyond prescribed work to include language, cross-cultural learning and ethics. Furthermore, literature reports on the benefits of peer learning in terms of creating a sense of closeness and co-operation as individuals encourage and facilitate each other’s development.[6] CHWs seemed to have enjoyed these repeated interactions and learning opportunities. Because students were friendly and open, CHWs felt free to ask questions and felt as though they were part of the learning process: ‘I formed a relationship with them and felt free to ask questions. They were not intimidating and they spoke in simple English. We felt part of a team because they can also learn something from us.’ (CHW-S5) ‘… some of them come back to work at the clinic and I am able to ask them anything because they are friendly.’ (CHW-D7) It is important to note that relationships need to be honed and developed, and often there are challenges that need to be addressed to facilitate relationship formation and learning. These challenges can include logistics, such as student numbers and continuity: ‘No, there is no relationship between us because they come in large numbers. I don’t feel part of the learning process because they are there for a short period of time.’ (CHW-S27)

Peer learning experience

Students prepared and presented topics related to their blocks. However, they also had to address topics and learning needs communicated by team leaders and CHWs. This was particularly significant, given the limited and varying training that CHWs undergo before they commence their work in the households. The students’ role was therefore to enhance and expand CHW knowledge and skill to equip them adequately for their work. The experience of peer learning was novel to students, as their only previous experience was a 2-hour introductory training session. Students were surprised about their own teaching skills, their enjoyment of the sessions, and the participation and interaction of the CHWs: ‘We made our session very interactive … to get a basic understanding of their knowledge. To our surprise they knew quite a lot.’ (STD-27) Most students understood that CHWs learnt more when the presentation was creative and entertaining: ‘Yes, it was so much fun. Some students would do role-plays, it makes the content more understandable than when they are just standing in front

and talking. They also leave us with pictures and information of what they were presenting.’ (CHW-P8) CHWs were encouraged to participate actively and share their knowledge with the students. In this way, true reciprocal learning took place and collaboration was honed: ‘I asked questions and would not be satisfied if I left without clarity.’ (CHW-S24) ‘When some of the information we were taught was inaccurate, I was able to make corrections to the students.’ (CHW-D9) ‘… by informing the students about the challenges we experience in the community.’ (CHW-P8) CHWs had much to offer in terms of experience, knowledge and skills. A study looking at the impact of CHWs on patients with diabetes mellitus showed an improvement in patient knowledge and behaviour when they were in contact with a CHW.[12,15] Most students found CHWs to be worthy PAL partners, noting the value of the contribution they made to their communities and to their own learning: ‘They clearly were of benefit to the community, but while so they also benefited us by making us do research and revise sections of work.’ (STD-38) This was especially so in terms of student understanding of non-academic aspects of medicine: ‘It was so lovely to see how passionate they are about taking care of the people and trying their best to make a difference in their lives.’ (STD-31) Some students, however, didn’t realise that PAL provided them with an opportu nity for reciprocal learning: ‘This [peer learning] wasn’t applicable to our visits as we were the ones teaching the CHWs.’ (STD-12)

Conclusion and take-home message

Consolidation of knowledge and cognitive development is enhanced when you teach someone else that which you have only recently learnt. It may, therefore, be a positive experience to entrust intermediate trainees with teaching responsibilities, as it may also accelerate their own learning.[6,9] By interacting with CHWs, through the methodology of PAL, students were provided with an alternative contextual learning opportunity without having to do home visits. CHWs formed a direct link between students and the community. The PAL interactions impacted on a professional and personal level on the students and the CHWs. The findings give some insight into the value and challenges of PAL activity to support capability. They also highlight the need to deepen and expand participants’ awareness of capability as a learning approach to selfdevelopment, personal awareness and understanding, and perceptions of acquiring new knowledge, skills and attitudes. Capability is an approach to learning that enables people at all levels of qualification and practice to be competent in unpredictable circumstances in an on-going and cumulative way. As Lizzio and Wilson[16] observe, ‘… professional or work-place relevant learning is rarely developed through formal or didactic means, but in informal, reflective and interactive episodic contexts’. In the process of addressing the challenge of preparing competent professionals, students need to be involved in activities that enhance their ability to learn in context and from experience. PAL positions peers in relation to each other as learning resources and support.[6] It also aids

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Research collaborative practice, an essential part of capability in holistic, patientcentred healthcare. PAL activities furthermore provided students the opportunity to experience collaborative practice within the COPC context, where teamwork is integral to individual and family health. Students had the opportunity to form a better understanding of the scope of practice, challenges and opportunities for the CHWs, and how they can support and empower them to make a difference within their communities. Although they did not go to people’s homes, they could obain a better understanding of the context of patient and community life through the eyes and experiences of the CHWs. Acknowledgement. We thank Drs J F M Hugo, T S Marcus and N Honniball for providing Fig. 2. 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. http://dx.doi.org/10.1016/S01406736(10)61854-5 2. National Department of Health. Guidelines for the Implementation of the Three Streams of PHC. Pretoria: NDoH, 2011. 3. Saunders J, Hart CS. The capability approach for medical education. AMEE Guide No. 97. Med Teach 2015;37(6):510-520. http://dx.doi.org/10.3109/0142159X.2015.1013927

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4. Stephenson J, Weil SW. Quality in Learning: A Capability Approach in Higher Education. London: Kogan Page, 1992. 5. Marcus T, Hugo J. Community orientated primary care. In: Mash B, ed. Handbook of Family Medicine. 4th ed. Cape Town: Oxford University Press, 2016. 6. Glynn LG, MacFarlane A, Kelly M, Cantillon P, Murphy AW. Helping each other to learn – a process evaluation of peer assisted learning. BCM Med Educ 2006;6(1):18. http://dx.doi.org/10.1186/1472-6920-6-18 7. Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: A novel approach to clinical skills learning for medical students. Med Educ 2007;41(4):411-418. http://dx.doi.org/101111/j1365-2929.2007.02713.x 8. Yu TC, Wilson NC, Sing PP, Lemanu DP, Hawken SJ, Hill AG. Medical students-as-teachers: A systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract 2011;2:157-172. http://dx.doi.org/10.2147/ AMEP.514383 9. Ten Cate O, Durning S. Peer teaching in medical education: Twelve reasons to move from theory to practice. Med Teach 2007;29(6):591-599. http://dx.doi.org/10.1080/01421590701606799 10. Tice M. Building collaboration and competence: Peer assisted learning and the interprofessional education of allied health students. Master of Arts/Science in Nursing Scholarly Projects. Paper 75. Sophia, Bulgaria: St Catherine University, 2014. 11. Witmer A, Seifer SD, Finnocchio L, Leslie J, O’Neil EH. Community health workers: Integral members of the health care work force. Am J Public Health 1995;85(8):1055-1058. 12. National Center for Chronic Disease Prevention and Health Promotion. Addressing Chronic Disease through Community Health Workers: A Policy and Systems-level Approach. CDC 2nd ed. CDC: Atlanta, GA, USA, 2015. https://www.cdc.gov/dhdsp/docs/chw_brief.pdf (accessed 28 April 2017). 13. Marcus TS. Community Oriented Primary Care L2: Primary Health. Series: Pathways. Cape Town: Pearson, 2013. 14. Sandars J. The use of reflection in medical education. AMEE Guide No. 44. Med Teach 2009;31(8):685-695. http:// dx.doi.org/10.1080/01421590903050374 15. Ross MT, Cameron HS. Peer assisted learning: A planning and implementation framework. AMEE Guide No. 30. Med Teach 2007;29(6):527-545. http://dx.doi.org/10.1080/01421590701665886 16. Lizzio A, Wilson K. Action learning in higher education: An investigation of its potential to develop professional capability. Studies Higher Educ 2004;29(4):469-488. http://dx.doi.org/10.1080/0307507042000236371

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education H Pandya, BDS, MPH; W Slemming, BSc (Physiotherapy), MPH; H Saloojee, MB ChB, FCPaed (SA), MSc Division of Community Paediatrics, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: H Pandya (drhimanip@gmail.com)

Background. Portfolios are increasingly used across a range of disciplines in health professional education to support reflective practice and to help assess students’ academic and professional development. However, their value in postgraduate education is uncertain. Objectives. To identify the role of portfolios in the development and assessment of professional competencies in postgraduate maternal and child public health education. Methods. A qualitative retrospective review of 35 student portfolios was conducted. Thematic content analysis of portfolios was done, identifying emerging themes and analysing patterns. Results. Two major themes were explored – the benefit of the portfolio to the student and to faculty. For students, portfolios promoted reflective abilities and critical thinking and assisted them in planning learning needs. For faculty, the portfolios assisted in monitoring students’ growth over time, identified learning gaps, helped to establish if expected learning outcomes were being attained and provided feedback on students’ application of academic learning to professional practice. Portfolios also offered students an opportunity to provide critical feedback on curricula content and course pedagogic activities. Conclusion. Portfolios are an under-utilised assessment and self-development tool in postgraduate training. They allow students to self-assess their attainment of personal learning needs, professional growth and competency achievement and provide faculty with useful feedback on curriculum content, educational activities and competency attainment. Afr J Health Professions Educ 2017;9(2):78-82. DOI:10.7196/AJHPE.2017.v9i2.796

Reflective portfolios are a collection of evidence that attests to achievement as well as personal and professional development through critical analysis and self-reflection.[1] Professional portfolios may be required for purposes such as seeking promotion and documenting continuing professional development, and for accreditation. In health professional education, portfolios have been used to support reflective practice, summative assessment, critical thinking, self-growth, learning and professionalism. In addition, they have been effective in aiding knowledge management processes and in bridging the gap between learning and practice.[2-4] Perceived benefits to students include greater learning autonomy and heightened understanding of exit learning outcomes.[5] Although portfolios have demonstrated positive effects in undergraduate programmes, evaluations of its use in postgraduate education have shown mixed results.[6] There is limited description of the contribution of portfolios to postgraduate health professional education, particularly within specialised public health programmes, such as maternal and child health (MCH) and in African and South African (SA) settings. The Master’s degree in Child Health (MSc) and Master’s degree in Public Health (MPH (MCH)) at the University of the Witwatersrand, Johannesburg, SA incorporated reflective portfolios as a course activity and assessment tool in 2010. We conducted this study to analyse the contribution of academic portfolios in the development of students’ reflective and critical thinking abilities, and its utility in assisting faculty to monitor and influence students’ learning and attainment of key competencies.

Methods

The University of the Witwatersrand offers two part-time 2-year Master’s programmes related to MCH; one in Child Health (MSc) and another in

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MCH (MPH). Both programmes are designed to prepare health professionals working in government departments, non-profit organisations, the private sector and at academic institutions for leadership positions in the field of MCH. A combination of lectures, student-led seminars and discussions, online learning, group work sessions and site visits are employed across the 8 - 12-course modules to achieve course competencies. In 2010, portfolios were introduced as an additional strategy for students to reflect on their learning experiences. Students are encouraged to review their engagement with course material and activities, and to showcase their academic, professional and personal growth. Creative presentation of ideas and learning constructs is promoted. Students submit an individual portfolio after each course module and an integrated portfolio at the end of each of the 2 years of study. Each portfolio is marked by two or three staff members to enhance reliability. A marking rubric is used to provide grades and feedback to students (Appendix 1). This study involved a qualitative, retrospective record review of postgraduate student portfolios submitted as part of their MSc/MPH coursework. We analysed all 35 integrated portfolios available since 2010 (when they were introduced) until 2014 (three cohorts of students). The final integrated, rather than individual module, portfolios were selected because they better reflected students’ overall experience. Narratives/text segments were analysed qualitatively by thematic content analysis, a method used to identify, analyse and report patterns (themes) within data.[7] Analysis was supported by MAXQDA version 11 (VERBI Software GmbH, Germany).[8] Deductive and inductive codes were used. We identified deductive codes by reviewing literature on the role of portfolios in health professional education, realising codes such as ‘achievement of

Research learning outcomes’, ‘reflective and critical thinking ability’ and ‘application of learning to practice’. New inductive codes such as ‘feedback on pedagogic techniques’ and ‘plan learning needs’ emerged while analysing the portfolio scripts. Finally, all codes were collated to develop two overarching themes, i.e. student benefits and faculty benefits. Ethical clearance for the study was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (ref. no. M150750).

I cannot imagine the life of girls begging and sleeping on the street and how fragile girls are in the street.’ (MPH, 2011) ‘I wrote an assignment on mental health of South African children with a new found understanding of and respect for the field. I always thought mental health services were for the most severe cases and the others would simply sort themselves out over time. However, millions of children throughout South Africa and the world suffer in silence from the myriad challenges, i.e. poverty, parental loss, abuse, etc., they are forced to face every day.’ (MPH, 2011)

Results

Students were exposed to MCH programmes and policies, and controversial issues, such as HIV infant feeding, abortion and reproductive health, were debated during modules. Portfolios contained evidence that students re-examined their own biases and pre-existing notions based on exposure to this additional knowledge and exposure: ‘There is a notice on the entrance to the family planning section of the clinic we visited that says: No male allowed. The lack of men’s participation in reproductive health services and family planning means that they do not benefit from any information given by heath providers regarding sexuality, pregnancy and their roles in these.’ (MSc, 2011) ‘On that day, only 20 people came for family planning services. Again I started asking myself. Why is it that there are so many people seeking termination of pregnancy (TOP) services and not family planning services? Are people using TOP as family planning method? This made me realise that designing interventions for public health problems is not easy, it needs careful planning, involvement of stakeholders and beneficiaries and there is need to constantly assess the impact of the designed intervention.’ (MPH, 2011)

Findings are presented under two major headings: the benefit of portfolios to students and to faculty. Portfolios substantially contributed to enhancing students’ critical thinking and reflective abilities and in planning their learning needs during the course of the degree. Portfolios assisted the faculty in assessing gaps in students’ learning, and in monitoring and appreciating their personal growth, achievement of learning outcomes and application of learning to professional practice. Fig.1 presents a framework that summarises the contribution of portfolios to both students and faculty in postgraduate public health education. It depicts the relationship between major themes and codes, with relevant examples for each code.

Student benefits of developing a portfolio

Portfolios promote students’ reflective abilities and stimulate critical thinking Students began relating topics and issues covered in modules to events in their daily lives and workplace and utilised the portfolio to reflect on this: ‘I was impressed most by the psychiatric disorder session; I could link this to street children in the Democratic Republic of Congo (where resided). Most of them were soldiers and rejected by their family by mothers saying they are not normal, they are sorcerers. The life in the street is very difficult and

Portfolios help students to plan their learning needs and reflect on performance Through portfolio writing, students systematically compared their learning with explicit MCH competencies they were expected to attain, assessed

To students

To Faculty

Assessment

Promote reflective abilities and critical thinking

Plan learning needs

– Course subject matter – Gaps in public health policies and programmes

– Attainment of competencies – Modification of learning approaches

Assess students’ growth

Assess application of learning in professional practice

– Improved communication, leadership and management

– Professional goal attainment – Change management at work place

Assess gaps in student learning

– Research design – Presentation skills – Data interpretation – Budgeting

Feedback from students

Feedback on curricula content and pedagogic activities

–

Feedback on group work and experiential visits to clinics

Examples

Fig. 1. Framework showing contribution of a portfolio in postgraduate public health education.

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Research gaps and indicated how they planned to modify their learning approaches. They also reflected on their performance in assignments and examinations during the modules, analysed reasons for poor performance and developed strategies to improve their performance: ‘I have compared my learning to the MCH competency framework for those areas relevant to all modules. I have decided to do this on an ongoing basis … since I will need to pursue a certain amount of selfdirected learning to ensure that I am up to speed in all areas of my studies.’ (MSc, 2010) ‘I realise that information comes from reading or seeking to know more. I will need to increase my level of reading of academic papers as well as challenge myself to think critically.’ (MPH, 2011) Students did not report any negative perceptions about the portfolio, such as fear of confidentiality being breached, distraction from other coursework activities or the repercussions of expressing negative views. Many students found the activity quite challenging at first, because it forced them to think creatively and critically, which deviated from their previous academic experiences. However, this challenge was overcome as more portfolio entries were completed and as they received positive feedback. Confidence in the lack of negative consequences grew as students recognised that unfavourable reflections on course activities were viewed positively rather than being discouraged by staff: ‘I was introduced to the concept of the “portfolio” – this filled me with a real sense of dread. It encouraged us to “think out of the box” and be creative. For scientifically-minded and very right-brained individuals, “creative” is often something that does not come easily! As more modules rolled around, I think that I understood the portfolio-thing a bit better and felt that I was synthesising many of the concepts learnt during the lecture block weeks.’ (MPH, 2013)

Benefits of the portfolio to faculty

Portfolios help faculty to assess gaps in students’ learning Student portfolios helped us, as faculty members/course organisers, to identify gaps in our students’ academic and professional knowledge and skills. Common gaps reported by students included poor epidemiology, research, health budgeting and strategic planning skills and inadequate knowledge of socioeconomic and community components of public health (specifically reported by clinician students): ‘As a clinician, I am able to perform exceptionally well. As a leader, a researcher, a manager and analyser of systems, I found myself in an uncomfortable place where I could understand what was needed to be done but felt lacking in terms of the knowledge and tools to reach my goals.’ (MSc, 2012) ‘I must admit that working out budgets was never one of my strong points. I always thought as a public health manager, I will just employ someone qualified to deal with that part. During the discussion session, it became clearer to me that as a leader it is wiser to be involved and understand the financial aspect of any MCH programme implemented.’ (MSc, 2010)

their newly acquired competencies improved their performance as health professionals: ‘After this module, I had learned a lot about programme planning and managing. All my life I have been taught to implement, not to plan, the experience that I gained over the years, to sit in the consultation room and see patients. At the end of the month I would write reports as part of my responsibility, not knowing that programme planning is based on numbers.’ (MPH, 2011) ‘During the course I was exposed to group presentations due to which my communication skills have improved and facing an audience is no longer as frightening as before. I conduct most of the mortality and morbidity meetings in my department and there is no doubt now that a big stage will be next.’ (MSc, 2011) Portfolios display how students apply learning to professional practice Portfolios offered a platform for students to identify and reflect on their professional goals and objectives and to indicate how they transferred their academic learning to professional practice. Students outlined their immediate and longer-term goals and described how they would achieve these. Students reflected on changes they implemented in their professional practice as a result of their learning: ‘I took back to hospital the use of zinc as one step to improve the outcome of diarrhoea in our ward and now all doctors prescribe it. The pharmacy has joined us in an effort to have zinc available all the time. We have already seen a change in the duration of paediatric patients’ stay in hospital in the last few weeks.’ (MSc, 2011) ‘By the time I wrote my third and fourth portfolio, it was great work. I drew up my personal experience and all the principles of writing which I learnt a long time ago and this really helped me. Currently, the reports that I write for my work look much better than before.’ (MPH, 2011) Portfolios provide feedback on curricula content and pedagogic activities Students reflected on various teaching and learning techniques experienced in the programme. Portfolios captured critical feedback from students not often acquired through other feedback mechanisms. Further, portfolios fostered the development of a professional identity: ‘It came to me as a pleasant surprise to find engagement, interrogation and stern but helpful questions and advice employed as tools of learning. As I already understood, this was just one of the skills that would be necessary for me to be successful as not only a Master’s candidate but also as a leader, researcher and public health professional.’ (MSc, 2014) ‘I was looking forward to the group work sessions, as these were important highlights for me during this module. The group work sessions were slowly training me to be the leader or manager I had in mind.’ (MSc, 2010)

Discussion

Portfolios demonstrate students’ growth and achievement of learning outcomes

This study demonstrates that reflective portfolios can substantially contribute to postgraduate and public health education. While the study echoes many of the findings from the existing literature on the benefits of portfolios in health professional education, it is the first to do so specifically in the context of maternal and child public health education and in an African setting.

Students used portfolios to reflect on ways in which they matured over the 2 years of the Master’s programme. They reported an improvement in their knowledge of MCH topics, communication skills (oral presentation and writing) and leadership/management skills. Some explained how

Key findings emanating from this study include the following: • Portfolios are similarly useful in postgraduate public health education, specifically MCH, as in other disciplines of health professional education.

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Research • Portfolios can assess students’ learning needs, growth and competency achievement and provide useful feedback on pedagogic activities and curriculum content. • Portfolio guidelines and marking rubrics can contribute greatly in directing students’ reflections and ensuring that a full range of activities and developmental areas are considered. • Portfolios of postgraduate public health students working within health systems while studying contain crucial evidence of ways in which academic learning is applied in professional practice. With the complexity of emerging public health issues, it is imperative that Master’s graduates not only demonstrate mastery of theoretical content, but also critical thinking and application in practice. They are expected to function as reflective practitioners capable of evaluating policies and programmes and fixing gaps in the public health system. We believe that portfolio writing enhanced students’ reflective ability and critical thinking skills. This conclusion concurs with that in a study indicating that portfolios contributed substantially in stimulating critical thinking in social work education.[9] There is mixed evidence as to whether portfolios aid or hinder reflection in postgraduate education, as it depends on individual learning preferences.[2] We found that writing a portfolio generally enabled students to relate the knowledge gained during the coursework to their real life experiences and to reflect on an ongoing basis. We identified no demographic, cultural or learning traits that restricted this conclusion being drawn. We established that students utilised the portfolio as a platform to identify their learning gaps, plan learning needs and organise their academic journey during the course of a Master’s programme. In a systematic review of the effectiveness of portfolios for postgraduate assessment and education, portfolio users were shown to take increased responsibility for their own learning and be less passive learners.[2] Keim et al.[10] showed that, compared with a control group, portfolio users produced more learning needs assessments and learning plans. Portfolios have been recognised as useful tools for faculty to conduct students’ assessments and identify gaps in their learning. However, there is wide variation in the literature in the level of reliability of portfolios for assessment. It is recommended that portfolios should not be used for summative judgements but for more qualitative and less structured student assessments.[2] We assigned summative judgements (20% of the year mark) to our portfolios, primarily to ensure that the task was taken seriously. The study was not designed to test the reliability of our assessment, but we noted good congruence between the three evaluators. Portfolio reflections influenced various curriculum change decisions in our programme, including the delivery and structure of curriculum content, facilitator changes and a greater focus on pedagogic techniques preferred by students, such as experiential site visits. Massive open online courses (MOOCs) were introduced as core ‘pre-readings’ based on portfolio comments suggesting that non-clinician students were struggling with basic clinical concepts during modules. Comments also directed course co-ordinators to the type of changes needed in student assessment and course evaluation tools. Portfolio reflections provided qualitative or descriptive insight into intangible aspects of students’ growth, which could not be assessed by conventional modes of assessment, such as written examinations and assignments. Portfolio entries demonstrated ways in which students grew and evolved over the duration of the MSc/MPH programme. The portfolio guidelines (and assessment rubric) also demanded student engagement

with activities that may otherwise have been ignored, such as continuous reflection on, and self-evaluation of, course competency achievement. Lastly, a particular strength of the portfolio was the students’ reflection on the transfer of academic learning to their respective workplaces. Literature suggests that portfolios support application of learning to practice in health professional education, especially if their use is continued at the workplace.[2] A portfolio can promote holistic learning by serving as a reflective bridge between the student, the workplace and the academy.[11] Our study expands this evidence base with a specific focus on postgraduate public health education in MCH. As this was a qualitative study based on narratives reported in portfolios, we cannot quantify the proportion of students to whom the positive findings were applicable. This limits the generalisability of the results. We acknowledge that some students had better reflective abilities than others. Students’ claims could not be verified by using other evaluative methods. Further, as the study did not follow up students after they graduated, we cannot verify if the students’ intentions and self-reported competencies were actually realised or put into practice after degree completion. As the portfolio contributed to summative assessment, students may have presented undue positive or favourable comments to curry favour from staff. To dissuade students’ from doing this, we rewarded critical, rather than overly positive comments. We believe this approach was successful. Future research should explore if there is a gap between self-reported learning, competency achievement and actual practice. It would be worthwhile ascertaining if graduates continue reflective activities, such as diaries, blogs or similar activities, in a professional setting when portfolio writing is no longer a compulsory course activity.

Conclusion

The continuing development and improvisation of higher education in specialised fields of health, such as MCH, demand more valid and reliable assessment of knowledge, competency and skill attainment, as well as attitude and behaviour assessment. A reflective portfolio can successfully serve this purpose for both students and faculty. Portfolios written by MSc/ MPH students contained crucial evidence of reflective practice, critical thinking, self-growth, professionalism, knowledge management processes and heightened appreciation of exit competency outcomes. The portfolio also enabled us, as faculty, to attain a better understanding of student experiences and exit outcomes accomplishment. Acknowledgement. We thank our students who agreed to have their portfolio entries analysed and publically shared on the promise of anonymity. 1. McMullan M, Endacott R, Gray MA, et al. Portfolios and assessment of competence: A review of the literature. J Adv Nurs 2003;41(3):283-294. http://dx.doi.org/10.1046/j.1365-2648.2003.02528.x 2. Tochel C, Haig A, Hesketh A, et al. The effectiveness of portfolios for post-graduate assessment and education: BEME Guide No. 12. Med Teach 2009;31(4):299-318. http://dx.doi.org/10.1080/01421590902883056 3. Sauer KA. Use of reflective portfolios in health sciences education. Am J Pharm Educ 2007;71(2):1. http://dx.doi. org/10.5688/aj710234 4. David MFB, Davis M, Harden R, Howie P, Ker J, Pippard M. AMEE Guide No. 24: Portfolios as a method of student assessment. Med Teach 2001;23(6):535-551. http://dx.doi.org/10.1080/01421590120090952 5. Davis MH, Ponnamperuma GG, Ker JS. Student perceptions of a portfolio assessment process. Med Educ 2009;43(1):89-98. http://dx.doi.org/10.1111/j.1365-2923.2008.03250.x 6. Driessen E, van Tartwijk J, van der Vleuten C, Wass V. Portfolios in medical education: Why do they meet with mixed success? A systematic review. Med Educ 2007;41(12):1224-1233. http://dx.doi.org/10.1111/j.13652923.2007.02944.x 7. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. http://dx.doi. org/10.1191/1478088706qp063oa 8. MAXQDA. The art of data analysis. 2016. http://maxqda.com/legalinfo (accessed 4 April 2016). 9. Coleman H, Rogers G, King J. Using portfolios to stimulate critical thinking in social work education. Social Work Educ 2002;21(5):583-595. http://dx.doi.org/10.1080/0261547022000015258 10. Keim KS, Gates GE, Johnson CA. Dietetics professionals have a positive perception of professional development. J Am Diet Assoc 2001;101(7):820-824. http://dx.doi.org/10.1016/s0002-8223(01)00202-4 11. Brown JO. The portfolio: A reflective bridge connecting the learner, higher education, and the workplace. J Contin Higher Educ 2001;49(2):2-13. http://dx.doi.org/10.1080/07377366.2001.10400426

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Research Appendix 1. Marking rubric for MSc/MPH portfolios Student Detail Name Module Characterisation of dimensions of portfolio design Style

Descriptive

‫ ٱ‬

‫ ٱ‬Reflective

Structure

Informal

‫ ٱ‬

‫ ٱ‬Formal

Confidentiality

Personal ‫ ٱ‬ ‫ ٱ‬ ‫ ٱ‬ ‫ ٱ‬ (closed)

‫ ٱ‬Public (open)

Content

Focused ‫ ٱ‬ ‫ ٱ‬ (e.g. critical incidents)

‫ ٱ‬

‫ٱ‬

Presentation

Grade

Comment

Grade

Comment

Grade

Comment

• Evidence of guidance framework (index, conclusion, captions, etc.) • Organisation • Visual appeal • Spelling/grammar • Referencing Content • Conciseness/length • Creativity • Effort • Professionalism • Additions (e.g. articles) Reflection on • Critical incidents • Educational activities • Programme objectives • Response or solutions to issues • Competencies achieved • Self growth (e.g. leadership, embracing diversity, communication, etc.) Evaluator’s comments • Overall decision: (%) • Most enjoyed or impressed by: • Could have been improved by: • General comment/s Evaluator’s name Date Grading

Percent