THE NETWORK TOWARDS UNITY FOR HEALTH
VOLUME 28 | NUMBER 02 | MARCH 2010
NEWSLETTER LETTER
GOODBYES AND HELLOS, that is what this Newsletter is all about. Because, dear friends, after 30 years of the Network Secretariat being managed from Maastricht, the Netherlands, we think it is time for some fresh air in our organisation and to pass on the (wisdom of our) Secretariat to one of our nearest and finest other Network: TUFH members: Ghent University in Belgium. Some of you already had the opportunity to get to know them better, as this university organised the 2006 Conference. Usually we try to make the content of the Newsletter as international as possible; we want to give a voice to all of you, hear from all of you, learn from all of you. But as I already mentioned in the headline, this time it is about goodbyes and hellos. Therefore, you will find special attention to Maastricht and Ghent in this Newsletter, translated into articles from our staff about international health education, promotion, research, authorities, professions, improvement, health in the community, et cetera. This is our chance to say our goodbyes and to introduce ourselves.
IN THIS ISSUE, AMONG OTHERS: Expanding the Scope and Quality of Learning for Healthy Communities 17 Once upon a Time in the West of Kenya... 19 Brighter Smiles for Aboriginal Children in Canada 20 Time for a Turnabout in the Treatment of the Elderly 24 EC Intelligence: Francisco Lamus 36
I have been co-editor of the Newsletter together with Pauline Vluggen for eight years, and I can say that this has been one of the most enjoyable parts of my job here in Maastricht. I like to thank you all for your cooperation and friendly contacts. Special thanks goes to Sandra McCollum, our language editor: as a native English speaker, you certainly helped us out a great deal, and I have learned a lot from you. Goodbye from Maastricht, and hopefully hello again during one of the upcoming Network: TUFH Conferences elsewhere in the world. The next one being in Nepal this year. Go Ghent! Marion Stijnen Editor
In the Newsletter we refer to The Network: Towards Unity for Health as The Network: TUFH.
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CONTENTS 03 Foreword From Maastricht to Ghent 05 The Network: TUFH in Action 05 Annual International Conference The 2010 Conference in Nepal in Brief | Host University and Faculty in Nepal | Low Threshold at Conference 06 Education for Health Upcoming Changes in Format of Articles 07 International Health Professions Education 07 Social Accountability Cultural and Clinical Immersion of Medical Students 08 Problem-based Learning and Community-based Education Problem-Based Learning in Mozambique and the Netherlands: A Comparison | Interdisciplinary Community-Based Teaching in Ghent 11 Leadership Column Jehu Iputo, Dean Walter Sisulu University, South Africa 12 Yellow Papers A Framework for Programme Evaluation in Medical Education | Potential Role of Creativity in Contemporary Nurse Management Education 15 Distance Learning The London Deanery E-Learning for Clinical Teachers | Distance Education and Problem-Based Learning | Expanding the Scope and Quality of Learning for Healthy Communities 18 Accreditation and Quality Assessment Continuous Assessment - Summative Assessment in Dental Colleges of Pakistan 19 The Like-Minded Working Together Once upon a Time in the West of Kenya... 20 Improving Health 20 Indigenous Health Brighter Smiles for Aboriginal Children in Canada 21 Health Services Quality Assessment of Health Services 22 Care for the Elderly From Nursing Home Medicine to Elderly Care Medicine | Time for a Turnabout in Treatment of the Elderly 25 Rural Health Taking Health Manpower to the Disadvantaged Poor 26 Health Research Only High Quality Research Can Influence Healthcare 27 Women’s Health Menstruation: Awareness and Perceptions in Adolescents and their Mothers 28 Health Authorities Improving Perinatal and Maternal Health Needs Restructuring of the Healthcare System | What Would I Change if I Were Minister of Health...? 30 Health Promotion Married Homosexuals; From Denial to Realism 31 Community Action 31 Health Festival: Health Promotion and Education for the Local Community 32 Students’ Column 32 Students’ Speakers Corner The Big Five | Network Tufh Alumni: Jelle van den Ameele, Belgium 34 Member and Organisational News 34 Messages from the Executive Committee General Meeting 2010, Nepal | In Memoriam: Professor Björn Bergdahl, M.D. | EC Intelligence: Francisco Lamus 37 Taskforces Women and Health Taskforce: 2009 Successes | Moving on: Changes in institutional Leadership | Taskforce on Social Accountability and Accreditation: Pushing the New Frontier | Taskforce International Education: Curtin University, Australia | Full Membership 39 About our Members Healthy Child Uganda | New Members | Tribute to… | A Passion for...
FOREWORD
From Maastricht to Ghent…
Old and new: Ingrid Melters and Yoka Cerfontaine from Maastricht University, Jan De Maeseneer and Kaat De Backer from Ghent University
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In the last years, The Network: TUFH has been very active in the international debate:
Ghent And what about Ghent? Ghent is an old city, founded in 600 by monks. The city has a long tradition of critical interactions with those ‘in power’ (Emperor Charles V has experienced this in the 16th century!). Another characteristic is that the city has always had a broad ‘outwards’ perspective, looking at the world. Hence, the city of Ghent is very multicultural. Over 120 nations are represented in the population of Ghent.
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But also in the previous century, the ‘Maastricht people’ have shaped the organisation to a powerful institution. In 1979, the Network of Community-Oriented Educational Institutions for the Health Sciences was born from the ideas of societal transformation, formulated by the student movements in the sixties. Ideas of emancipation, participation and social justice found their way to educational institutions through methods like Problem-Based Learning (PBL), Community-Oriented Teaching and Learning, et cetera. The Network has put these principles into
Thanks to Maastricht University, The Network: TUFH has also established a clear position in the international spectrum of non-governmental organisations (NGO): it is an NGO in official relationships with WHO. This co-operation with WHO brought the ‘Towards Unity for Health’-perspective into The Network, bringing all stakeholders together to contribute to relevant, equitable, high quality, cost-effective, sustainable, participatory and innovative healthcare.
For 30 years, the Maastricht leadership communicated all activities of The Network: TUFH through the Alerts and the Newsletter. The Dutch cheese was always present at the annual International Conferences and was appreciated by the key-note speakers. Not only was Maastricht the hub in the conferences, but many of the members of the The Network: TUFH came to Maastricht to learn, study and exchange.
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In the first decade of this century, Pauline Vluggen, Gerard Majoor, Jolanda Koetsier, Jan van Dalen, Yoka Cerfontaine, Ingrid Melters and Marion Stijnen have been the ‘points of contact’ with the Network: TUFH Secretariat in Maastricht for all its members.
The basic principles of the The Network were also reflected in the format of conferences: participants that attend the Network: TUFH Conference for the first time always report: “this is something different”. And what makes it ‘different’ are you, the members, the participants. At a Network: TUFH Conference every participant has an interesting story to tell. So we invite you to attend the next conference in Kathmandu, Nepal, November 13-17 2010, on the topic Advancing quality through partnerships with Health Professions Educations and Health Services Institutions, Institutions with the Post-Conference Excursion to Dharan on November 18-20.
at the Global Health Council in 2008, in the 15by2015 campaign (www.15by2015.org), in the World Health Assembly 2009, and in the Scientific Committee for the Renewal of Primary Health Care of WHO. In May 2009 during the World Health Assembly in Geneva, The Network: TUFH - together with Wonca and the European Forum for Primary Care - contributed to the formulation of the Resolution Primary Health Care, including health systems (WHA62.12).
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Maastricht For more than 30 years, Maastricht University has hosted The Network: TUFH. Thanks to Maastricht University, the organisation has flourished, and it became an important player at the international level, especially in the context of education and development.
action, not only in the Western world but also in developing regions.
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On the 1st of March 2010, the office of The Network: TUFH moves formally from Maastricht University (the Netherlands) to Ghent University (Belgium).
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FOREWORD
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The city was very happy to host the 2006 annual Conference and contributed a lot to the success of this Conference. Moreover, the city financed the construction of a Community Primary Health Care Centre Nueva Gante in Cochabamba (Bolivia) to train family physicians at the Universidad Mayor de San Simon. Ghent is also involved in many other international projects, with special emphasis on issues of social inequities and social justice.
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Ghent University was founded in 1815 (by the Dutch!), and the Faculty of Medicine and Health Sciences hosts over 5000 students. Inspired by international developments in McMaster, Sherbrooke, Maastricht, and many others, the Faculty transformed its medical education in 1999 towards an integrated curriculum, with focus on PBL, self-directed learning, community orientation and an interdisciplinary approach. Tutorials were integrated in the curriculum, and training in Community-Oriented Primary Care - looking at the problems of deprived areas in the city of Ghent - was developed. In 2005, at an assessment by an International Accreditation Board, the medical curriculum of Ghent University was the first in Flanders to receive a Special Quality Award for ‘Community Orientation’ and ‘Social Accountability’. The Faculty has a long tradition of international co-operation: in the sixties it contributed to the foundation of a Medical Faculty in Rwanda. Now students are very active in international exchange programmes, both within Europe and in developing countries (Cambodia, Uganda, Kenya, Ecuador, Bolivia, Rwanda, et cetera). Within this international student exchange the Faculty strives for reciprocity, so that students from developing countries can come to Ghent.
Coordinating international networks is not new to Ghent. Since 1997, the Department of Family Medicine and Primary Health Care has been involved in the development of training for family medicine and primary health care workers in Africa, Latin America and recently also in China. The Primafamed centre of Ghent University (www.primafamed.ugent.be) has developed a strategy of South-South co-operation to train family physicians in Africa, with special attention for the area’s most in need: rural and remote areas, townships, et cetera. Nowadays, the Department is active in 15 countries in Africa. The Department is looking forward to hosting the Secretariat of The Network: TUFH. Kaat De Backer will be the Executive Director at the Secretariat. Kaat has an academic background in East Asian Linguistics and International Political Sciences at Ghent University and Xiamen University (China). She has gained international experience through her work at the International Relations Office of the Flemish Ministry of Education and Training, where she was responsible for the educational programs of OECD, EU en UNICEF. In 2006, Kaat was involved in the organisation of the annual Conference of The Network: TUFH in Ghent. She will be accompanied by Sofie De Backere, who will work as Office Manager. After her applied psychology training, she was an Office Manager at an international music festival. For some time now, she is working at the Department of Family Medicine and Primary Health Care as a research assistant. Finally, Julie Vanden Bulcke, family physician, will be responsible for the Newsletter. After Medicine and GP training, she followed a post-graduate course in tropical
medicine and international health. For one year she worked in a refugee camp on the Thai-Burmese border with Karen refugees. Currently she is working as a GP in Brussels and part-time at the Department of Family Medicine in Ghent. Last year she was occupied in a First Line Health Care project in China, training GPs and nurses in Shanghai. You will find the Secretariat of The Network: TUFH at the University Hospital Campus, building K3, first floor, De Pintelaan 185, B-9000 Ghent, Belgium. Phone: +32 9 332 81 81; Fax: +32 9 332 49 67; Email: secretariat-network@ugent.be; Website is unchanged: www.the-networktufh.org We hope that the transition will be smooth for all of you, and we hope to see you in Ghent (only half an hour by train from Brussels). Jan De Maeseneer, Kaat De Backer, Sofie De Backere and Julie Vanden Bulcke | Secretariat The Network: TUFH, Ghent, Belgium Email: jan.demaeseneer@ugent.be
THE NETWORK: TUFH IN ACTION ANNUAL INTERNATIONAL CONFERENCE
The 2010 Conference in Nepal in Brief When: November 13 - 17 | Where: Kathmandu, Nepal | Theme: Advancing Quality through Partnerships of Health Professions Education and Health Services Institutions | Conference site: www.the-networktufh.org/conference | Preliminary Programme: www.the-networktufh.org/conference/programme.asp | Registration: www.the-networktufh.org/conference/registration.asp After the Conference (November 18 - 20) there will be an optional Post-Conference Excursion to the B.P. Koirala Institute of Health Sciences, Dharan, Nepal. More information is available at www.the-networktufh.org/conference
Host University and Faculty in Nepal
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in a variety of aspects I believe that meeting foreigners and visiting a foreign country is very useful for mutual understanding and respect of differences. Also for the physician who is going to work in his/her own multicultural society. It is two years later now, and I have attended several other conferences, but none of them had this small scale feeling with this low threshold to have discussions with people from different countries. For me it was a unique opportunity which I will never forget.
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I caught myself on a great amount of prejudices and I suddenly felt more aware of my own (cultural) references. Curiously I asked my colleagues from South Africa about genital mutilation: “does it really happen in your country? Why Why?” The explanation of the rituals around becoming a man or woman became clearer and the importance of belonging to a group suddenly more vivid. Although I still not justify genital mutilation of women or men, I can understand the sacrifices better. By not allowing your child to undergo the same ritual, you are risking him to be never recognised as a real man or woman, but at the same time you are also aware of the medical risks. As medicine is globalising more and more
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LOW THRESHOLD AT CONFERENCE Presenting a poster during a Network: TUFH Conference in Uganda? Not many students would reject such an idea. Same for me. In 2007 I stepped out of the plane in Kampala, not having the foggiest idea of what I could expect. First time in Africa, first conference. Primary colours in abundance and the most diversely dressed population awaited the start of the Conference: from woollen socks with sandals to three layered suits. Striking during the Conference was the low threshold which existed between the participants to discuss their experiences. Professors asked students their opinions during the multiple discussion moments. The usual hierarchy seemed vanished in the humid air of Uganda.
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BPKIHS curricula and the programmes are: need-based, integrated, and communityoriented and partially based on problem solving, in line with innovative medical education programmes epitomised in the Edinburgh Declaration of 1988. These principles include service delivery, and outreach services are an integral part of the commitment, which the Institute has pledged to the legislators. The university is fully committed to its social responsibility and accountability. Candidates from disadvantaged groups are given opportunities for admission in most of the academic programmes.
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providing holistic healthcare through training for a compassionate, caring, communicative and socially accountable health workforce, which acts as an agent of change in society and advances in research, service and education to ensure healthy individuals and families by collaborating with all stakeholders. BPKIHS has also been envisioned by the Nepali Parliament as a centre of national importance to produce skilled work force in the health sector to meet the country’s need and to function as a centre of excellence in the field of tropical and infectious diseases. In terms of achieving the educational goals of the university, the basic tenets of the
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B. P. Koirala Institute of Health Sciences (B PKIHS) was established on January 18, 1993. Subsequently, the Nepalese Parliament upgraded BPKIHS as an autonomous Health Sciences University on October 28, 1998, with a mandate to work towards developing a socially responsible and competent health work force through innovative teaching learning and research approaches. The university is located in eastern Nepal and has extended its continued health services to primary healthcare centres, district hospitals and zonal hospitals in six districts of the region through a teaching district approach. The main mission of BPKIHS is to improve the health status of the people of Nepal by
Mariëlle Jippes | 5th-year medical student, Maastricht University, the Netherlands Email: mjippes@hotmail.com 5
THE NETWORK: TUFH IN ACTION EDUCATION FOR HEALTH
Styles change, even formatting styles for papers published in medical journals. Since 1978, editors of a small number of general medical journals have met periodically, first to create and then to update format standards for research papers submitted to biomedical journals. Standards include sections headings for abstracts and the body of papers, the expected location of content within these sections, regular formats for references and tables, and conventions for use of abbreviations. This International Committee of Medical Journal Editors (ICMJE) decided to standardise the formats of submitted articles in order to ease the work of authors and journal staff and to strengthen the reporting of studies (ICMJE, 2009). Although these formats were not intended to guide how papers would look when published, many journals have adopted these same formats for the papers appearing in their issues, so these formats are now familiar to readers as well.
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Thirty years after the Uniform Requirements for Manuscripts Submitted to Biomedical Journals was introduced, more than 500 journals advertise that they use the Uniform Requirements and many others follow these standards in whole or part. The Uniform Requirements’ ‘IMRAD’ structure for research articles - Introduction, Methods, Results and Discussion - are ubiquitous in health sciences reports. Format Education for Health (EfH) has requested authors to submit manuscripts in the style of the Fifth Edition of the American Psychological Association’s Publication Manual (APA, 2001). This style is less common in the biomedical sciences and becoming increasingly less so as the Uniform Requirements have gained popularity.
As of the first issue of 2010, EfH will transition to the Uniform Requirements format. This change will ease the work of authors who submit to EfH. Authors who are in the habit of formatting the manuscripts they are writing according to the Uniform Requirements will need to make few adjustments when they submit to our journal. And manuscripts submitted to other journals before or after being submitted to EfH should not require much reformatting. Adopting these widely-used formats will also help EfH’s less experienced authors become familiar with an industry standard. In its updated instructions for authors, EfH is asking that all submissions follow the Uniform Requirements. Readers will be seeing the change in the upcoming issues. Referencing within the text will no longer appear as authors’ last names and publication year placed within parentheses, but as simple numbers corresponding to citations ordered sequentially within the references section. Formats for references will appear as: Kristina TN, Majoor GD, Van der Vleuten CPM. Does community-based education come close to what it should be? Education for Health. 2006;19:179 - 188. More examples of references can be found at the following website: www.nlm.nih.gov/bsd/uniform_requirements.html The EfH style will vary one element of the style as described on the ICMJE site, in that EfH will require journal names to be mentioned in full in the reference list (not abbreviated).
Length of Articles In addition to format changes, EfH will extend the maximum allowable length of articles. One of the advantages of EfH’s recent transition to an entirely online journal is that publishing lengthier articles no longer increases printing costs and longer articles no longer bump other articles from issues for lack of space. Again, our authors win. Authors can say what importantly needs to be said surrounding their work. To be certain that permitting longer articles does not leave readers wading through wordy, repetitive and rambling tomes, EfH will continue to push authors to be succinct and clear in their writing. To quote Gracián: “Good things, when short, are twice as good.” Reference AMERICAN PSYCHOLOGICAL ASSOCIATION (2001). Publication Manual of the American Psychological Association, Fifth Edition. Washington DC: APA. INTERNATIONAL COMMITTEE OF MEDICAL JOURNAL EDITORS (2009). Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication. Available at www.icmje.org This article is an abridged version of an editorial, published in EfH, Volume 22, issue 1 (2009). Donald Pathman and Michael Glasser | Co-Editors, Education for Health Email: don_pathman@unc.edu
INTERNATIONAL HEALTH PROFESSIONS EDUCATION SOCIAL ACCOUNTABILITY
Cultural and Clinical Immersion of Medical Students Northern Ontario is a culturally diverse region of Canada with various Aboriginal, Francophone, rural, remote, and urban communities stretching across some 800,000 km2. The people of Northern Ontario experience significant challenges to achieving optimal health, including geographical isolation, language barriers, lifestyle factors, and physician shortage.
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Acknowledgements: our sincere thanks to Dr. Marc Blayney for his guidance in writing this article.
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Upon completion of the four-year programme, NOSM students graduate as confident, resourceful physicians who have built on their strong affinities for practicing in rural and Northern regions. This innovative approach to distributed medical education may provide an example to other institutions endeavouring to produce clinically proficient, culturally sensitive doctors prepared to work anywhere in the world and particularly in underserviced communities.
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The first ICE takes place on an Aboriginal reserve at the end of the 1st year and provides students with the extraordinary cultural privilege to live, learn, and work
Deeper Appreciation Our experiences during ICE and CCC have been overwhelmingly positive. The staff at the clinics and hospitals have adapted extremely quickly to having medical students rotate through on a regular basis, and they welcome us each time with characteristic Northern hospitality. The nurses, physicians, and allied health professionals are quick to involve us in patient care. We feel that the experiential learning - instead of a primarily didactic curriculum - leads to a much deeper appreciation of what it
means to be a rural or Northern physician serving a culturally diverse population. Finally, there are few other medical students who can say that, after a day of clinical duties, they were invited to participate in a sweat lodge, go ice fishing or paddling on the lake, or attend a community dinner.
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ICE and CCC During the four-year MD programme, students embark on three four-week Integrated Community Experiences (ICE) and an eight-month Comprehensive Community Clerkship (CCC) that combine cultural immersion with medical education.
Clerkship at NOSM begins with CCC, when 3rd year medical students disperse across Northern Ontario to spend eight consecutive months in a large rural or small urban centre. Students spend the majority of time in primary care and a complementary amount of time working with specialists. CCC is not divided into rotations like a traditional clerkship, but instead allows students to follow patients longitudinally and experience the full breadth of rural medicine on a weekly basis. Students return in the 4th year to complete their core rotations and electives, empowered with three ICE and eight months of intensive, hands-on CCC experience in a wide variety of disciplines.
Medicine and culture combined
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Demographically Representative Opened in 2005, the Northern Ontario School of Medicine (NOSM) is a pioneering Faculty of Medicine that was created to respond to the medical, cultural, and social needs of the North and its inhabitants. According to its social accountability mandate, NOSM is receptive to the unique healthcare needs of Northern Ontario, as reflected in the school’s curriculum, research programmes, student demographics, and dual-campus structure. The school’s rigorous admissions process aims to attract Aboriginal, Francophone, rural, and Northern students in order to create a class that is demographically representative of Northern Ontario. To that end they have been largely successful: in its first four years, approximately 90% of NOSM students came from Northern Ontario with the remaining 10% from other rural and remote regions of Canada, 8% were Aboriginal, and 23% were Francophone.
with a First Nations community. The next two ICE take place during the 2nd year in small rural communities throughout Northern Ontario with a focus on clinical learning. These placements are a rare opportunity for pre-clerkship medical students to engage in daily patient care, while building their confidence and applying their academic knowledge in a meaningful, clinical context. While we feel that students derive the greatest benefit from these placements, the host communities also appreciate the opportunity to showcase their little piece of Northern Ontario and promote rural medicine.
Meghan Garnett, Jeniva Donaleshen, Sean Sullivan | Medical Students, Northern Ontario School of Medicine, Canada Email: meghan.garnett@normed.ca
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION PROBLEM-BASED LEARNING AND COMMUNITY-BASED EDUCATION
Problem-Based Learning in Mozambique and the Netherlands: A Comparison
Evaluating Different Aspects The authors of this article are medical students at Maastricht University (UM), the Netherlands, who undertook a placement at the Faculty of Medicine at the Universidade Cat贸lica de Mo莽ambique (UCM), in Beira. We evaluated a number of different aspects of the use of PBL between UM and UCM. Table 1 summarises the main differences we identified between the two universities.
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The effectiveness of PBL in developing countries is not known. PBL has certain features - such as the use of small group sessions, discussion of real-life problems and the use of skills training sessions (Maastricht University, 2007a) - which may pose different challenges in developing countries than in western countries (Carrera et al., 2003; Khoo, 2003). Hardly any literature exists about variations in the implementation and outcomes of PBL in different cultural and economic contexts.
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Strengths and Weaknesses A number of factors might explain the differences in medical education at the two universities. Cultural, social and economic factors all influence the parts of the curriculum which are emphasized most, the way students value their studies and the conditions in which students are educated. One of the strengths of the use of PBL at UCM is the emphasis on theoretical knowledge. Our impression and that of foreign teaching staff is that UCM students gain a more solid grasp of factual medical knowledge than their counterparts in Maastricht. The prohibition to consult notes during tutorials and the emphasis on basic knowledge during all activities of the course are very likely contributing factors. Another strong point of the curriculum is the community health programme. Students find
UM
UCM
Curriculum
- three preclinical years - premedical year - three years of clinical attachments - four preclinical years and research - two years of clinical attachments
Tutorials
Years 1 and 2: tutorials with emphasis on basic knowledge
Years 1 and 2: tutorials with emphasis on basic knowledge
Year 3: tutorials with emphasis on patient presentations
Year 3 and 4: tutorials with emphasis on clinical reasoning
Notes are allowed during sessions
Notes are strictly prohibited
Skills training
Emphasis on the practicing of clinical skills
Emphasis on the theoretical background
Clinical experience in preclinical years
Year 3: consultation in the hospital - medical history and physical examination under direct supervision - prediscussion and evaluation afterwards
Years 3 and 4: consultation in the clinic - complete medical history and physical examination - short case-presentation to the doctor afterwards
Communication training
Medical practical education course: - consultations with simulated patients - feedback from patient, fellow students and tutor
Recording of consults in the clinic - communication training session once per course, starting in the 3th year - feedback from fellow students and tutor
Academic training Prominent place in the curriculum - every unit an academic assignment - 18 weeks of research
No formal academic training
Public health
Community health programme in poor neighbourhood of the city Emphasis on public health in the curriculum
No community health programme Public health scarcely covered in the curriculum
Facilities
Great diversity of books and articles in the library Large number of computers available Use of Electronic Learning Environment
Less diversity of books in the library, older editions Computers often not available Internet rarely used as a learning resource
Students
Spending on average 30h/wk on their studies Valuing extracurricular activities as important
Spending on average 50h/wk on their studies Few students spending time on extracurricular activities
Evaluation
Evaluation of tutorials twice a unit - Critical feedback from students and tutor
Evaluation of tutorials after each session - General comments from students and tutor
Evaluation of every unit Students are represented in university decision-making processes
Not all unit tests are evaluated No organisation which represents the opinion of students
Table 1: Main differences in the use of PBL between the medical faculties of Universiteit Maastricht and Universidade Cath贸lica de Mo莽ambique
themselves confronted with ‘real’ healthcare issues in one of the poorest neighbourhoods in their city and gain an insight in public health through case studies, lectures and discussions.
hope both faculties can learn from each other and their way PBL is used.
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Joany Zachariasse and Jessica Maltha | Medical students, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands. Email: j.zachariasse@student.maastrichtuniversity.nl
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References CARRERA, L. I., TELLEZ, T. E., & D’OTTAVIO, A. E. (2003). Implementing a Problem-Based Learning Curriculum in an Argentinean Medical School: Implications for Developing Countries. Academic Medicine, 78, 798-801. KHOO, H. E. (2003). Implementation of problem-based learning in Asian medical schools and students’ perceptions of their experience. Medical Education, 37, 401-409. LAMBREGTS, M., WARRIS, L., & BUITEN, M. (2009). ‘Vroeger waren co’s veel beter’. Geneeskundestudenten kritisch over eigen kennis. Medisch Contact Contact; 64 (8): 337-40. Maastricht University (2007a). Retrieved from: www.unimaas.nl/default.asp?template =werkveld.htm&id=3A5J335QP77T1233G147 &taal=en
HARDLY ANY LITERATURE EXISTS ABOUT VARIATIONS IN THE IMPLEMENTATION AND OUTCOMES OF PBL IN DIFFERENT CULTURAL AND ECONOMIC CONTEXTS.
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Conclusion Both curricula have their strengths and weaknesses, explained by economic, social and cultural factors. To improve the curricula UM could focus more on public health and factual medical knowledge, while UCM could focus more on academic skills and increase student supervision. We
Students from UCM present their result M A R C H
A weak point of the PBL system at UCM is the meagre supervision that students receive. We recognise that this would be difficult to address due to the shortage of qualified staff at this institution. The lack of academic skills training at UCM is another weakness in its curriculum. Competencies such as the ability to critically evaluate evidence, give presentations and understand research are such important skills for medical practice and decision-making that they seem essential in medical education. A strength of PBL at UM is its focus on clinical skills and academic skills training. Moreover, there is strong emphasis on the development of such skills as leadership, teamwork and the ability to obtain and process information. In the Netherlands both students and medical professionals value these traits in personal life as well as in the job application process. Feedback and evaluation characterise the PBL system at UM and contribute to a constant process of quality control and improvement when necessary. A weakness of the Maastricht curriculum is that the PBL system does not encourage students to study factual knowledge as much as it does at UCM, which is recognised by doctors when students enter their clinical years (Lambregts et al., 2009).
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Interdisciplinary Community-Based Teaching in Ghent
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Using the model of Community-oriented Primary Care, the Department of Family Medicine and Primary Healthcare of Ghent University introduces 240 third year students to local communities to study health needs both at the individual and community level during the Community-oriented Primary Care (COPC) course. As a starting point a student-patient interview is used, in which both individual and community issues are addressed. Later, students interview healthcare workers involved in ‘their’ patients’ care, as well as community workers. In groups of 20 students, they work during three sessions towards a ’community diagnosis’, facilitated by a local healthcare or social worker. Information from the interviews and data from different sources (population surveys, health statistics) are integrated and discussed. This community diagnosis is completed with a proposal for an intervention, tackling some of the communities’ perceived problems. Finally, a poster is designed to use in the community, and all results are presented to fellow students, a jury of academic personnel and local healthcare workers and policymakers. Strengths From the initial ideas about introducing a community-oriented approach to medical students, it was clear to participating students, the health centres involved and the tutors that this should be an interdisciplinary course. By working with a strong network of community health centres throughout the city of Ghent, a solid basis was created to recruit patients of diverse backgrounds and enthusiastic healthcare workers year after year, and to have an organisational framework capable of ‘delivering’ within the tight academic calendar. The medical students achieve their goals in a four-day course, developing skills and attitudes as they work together on the project with students from more ‘social’ disci-
plines (social work, sociology, nursing and health promotion). The ‘real-life’ starting point involving a patient and his care givers is always an important moment in the student’s educational (and professional) career, and a point of reference in later years.
infrastructure (e.g. the renovation of the Ledeberg community with attention to green spaces for children) and the city’s Local Social Policy, stimulating collaboration between healthcare and social sectors, have in part been inspired by the yearly reports policymakers receive from students.
Weaknesses The local community health centres have capacity limits in terms of the number of students they can support during this course. With growing numbers of medical students each year, new solutions must be found to not overload the centres. Contrary to the medical students, the number of social work students has not risen over recent years, creating an unbalance of eight medical students to one social work student. Involving other disciplines creates problems of capacity with the health centres, and organisational challenges (calendar). For practical reasons the organisation fails to address some of the remarks students make when evaluating the course: they want smaller groups, and more time within the community.
As every student graduating from Ghent University has at least one contact with community health centres and knows how they work, this experience works as a basis for later staff recruitment for the health centres. This may partly explain the relative lack of problems these practices experience in recruiting new doctors. By placing this experience relatively early in the curriculum, their hearts and minds open to reflect on their social responsibility and future role as physicians, especially towards those most in need.
Outcome? This course has goals set at the levels of student education and attitude change. Are students more community responsive once they have completed the course, do they work interdisciplinary? This remains unclear, as we do not have a formal preand post-evaluation.
THE ‘REAL-LIFE’ STARTING POINT INVOLVING A PATIENT AND HIS CARE GIVERS IS ALWAYS AN IMPORTANT MOMENT.
Do communities benefit? Although this is not the primary objective, there are indications that sometimes the patients involved benefit (e.g. an advocacy action by the students to give a handicapped ’illegal’ immigrant child access to institutional care). Moreover, some of the cities recent investments in healthcare and community
Bruno Art, Jan De Maeseneer | Department of Family Medicine and Primary Health Care, Ghent University, Belgium Email: bruno.art@ugent.be
LEADERSHIP COLUMN
Leadership Column: Jehu Iputo, Dean Walter Sisulu University, South Africa
champion the change process. The team should be representative of the spectrum of stake holders and should have the right mix
There must be involvement and agreement from the people with a stake in the proposed changes. In medical education, it is imperative that politicians, community leaders, health professionals, university administration, staff and students are
ry when the older people retire. The
Those Who are Against Change What we did was engage with them and explain to them the need for curricular change and the benefits of the changes. We exposed them to institutions that had adopted the PBL/CBE curriculum. We organised training workshops that dealt with issues that they were having difficulties with. We had to ease some of the changes that they found threatening. We had to let go of a couple of staff members who could not adjust to the workings of the innovative curriculum.
buy-in, the change process will be difficult. Which curriculum an institution adopts is
role
should progressively be turned over to
Dr. Jehu Iputo
younger staff members while the old ones are still around. Hold regular workshops to induct new members of staff on the way the institution works. Hold regular refresher workshops to ensure that people do not revert to old habits. Be reflective - ask feedback from staff, students, and other stake holders on the performance of your graduates. If there are shortcomings, identify them and seek for remedy. You should not settle into complacency.
Required Assets for a Leader A leader must be knowledgeable about the proposed changes. He should be credible in the eyes of the stakeholders as a person conversant with the issues at stake. He should be prepared to engage with stakeholders in discussions and debates to gain agreement and support for the reasons for change. The leader should be prepared to listen, especially to those with contrary views and try to convince those to give change a chance. The leader should not be rigid and hasty, but rather patient and accommodating - prepared to take change at an incremental pace that is not threatening to the stake holders. A leader should be able to negotiate away some advantages in order to attain bigger things - (s)he should be able to stoop to conquer! I lead by example and evidence, and I would like to believe that I am a patient and tolerant leader who prefers gentle persuasion to coercion.
involved in and agree with the proposed changes to a curriculum. Without their
leadership
Make Change Sustainable, Secure Continuity Always make change a group effort. In your
Jehu Iputo | Dean, Walter Sisulu University, South Africa Email: iputo@worldonline.co.za
I LEAD BY EXAMPLE AND EVIDENCE, AND I WOULD LIKE TO BELIEVE THAT I AM A PATIENT AND TOLERANT LEADER WHO PREFERS GENTLE PERSUASION TO COERCION.
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of skills and experience.
institutional memo-
with the aim of having them on your side.
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stakeholders, we build a team that will
your community and to engage with them
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until a consensus is reached. From the
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mix of skills and lev-
important to identify the power brokers in
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talk of the South African process, where we
vails is a matter of political clout. It is
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Their role is paramount. In South Africa, we
team, have a proper
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Other Stakeholders Establishing the innovative training programme was a team effort that involved a wide variety of stakeholders. These included national and regional political leaders, civic community leaders, medical professional bodies, medical professionals, university administrators, staff labour unions, student bodies, staff members, and of course the students themselves.
a matter of opinion. Whose opinion pre-
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Change Processes in the Past I was part of the team that established a medical school at the then University of Transkei in one of the homelands of South Africa. I was instrumental in the introduction of an innovative, socially accountable medical training programme in this medical school, the first of its kind in Southern Africa, We recruited students from the local community, including those without the pre-requisite training in mathematics and science, for the doctor training programme. They were trained in a problembased, community-based curriculum that involved both small group tutorial settings and early clinical exposure.
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION YELLOW PAPERS Between those outstanding publications that were already published in leading journals, and some preliminary notes scribbled on the last page of an agenda, there are also papers or reports that belong to the in-between (‘grey area’) category. Papers that, for whatever reason, have not been published before. Within this ocean of ‘grey’ papers, there are some which by content are most relevant to the Network: TUFH’s mission and aims. We will pick those pieces of gold from the ‘grey’ ocean, change their status to ‘yellow’ (because we can’t print in gold) and publish them in this section. Here you will find two such yellow papers.
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A Framework for Programme Evaluation in Medical Education
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The quality of evaluation processes in medical education depends on the chosen approach. We devised a framework that can be helpful to those who intent a realistic and appropriate evaluation. It contains aspects derived from three models but widens the scope of the other models by taking into account the outcomes of education programmes. Three Models As educational systems are extremely complex structures, it is advisable to use an evaluation model that enables circumscribed and orderly entities to be discerned (Sallis, 1997). Several approaches have been proposed for this type of categorisation, each with their own drawbacks and pitfalls. In healthcare evaluation, Donabedian contended that it is useful to make a distinction between ‘structure’, ‘process’, and ‘outcome’ (Donabedian, 1966; Donabedian, 1988), representing more or less discrete entities. • Structure. Structural characteristics are relatively stable. In medical education they would include entering students’ level of previous education and facilities for education. • Process. This dimension corresponds to the interactions between consumers and suppliers. A self-evident process measurement would be the quality and frequency of feedback on students’ clinical skills performance. • Outcome. Valid outcome indicators may be difficult to identify. Frequently, proxy measures are used like assessments. It is important to note that these concepts are not entirely unambiguous. It is not always crystal clear to which dimension a certain quality indicator is to be allocated.
For example, students’ satisfaction with a course could be regarded as both a process and an outcome indicator.
models and from Coles’ model we copied the idea of the Venn diagrams, and we included the importance of student assessment (Shumway, 2003).
Nelson proposed three dimensions to show what is going on in medical education (Nelson et al., 1992). Alongside the ‘intended curriculum’, i.e. the curriculum as designed by the teachers, there are also the ‘actualised curriculum’, i.e. what students learn and what they remember, and the ‘unintended curriculum’, i.e. what students learn but is not explicitly described among the intended curriculum objectives. Coles presented a model using Venn diagrams (Coles et al., 1985). The first ring is called the ‘curriculum on paper’ and its contents can be found in student guides and in curriculum reports. The second ring represents the ‘curriculum in action’, i.e. content that is actually delivered to students in lectures and clerkships. Finally, the third ring is the ‘experienced curriculum’. It covers that part of the curriculum that is actually experienced by the students and the learning resulting from it. Perfect congruence of the three dimensions is not often seen in educational practice. What these models emphasize is that a curriculum is not simply the sum of a list of objectives. What students ‘absorb’ can be quite different from what they are expected to learn. The teaching organisation determines what they are supposed to learn by the ongoing process of choices about the education programme. New Framework for Curriculum Evaluation We selected dimensions from each of the
Intended curriculum
A B E Learned curriculum
C F
D G Curriculum in action
Figure 1: The framework The intended curriculum is analogous to the components posited by Coles and Nelson and comprises the parts of the curriculum defined by the teachers as the essential curriculum content. It covers the curriculum that has actually been put in writing and also includes the standards and values that remain implicit. The curriculum in action is the teaching that is actually delivered to the students.The learned curriculum describes what students ‘pick up’ during their training. The learned curriculum consists of the educational effects that the curriculum has on the students. In reality, the rings are unlikely to show perfect congruence and there is no 100%
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WE DEVISED A FRAMEWORK THAT CAN BE HELPFUL TO THOSE WHO INTENT A REALISTIC AND APPROPRIATE EVALUATION.
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The model showed effective in communicating our findings to faculty, and the findings triggered large scale innovation in our medical school.
Roy Remmen | Department of Primary and Interdisciplinary Care, General Practice, Faculty of Medicine, University of Antwerp, Belgium roy.remmen@ua.ac.be
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Using the framework and qualitative and quantitative methods, we evaluated parts of undergraduate training at the University of Antwerp. This revealed that the intended curriculum was not covered by the curriculum in action, and this in turn was responsible for rather poor results in terms of the learned curriculum. Indeed, the assessment of our students revealed considerable deficiencies in the performance of simple clinical skills (Remmen et al., 2000; Remmen et al., 1999; Remmen et al., 1998). We also showed differences between medical schools in the learned curricula (Remmen et al., 2001; Armstrong et al., 2004).
A.J.J.A., HERMANN. I., VAN DER VLEUTEN, C.P.M., & VAN ROYEN, P., L.B. (2000). An evaluation study of the didactic quality of clerkships. Medical Education; 34: 460-4. REMMEN, R., SCHERPBIER, A.J.J.A., VAN DER VLEUTEN, C.P.M., DENEKENS, J., DERESE, A., HERMANN. I., HOOGENBOOM, R., KRAMER, A., VAN ROSSUM, H., & VAN ROYEN, P., L.B. (2001). Effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools. Medical Education; 35: 121-8.
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Some parts of the curriculum may fall into only one dimension and be absent from the other two. Parts of the curriculum may have been planned but are not taught (a). Another part (g) may be offered although it was not planned and it is not part of the students’ learned curriculum. Finally, there is the part of the curriculum (e) that students ‘pick up’ somewhere, without teachers either intending to teach it or actually teaching it. This part of the curriculum is sometimes called the ‘hidden’ curriculum.
References ARMSTRONG, E.G., MACKEY, M., & SJ. S (2004). Medical education as a process management problem. Academic Medicine Journal; 79: 721-8. COLES, C.R., & GRANT, J.G. (1985). Curriculum evaluation in medical and healthcare education. Medical Education; 19: 405-22. DONABEDIAN, A. (1966). Evaluating the quality of medical care. Millbank Memorial Fund Quarterly Quarterly: 166-206. DONABEDIAN, A. (1988). The Quality of Care. How Can It Be Assessed? Journal of the American Medical Association; 260: 1743-1748. NELSON, M., JACOBS, C., & CUBAN, L. (1992). Concepts of Curriculum (editorial). Teaching and Learning in Medicine; 4: 202-5 SALLIS, E. (1997). Total Quality Management in Education: 2 Edition. London: Kogan Page Limited. SHUMWAY, J.M. HR (2003). AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician. Medical Teacher; 25: 565-8. REMMEN, R., VAN PUYMBROECK, H., DENEKENS, J., SCHERPBIER, A.J.J.A., VAN DER VLEUTEN, C.P.M., & HERMANN. I., L.B. (1998). Evaluation of skills training during clerkships using student focus groups. Medical Teacher Teacher; 20: 428-31. REMMEN, R., SCHERPBIER, A.J.J.A., DERESE, A., DENEKENS, J., HERMANN. I., VAN DER VLEUTEN, C.P.M., & VAN ROYEN, P., L.B. (1998). Unsatisfactory basic skills performance by students in traditional medical curricula. Medical Teacher Teacher; 20: 579-82. REMMEN, R., DERESE, A., SCHERPBIER, A.J.J.A., DENEKENS, J., HERMANN. I., VAN DER VLEUTEN, C.P.M., & VAN ROYEN, P., L.B. (1999). Can medical schools rely on clerkships to train students in basic clinical skills? Medical Education; 33: 600-5. REMMEN, R., DENEKENS, J., SCHERPBIER,
M A R C H
overlap. The framework enables us to trace where the mismatch is located, thereby directing areas for remedial action. Some parts of the curriculum may be covered by two dimensions of the model. Students may learn part of the curriculum on paper even though this part is not actually taught (b); or a part of the curriculum is taught but the students somehow do not ‘learn’ it (d). Some topics may be part of both the ‘curriculum in action’ and the ‘learned curriculum’ but not considered desirable curriculum content (f) from the curriculum designers’ point of view.
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION YELLOW PAPERS
Potential Role of Creativity in Contemporary Nurse Management Education
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In a world marked by knowledge, information and innovation, organisations can improve their performance and achieve excellent results by permanently encouraging people to use their imagination and creativity. Health and service organisations should follow this paradigm, especially management professionals like nurses. Brazilian nurse management professionals have prioritised technical and bureaucratic actions to comply with immediate and mediate supervisors’ expectations. It is a behaviour mechanically developed through routine, repetition and imitation. This article summarizes a case study that looks at the limits of nurse management exercise in Brazil and proposes elements of creative production that can contribute to nurse management education. The case study was based on intermittent observation of head nurses’ activities at hospitalisation units of a teaching hospital, through secondary analysis of data collected between the ‘70s and 2000 (Trevizan, 1978; Tervizan, 1988; Fernandes, 2000). The analysis reveals a repetitive practice with the constant presence of pre-determined and routine activities at the hospitalisation unit. Head nurses are primarily involved with unit administration, to the detriment of care administration in the study context. These findings show a fragile management exercise in the study context, and recommend that transformations are needed. Hence, ways should be indicated that stimulate these professionals’ creative potential. Nurses’ minds at the study hospital seem to be so accustomed to routine repetition that they have forgotten about their creative potential and competencies. This may be a result of their socialisation experiences at the hospital, which makes it understandable that they have tried to 14
incorporate the behaviours their organisational culture expects and values. However, in a changing world, human beings, their perspectives, needs and behaviours should also change. Today, the continuation of the same nurse management behaviour can no longer be accepted, nor can a bureaucratic culture that gives rise to different power types continue to oppress nurses, and nurses should no longer let themselves be oppressed. In this context, nurses need to look at themselves as human beings and attempt to understand both their internal clients (their fellow professionals) and external clients (i.e. the patients they are delivering care to). Different alternatives can contribute to achieve this necessary change, one of which can be creativity. Based on the findings of the case study, we believe that the elements of creative production discussed here can enhance nurse management education. In the Age of Knowledge and Information, creative organisations are replacing the fixed organisations from the Industrial Age. Creative organisations base their work to create the future on learning from past experiences, as well as on the wishes, needs and demands of clients, investors, employees and suppliers. The following characteristics of such organisation should be highlighted for the service sector: • permanently reassess the foundations of the organisation; • surprise, satisfy and please clients with its services; • take the forefront in changes, using well planned strategies in terms of structure, policies and organisation; • recognise obsolete services and when and how to transform them; • encourage experiments; • work to achieve its dreams (Janov, 1996).
Dr. Isabel Amélia Costa Mendes As “the generating potential of scientific, technological and human development” (Torre, 2005), creativity has a place in all spheres of human activity, in all professions, even when practice remains oriented by bureaucratisation. In nurse management education, three elements of creative thinking and production are thought useful: • metacognitive processing, a group of strategies or cognitive skills to process new information and use the achieved knowledge base; • knowledge base, related to the effort required to bring this knowledge into the open and control skills in a specific area; and • personality variables, a range of attitudes, willingness and motivation obtained during contacts with parents, teachers and colleagues, together with personal experiences, which guide persons to try and find new alternatives and configurations or appropriate and unique solutions (Feldhusen, 1995). Nurses’ administrative work should be enhanced by creative production. The three elements above inspire creative thinking, actions and products. The organisational culture they function in should be favourable to this development. We are conscious that this concept represents a challenge for nursing profession-
DISTANCE LEARNING
als, people and nursing teams. It is important to underline that this proposal can bring about further opportunities for nurses to look at themselves and their activities with more freedom, which is fundamental to help their internal and external clients, by means of effective management from human being to human being.
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References DEPARTMENT OF HEALTH (2008). High quality care for all: The NHS next stage review final report. London: Department of Health. DEPARTMENT OF HEALTH (2008). A Reference Guide for Postgraduate Speciality Training in the UK (‘Gold Guide’), London: Department of Health. LONDON DEANERY (2009). Professional development Framework for Supervisors. http://faculty.londondeanery.ac.uk/professional-developmentframework-for-supervisors (accessed June 2009). POSTGRADUTE MEDICAL EDUCATION AND TRAINING BOARD (2008). PMETB Standards for Trainers. London, PMETB.
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Key Features • The modules are designed as an introduction for clinical teachers. • The series can be used as a refresher or a complementary resource to award bearing programmes. • Each module includes: • definition of the topic and learning theory, • suggested workplace-based activities designed to encourage application of knowledge in the clinical context and support reflective self-assessment, • completion of a reflective log, • further reading, web-links and other resources and a glossary of terms, • the facility to print out a certificate for teachers’ revalidation, promotion or appraisal purposes. • Because of the large number of diverse users, formal summative assessments or discussion boards are not included.
User evaluation has been extremely positive and the site has been accessed by a wide range of people - students, trainees, qualified professionals, supervisors, staff developers - from various health professions across the world.
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Topics The modules cover core topics in clinical teaching: feedback; supervision; workplace-based teaching and assessment; diversity and equal opportunities; career development; appraisal; lecturing; small group teaching; interprofessional education and setting learning objectives.
Monthly Series in Journal In response to policy changes, ongoing monitoring and user feedback, we have reviewed, updated and developed the series. A digest of each module is currently being published as a monthly series in the British Journal of Hospital Medicine and the resource and modules have been peer-reviewed and accepted for publication by MedEdPortal (Academy of American Medical Colleges).
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Isabel Amélia Costa Mendes (Corresponding author), Full Professor; Maria Auxiliadora Trevizan, Full Professor; Eliana Ofelia Llapa Rodriguez; Elyrose Sousa Brito Rocha, doctoral student; Cláudia Elisângela Fernandes Bis Furlan, doctoral student | University of São Paulo at Ribeirão Preto College of Nursing, Brazil Email: iamendes@eerp.usp.br
In 2002, the London Deanery commissioned a project to develop a web-based resource for clinical teachers written by a group of medical educators. In 20072008, in response to policy drivers, workforce demands and service changes (Department of Health, 2008), the Deanery reviewed the resource, repurposed some of the original material and commissioned new modules to form a series of 16 short, open-access, free-standing modules supporting the professional development of clinical teachers and postgraduate supervisors (London Deanery, 2009; Postgraduate Medical Education and Training Board, 2008).
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References ALENCAR, E.S., FLEITH, D.S. (2003). Criatividade: múltiplas perspectivas. 3ª ed., Brasília, Editora da Universidade de Brasília. FELDHUSEN, J.F. (1995). Creativity: a knowledge base, metacognitive skills, and personality factors. Journal of Creative Behavior, 29 (4): 255-268/ Behavior FERNANDES, M.S. (2000). A função do enfermeiro nos anos 90: réplica de um estudo Ribeirão Preto - SP SP. Dissertação de Mestrado apresentada à Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo. 134p JANOV, J. (1996). A organização inventiva: ousadia e dedicação no trabalho. Trad. Roberto Raposo. Rio de Janeiro, Ediouro, TORRE, S. (2005). Dialogando com a criatividade. Trad. Cristina Mendes Rodríguez. São Paulo, Madras, 2005 p. 21 e p. 25 TREVIZAN, M.A. (1978). Estudo das atividades dos enfermeiros-chefes de unidades de internação de um hospital - escola. Ribeirão Preto. Escola de Enfermagem de Ribeirão Preto - USP. 117p. Master`s thesis. TREVIZAN, M.A. (1988). Enfermagem Hospitalar: administração & burocracia. Brasília, Ed. UnB.
THE LONDON DEANERY E-LEARNING FOR CLINICAL TEACHERS
Judy McKimm and Tim Swanwick | London Deanery, United Kingdom Website: www.faculty.londondeanery.ac. uk/e-learning
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION DISTANCE LEARNING
Distance Education and Problem-Based Learning
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Why, when, and how should e-learning be used. Ideally, e-learning should support or at least not conflict with - the chosen educational model, which is Problem-based Learning (PBL) at Maastricht University. Different Ways of Supporting Learning specific knowledge and skills can be supported by digital resources or various sizes, e.g. virtual patients, computer-based training modules or even games. Large collections of them are available on the Internet in open or subscription-based repositories in the medical domain. Dedicated tools have been developed to support assessment and reflection in PBL, e.g. the use of portfolio, Computerized Case-based Testing, and the Manchester-Maastricht Test Service System to support workplace-based assessment during residency training (Govaerts, et al., 2009; Donkers et al., 2010). The Virtual Learning Environment (VLE) plays an important role in supporting communication and interaction between students and teachers. In the context of PBL, however, it is even more interesting to look at purposively using specific facilities to support and stimulate group work, ranging from group spaces and discussion fora to Web 2.0 tools. Blended Learning There is an increasing demand for distance learning, for example from international students who attend (part of) a master’s course from their own country. In principle, the participation of students from different backgrounds and levels of experience can enrich PBL. It can lead to more elaborate discussions and richer information. PBL distance courses vary in the way they use media or e-learning tools for synchronous and asynchronous communication. Some courses combine distance learning with a limited number of face-to-face meetings in order to enable students and teaching staff to get to know each other and to 16
provide skills training. This format is called blended learning. An example of blended learning - that is close to ‘traditional’ PBL is the master of Health Services Innovation (HSI) at Maastricht University (De Jong, 2009). The part-time version is offered as a blended learning course: students meet at least twice (at the beginning and at the end of a course). The tutorial groups are provided with web conferencing connections. The VLE of Maastricht University is used to distribute literature, exchange documents, and for discussion in a discussion forum. Recorded lectures are made available in the VLE as streaming video. Web conferencing is also used to enable distance students to attend lectures and presentations of their fellow students. (Dis)advantages A big advantage for students is, of course, that the amount of travelling is limited. They also appreciate that they can occasionally invite others to participate in discussions. This approach does, however, require technical support and some skills from both students and tutors. Moreover, all students have to be available at the same time. Students also reported problems with communication patterns: there was not enough time and there was less discussion because they had to wait until someone else had stopped talking. It is difficult to react spontaneously when you have to wait your turn. The reactions to the online lectures were similar easy to use, no traveling, and lectures could be replayed, but less optimal interaction. The reactions of students, tutors and lecturers illustrate that any kind of mediation inevitably changes the interaction and communication. The depth and quality of discussions in online PBL tutorial groups are currently analysed and compared to the depth and quality of discussions in face-to-face tutorial groups (De Jong and Verstegen, work in preparation).
A web conferencing tutorial group Other forms of online PBL have been tried out, e.g. combining synchronous and asynchronous discussion. To get more insight in concepts for on-line PBL, Maastricht University invests in implementing and evaluating different implementations over all Faculties. References DONKERS, J., VERSTEGEN, D.M.L., LENG, B. de, & JONG, N. de (2010). E-learning in Problem-Based Learning, in H. van Berkel, A. Scherpbier, H. Hillen, & C. van der Vleuten (Eds.) Lessons from ProblemBased Learning (Provisional title). UK: Oxford Press. GOVAERTS, M., DONKERS, J., BRACKEL, H., VERHOEVEN, B., VLEUTEN, C, van der, & DORNAN, T. (2009). Making sense of competency-based assessment in the workplace through the use of an e-portfolio. AMEE 2009, short communication. JONG, N. de & VERSTEGEN, D.M.L. (2009). A comparison of traditional face-toface problem-based learning (pbl) and online pbl tutorial groups in a public health masters programme at Maastricht University: Experiences of the students and the tutor. In N. Brouwer et al. (Eds.), Proceedings conference: Student Mobility and ICT: Dimensions of Transition. Maastricht: FEBA ERD Press. Daniëlle Verstegen, Nynke de Jong, Jeroen Donkers | Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands Email: d.verstegen@educ.unimaas.nl
Expanding the Scope and Quality of Learning for Healthy Communities
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References DANIEL, J., KANWAR, A., & UVALICTRUBMIC, S. (2008). Achieving Quality in Distance Education. Speech delivered at a meeting of private ODL institutions in Pune, India, 4 April. Available at www.col.org/resources/speeches/ 2008presentations/Pages/2008-04-04.aspx PRINGLE, I., ROSATO, M., & SIMBI, C. (2009). Community learning: Perspectives on the role of media in non-formal education with a case study from Mchinji District, Malawi. Commonwealth Education Partnerships, 2009/10. Commonwealth Secretariat: London.
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Following the idea of the ODL course team, in which lecturers work together with instructional designers, one of the main aims and challenges in developing non-for-
mal ODL is to foster collaboration among education, development and media/ICT groups to create educational content as well as providing learner support at a community level. There are increasingly large numbers of localised media centres which use information and communication technologies (ICT), from radio and television to computers, internet and mobile telephony. Working alongside participatory development projects and organisations that often have the expertise required to meet health and livelihood needs, community-oriented media and ICT centres offer opportunities to expand scope and improve quality.
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Key Considerations in ODL Although open and distance learning is best known in the context of formal education correspondence and distance education through universities leading to qualifica-
Participation and Collaboration Participation in decision-making about learning - across design, content-making and learner support - is essential in ensuring the relevance of programming to local needs, ownership and investment by local stakeholders, and ultimately their engagement in the learning process and action in terms of development goals. Key success factors for Phukusi la Moyo include the participatory nature of the women’s groups’ approach to health development, as well as the interactive approach taken by the programme developers and producers.
Talking on Phukusi la
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Support for the development of Phukusi la Moyo was provided through the Commonwealth of Learning’s Healthy Communities initiative, part of the organisation’s Livelihoods and Health sector, which aims to develop and operationalise models for non-formal open and distance learning (ODL). Phukusi la Moyo is a good example of how the principles of formal distance education can be successfully applied to non-formal learning.
tions - there is an increasingly important role for ODL practice in non-formal learning in areas such as health, life skills, and livelihoods. The core principles of ODL - openness, scalability, geographic reach, flexibility for learners, and cost-effectiveness - make it especially relevant in rural, remote and resource-poor areas. In areas like Mchinji in Malawi where infrastructure and services are limited, educational approaches that make use of suitable and available community networks, specialist knowledge and appropriate technologies are perhaps the only way that mass learning can take place. John Daniel, President of the Commonwealth of Learning (COL) and a leading global figure in ODL, has described formal open and distance learning in terms of a student sitting on a three-legged stool comprised of good study material, good student support and good logistics. Study materials are no use unless they reach the students (Daniels et al., 2008). In the context of non-formal ODL, which has a less structured relationship between education providers and learners, a fourth leg needs to be added to the stool, that of stakeholder participation.
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Every Tuesday more than 3,000 women in the rural Mchinji district of Malawi tune in for a 30-minute radio programme about maternal and child health called Phukusi la Moyo (Bag of Life). A collaborative effort of health, development and media groups that combines media content and face-toface interaction, the programme represents a unique way for a large and growing number of women to learn about and take charge of their health in an area with one of the highest maternal and child mortality rates in the world. The radio content of Phukusi la Moyo features a combination of stakeholders, primarily pregnant women and new mothers, speaking about their experience of pregnancy, childbirth, and antenatal care, alongside information from local health ‘experts’, interspersed with local music. The women listen to the programme in groups of 20-30 members, discussing the programme’s content and what related actions they can take. The origins of the programme lie with the women’s groups themselves. Through a district-wide representative structure the groups participated in designing the Phukusi la Moyo’s format; its simple, lifesaving messages, and its ongoing programming and operations.
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION ACCREDITATION AND QUALITY ASSESSMENT
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Continuous Assessment - Summative Assessment in Dental Colleges of Pakistan
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Continuous assessment initially used to give feedback to students and programme developers (Rushton, 2005), is becoming an integral part of summative assessment and assessment of achieving programme goals in institutions world-wide (Carswell et al., 1999). Continuous assessment is unique in that it provides a more complete picture of the progress of the students as well as the programme, when compared to end-of-year summative assessment which at best can only give a snap-shot of the competence of the students at the end of the course. At the University of Health Scienceâ&#x20AC;&#x2122;s (UHS) Baccalaureate of Dental Surgery programme, continuous assessment carries 10% weight in the end-of-year summative grading of the students. Over the last decade the province of Punjab Pakistan has seen private dental colleges surpass the public dental colleges in number and student strength. However, private schools are considered by some as nothing more than corporate machines (Hansen, 2005). Private institutions also lack adequate patient-student exposure (Kumar, 2004). Whereas each institution exercises its independent policy and strategies in calculating continuous assessment, all private and public dental students sit in a single standardised objective summative examination administered by UHS. In order to determine the extent to which the continuous assessment is a guide to summative assessment, awards of continuous assessment of private and public students were compared over a three year period from 2006-2009. These awards were also compared with the awards of theory and objectively structured performance/practical examination (OSPE) in all subjects using independent sample t-test in SPSS version 16 (p<0.05).
Dental colleges Results Overall, the public sector dental students scored higher marks in the theory (p< 0.01), OSPE (p<0.01) but not in internal assessment (p>0.05) components of the examination when compared to the private sector counterparts. When the awards were compared subject-wise it was identified that the private sector students scored higher continuous assessment awards, but scored less in the theory and OSPE components of all the non-clinical subjects and the difference was statistically significant (p<0.05). In the Basic Sciences subjects this trend was reversed and was again statistically significant. Conclusion It was observed consistently over a threeyear period that the private sector tends to award higher marks to their students in the continuous assessment component, which is institutionally controlled. However, their students did less well than the public sector students in the standardised uniform University controlled examinations. Therefore, in conclusion, continuous assessment is a poor guide to summative assessment in the absence of a single yardstick for calculating continuous assessment in all institutions.
References CARSWELL, F., PRIMAVESI, R., & WARD, P. (1987). Qualifying Exams for Medical Students: Are both major finals and continuous assessment necessary? Medical Teacher 9,1:83-90. HANSEN, M.N. (2005a). Private education and academic performance among medical students. Tidsskrift for den Norske Laegeforening, 25, 2216-8. KUMAR, S. (2004). Report highlights shortcomings in private medical schools in India. British Medical Journal, 10, 70. RUSHTON, A. (2005). Formative assessment: a key to deep learning? Medical Teacher 27,6:509-513. Junaid Sarfraz Khan | Controller of Examinations, Department of Examinations, University of Health Sciences, Pakistan Email: junaidsarfraz@hotmail.com
THE LIKE-MINDED WORKING TOGETHER
Once upon a Time in the West of Kenya… …there was a university with the mission to preserve, create, and disseminate knowledge and, at the same time, conserve and develop scientific, technological and cultural heritage through quality teaching and research; to create conducive work and learning environment; and to work with stakeholders for the betterment of society: Moi University was established in 1984 in Eldoret (www.mu.ac.ke).
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Geraldine van Kasteren | Project Manager MUNDO, the Netherlands Email: g.vankasteren@maastrichtuniversity.nl
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The challenge is now to gather data to prove that this new profession in Kenya contributes to the improvement of the national healthcare system. So far, the marriage between Maastricht University and Moi University has been a merry one. Hopefully, one will be able to say, “and they lived happily ever after…”.
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Moi University School of Medicine was determined to start the first Master in Medicine in the area of Family Medicine in Kenya. To be able to do so, the School sought for partners world-wide to enlighten them in Family Medicine. In 2005, the first students enrolled. Over the years many partners - including Maastricht University’s Faculty of Health, Medicine and Life Sciences which through MUNDO and with the Dutch Support Group (see www.whig.nl) - supported the master’s programme in Family Medicine by: • providing short- and long-term (senior) lecturers in Family Medicine from the Netherlands: Family Physicians with experience in developing countries, education and research; • coaching and conducting applied research;
Ministry of Health However, training very motivated medical doctors to become ‘Kenyan’ style Family Physicians was not enough. The Ministry of Health (MoH) needed to be convinced that this new specialisation would contribute to a more accessible and affordable healthcare system. Therefore, in 2007 a national team consisting of academic and ministerial staff developed a policy that was signed by the MoH in 2009. The commitment of the MoH was demonstrated by the fact that, for instance, in this academic year 2009/2010 all six students received a scholarship. The nine graduates from the first two groups in 2008 and 2009 are now working in the field in different corners of the country and at different health care facilities.
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MUNDO Maastricht University (through the Maastricht University Centre for International Cooperation in Academic Development, MUNDO, www.maastricht university.nl/web/Main/Misc/MUNDO.htm) was involved from the early days in developing a Problem–based Learning (PBL) curriculum, setting up learning facilities (lab, learning and resource centre, skills lab) and promoting the exchange of staff and students. In September 2002, a team with staff from both Moi and Maastricht Universities organised the Network Conference Sustaining Innovative Education, Health Services and Research against Declining Resources in Eldoret. About 350 participants from 34 different countries attended the Conference.
Technically, Family Physicians distinguish themselves from other physicians; they are ‘generalists’, have a ‘working knowledge’ of specialties, ensuring comprehensive and quality care in the facilities where they work. They are meant to complement each other, but work also outside their facilities as the clinical care leader within the District Health Management Team (DHMT).
• equipping selected hospitals with a basic laboratory, library, and computerfacilities with internet connection; and • granting scholarships to students.
M A R C H
In 1988, the School of Medicine was founded, which, at that time, was the second medical school in Kenya. The School admitted the first intake of medical students in 1990 and graduated the first cohort of doctors in 1997. The philosophy of the School entails training a health professional in the context of the community, in which he/she will later practice. It encourages the student to acquire the important skills of self-directed learning, problem-solving and effective communication. Moreover, the School emphasizes not only curative, hospital-based medicine, but also, through its community-oriented approach, prevention of diseases and promotion of good health.
Family Physicians The focus shifted to postgraduate training towards the end of the co-operation in undergraduate teaching supported by the Dutch Capacity Development Programme for Higher Education (1995-2004). It was felt there was a need for a new type of medical doctor who could provide competent clinical care to a wide range of patients by taking into account the patient’s physiological, psychological, socio-economic, cultural and spiritual dimensions within the context of their family and community. Such care would not be limited by the person’s age, gender, organ system or disease entity. Let’s call them Family Physicians.
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IMPROVING HEALTH INDIGENOUS HEALTH
Brighter Smiles for Aboriginal Children in Canada
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Health education seeks to establish knowledge and effective practices. Dental caries (tooth decay) is the most common infectious disease amongst children world-wide, and chronic periodontal disease (poor oral health) increases the risk of diabetes, heart disease, stroke and premature labour. Poor Oral Health When the Director of the training programme for children’s doctors at the University of British Columbia (UBC) learned that the remote Canadian First Nations community (Hartley Bay) wanted to improve the health of their children, he wondered what he could do to help. He took a small team to the community - which has about 300 residents, is accessible only by float plane or boat, and is more than 100 km from the nearest healthcare facilities - and met with the elders, the band council, and parents to find out what the most urgent problems were. A number of major problems were described; however, the one that looked possible to address in a relatively short time and with limited resources was the rampant tooth decay and poor oral health (aboriginal children and many in developing countries have two-three times higher rates of caries compared to other populations). Importantly, in addition to a direct effect, improving oral health would likely also have a positive impact on a wide range of health issues relevant to aboriginal populations, from self-esteem to long term cardiac and metabolic health. Health Promoting School After reviewing potential interventions the team returned and offered several potential solutions, including fluoridating the community water source, using traditional soothing methods (lullabies and rocking) instead of offering infants bottles of juice or milk, and initiating measures 20
to address dietary deficiencies and life style practices. The option the community chose was a school-based health education programme with daily ‘brush-ins’, bi-weekly fluoride rinse, and six-monthly topical fluoride application. This choice to use a ‘Health Promoting School’ model presented an opportunity for the UBC training programme to establish a symbiotic partnership with this remote First Nations community where there would be educational benefits for both parties. The community would learn from the schoolbased programme and contact with the UBC educators, and the UBC faculty and trainees would gain practical experience of aboriginal and remote community health issues during their stays in the community. Thus began the Brighter Smiles programme. Brush-ins Before the school-based programme began, an evaluation of the oral health status and practices of the children was conducted. All children in the community were enrolled (parents provided informed consent). The UBC trainees were taught about oral health, attended a dental clinic, and were given information on working with First Nations communities, and prepared culturally and age-appropriate educational materials. Teams of two residents with a supervisor visited the community for three days approximately every six to eight weeks. They began with schoolbased education sessions but were soon asked to hold well-child clinics. Thus the teams worked with the teachers, parents, health director, nurses, and the band council to maintain the programme, and they were soon asked to add other health education/promotion topics and activities. The teachers supervised daily ‘brush-ins’ at lunch time, included health topics in class, awarded prizes for participation, and maintained a wall of photographs of children who are caries free.
Aboriginal children at play in the community of Hartley Bay Evaluation After the programme had been in place for three years, another dentist checked the oral health of the children, and a significant improvement was found (fourfold reduction in caries, increased brushing, less ‘pop’ consumption, and reduced need for dental interventions). All children remained enrolled, and the community’s pride in their success and motivation of each other was very evident. Ongoing evaluation indicated that Brighter Smiles teams were always welcomed, and reports of their experience gave them greater insight and understanding of the health issues and challenges faced by their aboriginal patients. Many trainees described the programme as “their most educational rotation” or “a unique learning experience.” The confidence and mutual trust established through success with oral health enabled the community to ask for other health issues to be addressed; successful interventions included higher immunization rates, improved nutritional practices, and screening/education of all children for Type 2 diabetes. The value of the ‘Health Education Promoting School’ model is emphasized by the school’s central place in the success of Brighter Smiles. This model can promote a range of health initiatives; other aboriginal communities in Canada have embraced it, and a partnership between UBC and Makerere University in Uganda has recently translated the Brighter Smiles programme and this model to five communities in Uganda. Andrew Macnab | Professor of Paediatrics, University of British Columbia, Canada Email: amacnab@cw.bc.ca
HEALTH SERVICES
Quality Assessment of Health Services
Evaluating quality is different from evaluating outcome. The main difference is that quality evaluation usually measures the aspects of the process as well as the outcome. There are two reasons for measuring the aspect of processes: • Outcome alone is not a reliable means of quality. • Knowing the outcome alone rarely helps service providers to know what to change or keep constant, so as to improve quality.
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Jameel Saleh | Assistant Professor, Department of Community Medicine, Faculty of Medicine and Health Sciences, University of Aden, Yemen Email: jameel5200@yahoo.com
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It is worth mentioning that in order to assess the quality of healthcare services in public health institutions, the following aspects should be taken into consideration: • The patient’s satisfaction. • Knowledge of an attitude among healthcare providers regarding healthcare quality aspects. • Job satisfaction among healthcare providers. • To what extent the healthcare quality is reflected in the National Health Policy.
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According to Overateit, quality health services provide the range of services which meets the most health needs of the populations (including preventive services) in a safe and effective way without waste and high level of regulations. There are different aspects to the quality of a service, each of them needs standards which state what is to be expected: • Accessible: the service is nearby, and has convenient opening times. • Affordable: the service is not too costly
The goal of quality assessment in healthcare is continuous improvement of the quality of services provided to patients and population and the ways and means to provide these services. Those involved in patient work have to look after necessary preconditions for good quality work and evaluation of the quality of the work. Quality assessment is a means of promoting the quality of care by identifying cases of poor quality or of inappropriate carebased on preexisting criteria, providing feedback and undertaking interventions if necessary. Practices have three general goals when they interact with patients: • To provide quality healthcare (Quality Issues). • To make that care accessible (Accessible Issues). • To treat patients with courtesy and respect (Interpersonal Issues).
patient as an integral part of a family and of a community.
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The most commonly accepted definition of healthcare quality is: “The extent/degree to which the healthcare resources and activities correspond to specific standards which when applied are generally expected to: • increase the probability of desired outcomes, • decrease the probability of risks and undesired outcomes, • increase the efficient use of healthcare resources, and • increase the satisfaction of both customers and providers.”
to the patient in direct payment, and indirect travel costs, and avoids a loss of income whilst seeking the service. • Acceptable: the patients’ experience of treatment is acceptable to them, they are treated with respect and politeness, the treatment is not too painful, uncomfortable or difficult, and is culturally acceptable. • Effective: the service properly diagnoses and treats the patients’ problem, and does not have or put them at risk. • Efficient: the service makes use of its resources and does not waste them. • Lawful: the service follows laws and regulations for treated patients, applying personal and contracting suppliers.
M A R C H
In recent years, there has been a growing concern about the quality of healthcare in developing countries, including countries of the Eastern Mediterranean Region. In the 1970s and 1980s, the concern of the majority of the national health programmes in these countries mainly focused on the quantitative aspects of healthcare. In the 1990s, the need for improving the quality of healthcare began to surface and interest in quality care could be seen increasing progressively. This interest to improve the quality of healthcare has been enhanced by many other factors: • the rising cost of healthcare, • the improvement of the socio-economic conditions of the people and their increasing demands of the concepts of quality and quality assurance by healthcare providers.
It becomes obvious that in order to follow the global strategy Health For All, there is a need for a new type of doctor who can assess and improve the quality of care by responding to the patient’s needs with interrelated preventive, curative and rehabilitative services and by considering the 21
IMPROVING HEALTH CARE FOR THE ELDERLY
From Nursing Home Medicine to Elderly Care Medicine
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The Dutch healthcare system is still characterised by relatively sharp boundaries between community healthcare services, hospital services, and long-term care services. All three kinds of healthcare services have their own regulations and financing systems. Medical Care Axis Care for patients with chronic diseases and for the elderly disabled in the Netherlands also has a graduated structure: acute care in the hospital, chronic care at home by the home care services, and - where these agencies as well as low intensity community care residential facilities can no longer meet the care needs - in the nursing home. In line with this, the medical care is plotted along the following axis: the medical specialist (e.g. hospital geriatrician) in the hospital, the general practitioner (GP) in the community, and the nursing home physician in the nursing home. In most Western countries, medical care in nursing homes is provided by GPs or consulting specialists who attend patients in nursing homes intermittently. Earlier studies, e.g. in Great Britain, have shown that caring for older people in nursing homes places major demands on GPs and often does not fit easily into the logistics of general practice. This leads to extensive variations in homes’ policies and local GP services and raises serious questions about the levels of GP service and about equity among residents within homes, among homes, and between those in homes and in the community. Nursing Home Physician The specific characteristics of nursing home residents and their requirements for care have driven the need to develop a dedicated ‘nursing home physician’ (NHP) in the Netherlands, which is currently the only country in the world where medical 22
treatment for nursing home patients has attained independent status (since 1990) and moreover has become an official medical discipline.
Therefore, medical care in nursing homes is not a job that can be done fast and simply, neither by family medicine nor hospital medicine.
by many different consulting physicians. Moreover, in-house physicians contribute to building specific expertise in medical care for very frail and disabled elderly. A nursing home physician has specific expertise in: • the presentation and progression of physical and mental disorders in elderly people and in patients with chronic diseases, which at the same time lead to complex problems in providing adequate long-term care; • the general examination, treatment, and support of elderly patients and patients with chronic diseases, whose problems are associated with several disabilities; • the assessment of complex problems of care; • rehabilitation (often long-term, at a slower speed) aimed at discharge from the institute if possible; • long-term care and palliative care; • the care plan-directed method of working in a multidisciplinary setting and also in managing this type of care approach; and • the organisation of complex and combined care services, both in- and outside the institutions.
By appointing their own doctors, Dutch nursing homes can achieve logistic and organisational advantages contrary to the situation in which a nursing home is visited
Shared Care In the last decades, Dutch nursing homes have gradually developed into centres of expertise in chronic care for the elderly,
Nursing home patients show complex interactions among morbidity, co-morbidity, disabilities, and mental and social problems. In general, they use many drugs (polypharmacy) with a considerable risk for dangerous interactions. These patients, therefore, need more and longer medical consultations than people of the same age and gender who are residing in the community. Often, special attention also has to be paid to feeding problems, pressure ulcers, prevention of infections, and to performing prudent pharmacotherapy. Their problems require more continuity of medical care and also more proactive and preventive interventions. For a large group of nursing home patients, medical care requires a continuous search for the appropriate balance between cure and care, in which many ethical questions are involved.
with a knowledge base that is becoming more and more useful in the community. This is particularly important because the capacity of nursing home beds will soon be inadequate for the projected numbers of frail elderly people.
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Jos Schols | Department of General Practice (section nursing home medicine), MUMC+, Maastricht, the Netherlands Email: jos.schols@hag.unimaas.nl
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To become registered as an elderly care physician, a specific three-year residency training programme in (general) elderly care medicine has to be followed after graduating from medical school. This is contrary to the postgraduate training programme to become a hospital geriatrician (a specialty closely linked to internal medicine), which requires a five-year specialist training in the hospital. The structure of the three-year training programme in elderly care medicine has a similar structure as the three-year training programmes of family medicine (general practice medicine). Today, university training programmes have been established at the Dutch universities of Amsterdam (Free University), Nijmegen and Leiden.
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Elderly Care Physician Fitting in this trend, recently the original name ‘nursing home medicine’ has been changed officially in ‘elderly care medicine’ and the ‘nursing home physician’ has become an ‘elderly care physician’.
M A R C H
The latter fact reinforces the need to focus care where most elderly patients live (i.e. in the community), and encourages nursing homes also to develop an outreaching role. In the Netherlands today, nursing homes in general and NHPs in particular increasingly stress their contribution to communitybased care for the elderly by offering outreaching care and support, complementary to the community healthcare services at home. Even more, NHPs have in fact achieved a more dynamic role in the total medical axis of elderly care medicine and next to their institutional activities, they also perform activities in the hospital. In this way, they may support the work of the GP as well as of the hospital geriatrician. This additional service involves a variety of activities and in general includes support with regard to an adequate and integral disease-related as well as care-related patient assessment and the planning of proper treatment activities and continuing care services. In nursing home outreaching care services, the NHP mostly acts as a consultant for the GP or hospital specialist, who are both responsible for the patients involved. However, where GP or hospital specialist and NHP agree that the NHP takes over part or total treatment, this responsibility moves to the NHP. It will be clear that, as a consequence of the growing outreaching activities of nursing homes, the relationships with GPs, hospi-
tal specialists, community nurses, and others have become even more important for NHPs. Currently, in elderly care, we are gradually growing towards a model of ‘shared care’ in the community, aiming to provide (medical) care tailored to the patient’s individual needs and wishes.
THE SPECIFIC CHARACTERISTICS OF NURSING HOME RESIDENTS AND THEIR REQUIREMENTS FOR CARE HAVE DRIVEN THE NEED TO DEVELOP A DEDICATED ‘NURSING HOME PHYSICIAN’ IN THE NETHERLANDS, WHICH IS CURRENTLY THE ONLY COUNTRY IN THE WORLD WHERE MEDICAL TREATMENT FOR NURSING HOME PATIENTS HAS ATTAINED INDEPENDENT STATUS.
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The Dutch population is ageing and living increasingly longer. Although being old in itself is not an illness, growing older is associated with diseases and problems. These are nothing more than an accumulation of defects in our body. The truth is, however, that current medicine is not tailored to treating elderly patients. The fact that the majority of these patients has not one, but two or more diseases at the same time (multimorbidity) requires doctors to take a more integral approach to the problems. This means considering the patient as a whole before tinkering with just one of the diseases. Such an approach will require a turnabout in current medical treatment: take a holistic view first, then the specialist approach. This change means that not only geriatricians, but all doctors will have to become skilled in the treatment of elderly people. Although the diseases do not differ from those in young people, there are specific factors associated with advanced age which should be taken into consideration. An elderly body will react differently to medication and procedures. For example, the use of blood pressure-lowering drugs in elderly patients can lead to cognitive problems and there are also different factors to consider when deciding whether or not to treat a patient. An actual change in the current healthcare system will require all specialists to learn additional skills and be prepared to look beyond their own area of expertise. Furthermore, they will have to be prepared to hand over the treatment of certain patients to others. Such a change will necessitate a fundamental shift in the training policy for students and doctors. First, each student will have to become sufficiently well-read in all medical aspects of the ageing process. This cannot be achieved with simply one module on ageing or one on
geriatrics. The current undergraduate medicine course dedicates about three weeks to these subjects over the course of 6 years! Far more is necessary. First of all, we have to do away with the notion that being elderly equals being defunct. Yes, people do age but there is no hard correlation between age and health problems. There are many perfectly healthy men and women in their nineties and a great number of done-for patients in their sixties. Even the training programmes subscribe to the general, fixed belief that old-age is, by definition, accompanied by problems such as incontinence, depression and cardiovascular disease, and that these are part of being elderly. This too is incorrect. By breaking down this generic notion that ‘old equals defunct’, it will become possible to view the patient as a whole and to judiciously consider and treat all the problems together. Consequently, the stereotypical image of old age and the associated aversion will decline. This is Part One of the shift in thinking. Part Two of the shift involves our vision of care. The integral and holistic approach to treating the patient should be reintroduced. At present, there is very little sign of such an approach in either medical education or clinical practice. Each specialist is increasingly becoming a specialist in his or
her own, sometimes very small, field and leaves the rest of the body and the mind to other colleagues, without anyone taking responsibility for coordinating the treatment. Coordination and interdisciplinary communication are necessary, not something which doctors are generally good at. For this reason we call for patient-specific coordination of multimorbidity in the elderly. Ideally such a coordinating function should be held by the patient themselves (self-coordination), but often the patient is no longer capable of fulfilling this role due to physical and/or mental illness. We therefore call for relatives to take on this coordinating role (carer coordination), in close dialogue with the Family Physician who would fulfil the role of ‘personal physician’. To ensure self- and carer coordination is successful, there should also be a short line of communication between the Family Physician and the specialists in general, and between the specialists themselves. Back to basics: education. Professional healthcare training courses should (once again) train their students in communicating and collaborating with colleagues, and make it clear that the patient is the centre of the medical universe, even when elderly. This is no mean task given the highly individualistic fields in which many doctors have built their kingdoms and where patients seek their audience. Hans Meij, Rudi Westendorp | Leyden Academy on Vitality and Ageing (www.leydenacademy.nl www.leydenacademy.nl); Department of Gerontology and Geriatrics, Leiden University Medical Centre, the Netherlands Email: r.g.j.westendorp@lumc.nl
RURAL HEALTH
Taking Health Manpower to the Disadvantaged Poor Qualified doctors hesitate to practice in rural areas of Bangladesh, often because of lack of urban comfort and facilities. As a result, rural health centres with some indoor facilities remain vacant, despite regular placement of doctors employed by the Government. Patients with even easily treatable conditions remain ill. Many are unaware of the treatment for their diseases available in the country. Patients with mature removable cataract resulting in blindness accept the disability as incurable and continue to remain blind as a fait accompli.
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Treatment of diseases like cataract, hernia and other minor surgery will quickly make the Health Team concept popular.
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Benefits derived from the Health Team outweigh the cost. This concept should be applied in the poorer countries for the benefit of the poor living in rural areas deprived of healthcare facilities offered by the Government.
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The Government network of healthcare centres could never completely satisfy the healthcare needs of the rural population. Placements of specialists are often cancelled due to various circumstances, often personal or political. However, the Health Team model creates a pleasant and hopeful environment with a holiday-like atmosphere. Free consultation and medicine attract large numbers of poor patients who cannot afford either. This model is therefore a significant intervention that provides healthcare for the disadvantaged poor at a minimum cost.
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Various skin diseases are common among the rural people, especially among children, because of overcrowding and unhealthy living conditions. Dermatologists of the team can tackle these diseases easily and inexpensively with few drugs. People are informed that the specialist team shall be available free of cost. This
The response of the local people has been positive. Only a few people are unable to receive treatment, often those who are disabled or unable to move. Many patients, moreover, do not know whether or not they have treatable diseases. Examples include cataracts, anaemia, peptic ulcer with pyloric stenosis, hernias and tuberculosis.
lacking of modern amenities in rural life cannot easily be substituted. Ignorance of the people is difficult to eradicate without health education. The Health Team is a clear demonstration of what can be done, and by whom, in the absence of facilities for poor disadvantaged patients of all ages. The concept should therefore be well circulated and made available to the disadvantaged poor in rural areas. Financial support for transport and medicine may not be lacking if the Government takes initiative.
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Areas are selected where healthcare facilities are scarce and qualified specialists are not available. The Health Team, consisting of 20-30 qualified doctors representing various specialties, is taken to the designated area where the local people provide space for medical examination and treatment. If indicated, referral is made to a Central Hospital for further investigation and appropriate surgery, generally performed in the city.
announcement attracts a large number of people, especially in the city, where people are poor and cannot afford treatment. In fact they consider it as a unique opportunity or a boon for them.
M A R C H
The main objective of the University of Science & Technology Chittagong (USTC) Health Team is to help treat economically disadvantaged patients in rural areas of Bangladesh, by transporting qualified doctors and specialists to these areas as a team for a full day at a time (10.00 am to 5.00 pm), with a lunch break provided locally by a rich inhabitant, usually a community leader, Chairman of the Union Council or a businessman of standing with a desire to help the group for this sort of service.
Professor Islam examining a patient for prescription in a Health Camp in Banderban, an area with scarce PHC facilities
Nurul Islam | FRCP (Edin & London), Vice Chancellor, University of Science & Technology Chittagong (USTC), Bangladesh Email: ustcbd@bangla.net
The existing drawback of rural life with no electric power is difficult to overcome. The 25
IMPROVING HEALTH HEALTH RESEARCH
Only High Quality Research Can Influence Healthcare
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Preventive Treatment And that, according to Van Schayck, is exactly what Caphri is aiming to do. The official mission statement is that Caphri wants to be of direct influence on the norms and guidelines within healthcare through its high quality research in the realm of Public Health and Primary Care. Social impact is a first priority for Caphri with respect to all investments in education and research, which is aimed at improving and renewing the entire care chain, from prevention to aftercare and rehabilitation. All healthcare innovations are subsequently studied to determine their effectiveness. The importance of the choice for prevention in Public Health and Primary Care is self-evident, declares the Scientific Director. “The emphasis still lies on curative care and doctors are being trained to treat people who come to them with complaints, but preventive treatment saves far more lives than curative care. Caphri is acting on this.” Using several examples, Van Schayck is happy to discuss the positive effects of measures on the prevention of contagious diseases. He considers the annual flu vaccination programme for vulnerable groups one of the most costeffective measures taken in the health sector.
Health Profit Van Schayck is personally involved in various projects within Caphri, including the internationally recognised Stop Smoking campaign. “World-wide, one in two smokers is dying of a smoking-related disease. Many people try to stop smoking, but ultimately, 19 out of 20 smokers do not succeed. If you book even a small percentage of improvement there, huge health profit margins can be gained instantly.” The Scientific Director emphasizes this is just one example why Caphri is targeting early diagnostics and early treatment and establishing contact with carers outside the clinic. Caphri purposefully manifests itself in the field of care innovation and improved co-operation between primary and secondary care. “This position makes us unique, but also vulnerable,” says Van Schayck. Clinic managers and health insurers may be increasingly aware of the need for extramural care innovation, but high-tech innovations are still usually given precedence. “Even though from a cost-efficiency point of view, enormous improvements can be achieved in primary care, because it is dayto-day medicine that most patients are involved with.” Success In his capacity as Scientific Director, Van Schayck is angling for more investments in scientific research and education in the fields of Primary Care, Innovation of Care and Public Health. In that respect he is very pleased with how the institute has developed in such a short time. Caphri came into existence seven years ago after a merger between two distinct institutes and is performing considerably better than the separate institutes. In those seven years, Caphri has matured into a recognised centre of excellence.
The great success of the institute is shown once again in the fact that its scientific research is internationally frequently cited. Additionally, a relatively high number of students are obtaining their PhDs at Caphri every year; last year there were more than forty PhD graduates, two of whom graduated cum laude. Furthermore, Caphri is very persuasive in gaining subsidies: in the last years 12 European subsidies were obtained. In education, Caphri is responsible for eight master programmes, and the institute devotes itself to attracting excellent students. The Health Sciences Research Master, specifically for students who want to become researchers, scored 8.2 (out of 10) last year in the Dutch Elsevier magazine review, a mark not awarded to any other master’s programme. Ultimately, the academic successes contribute to achieving Caphri’s objective, Van Schayck concludes: “We want to improve the quality of healthcare by filling in the gaps that are preventing improvements in care.” Karin Burhenne | Journalist, the Netherlands Email Onno van Schayck: tanja.debruijn@maastrichtuniversity.nl
WOMEN’S HEALTH
Menstruation: Awareness and Perceptions in Adolescents and their Mothers Knowledge of changes of menarche (onset of menstruation) during adolescence influences girls’attitude, behaviour, and critical health issues. Parents believe and hope their daughters will learn about menstruation from friends, or at schools, which may not be true. For many girls the knowledge they obtain, formally or informally, from their mothers is very important for the girls’ wellbeing. However, mothers and daughters may not have any interaction on this topic. In addition myths, mysteries, and superstitions have enveloped facts about menstruation.
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Menstruation is still frequently perceived in a negative light, with little research conducted on healthy menstruation of ‘normal’ women (Houppert, 2000). In India, menstruation is considered a polluting factor among Hindus. In many places menstruating girls and women are considered untouchable. A majority of the girls had negative reactions to menarche, which might be a reflection of taboos and prejudices in society about menstruation. Such practices are unlikely to create a positive self image in girls. The lack of factual information, compounded by the prevalence of myths, means that girls’ practical needs related to managing menstruation are often not appreciated or appropriately addressed, like the provision of adequate sanitary protection (Shukla, 2005).
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References HOUPPERT, K. (2000). The curse: confronting the last taboo, menstruation. Vancouver: Douglas & McIntyre Publishing Group. SHUKLA, S. (2005). Working on menstruation with girls in Mumbai, India: Vacha Women’s Resource Centre. EQUALS, (15) p.5.
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Of 500 daughters: • only 170 (34%) knew about menstruation prior to menarche; • 300 (60%) were told after menarche;
Discussion Menarche, the landmark of reproductive preparation is a stressful event in a girl’s life. It is not always positively received; shame, fear, anxiety, or depressions are very common. Awareness about menstruation prior to menarche is low among rural girls. Mothers do not always impart knowledge to their daughters regarding menstruation. Girls should be properly informed about menstruation prior to menarche. They should be educated regarding the maintenance of hygiene, associated problems, and social issues. It is the primary responsibility of mothers to educate their daughters regarding menstruation, although schools also contribute knowledge. Hence, a proper interaction between mothers and daughters
is necessary. A majority of daughters reported that communication with their mothers was negative in language and tone, though.
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Observations Out of 500 mothers: • 173 (34.6%) checked whether their daughters were having menstruation every month and marked the menstruation date on a calendar; • 37 (6.8%) reported that their daughters were not permitted to enter the kitchen during menstruation; • 65 (13.%) girls and mothers had misbelieves, like not to worship God, visit temples, sleep on the ground on mats, have simple meals without spices, not to touch water and plants, and not to work in the fields.
Mother and daughter
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Settings and Methods Rural community-based study was conducted by the Medical Educational Health Care Institute in Central India. The objective was to learn whether mothers impart information to their daughters prior to menarche, keep track of their daughters’ menstruation, menstrual problems, social issues, and taboos associated with menstruation. A total sample of 500 mother-daughter pairs in villages where community-based maternal care is being provided, were interviewed.
• 30 (6%) had no knowledge about menstruation; • their overall sources of information were 153 mothers (30%), 50 grandmothers (10%), 65 sisters (13%), 34 aunts (6.8%), 110 friends (22%), 88 books (17.6%); • 167 (33.4%) girls used new cotton cloth/pad once daily, 77 (15.4 %) used new cloth twice daily, 256 (51.2%) used clean old cloth. Use of sanitary pads was not there because most girls were from poor families. Majority of the girls did use clean clothes; • 124 (24.8%) took a daily bath and properly cleaned the private parts, 376 (75.2%) took a bath without proper cleaning of private parts; • 308 (61.6%) had pain in the lower abdomen, 95 (19%) had backache and discomfort, 50 (10%) felt weakness, and 47 (9.4%) had other problems; • only 167 (33.4%) girls were permitted full diet; • 225 (45%) girls reported changes in lifestyle, like staying aloof, confined to houses, not going into the neighbourhood, and not mixing with other girls.
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IMPROVING HEALTH HEALTH AUTHORITIES
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Improving Perinatal and Maternal Health Needs Restructuring of the Healthcare System
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With 365 maternal deaths per 100,000 live births (Yemen Family Health Survey, 2005) Yemen has the highest maternal mortality ratio in the Middle East and North African region. Linked to this high level of maternal morbidity and mortality are economic, social, cultural and religious factors, compounded by poor access to services in rural areas and limited health infrastructure. Only 25% of eligible women receive comprehensive antenatal care and 12% receive post-natal care. Over 77% of deliveries take place at home, with the majority of women receiving care from untrained birth attendants. The neonatal mortality rate in Yemen is estimated at 44 per 1,000 live births (UNFPA, UNICEF, WHO Assessment, 2005) and accounts for almost half of the infant deaths. Services for neonatal emergency care provision were reported as virtually non-existent. Yemen has witnessed a large and fast growing population over the past decades with a fertility rate peak at 7.7 in 1992 which has now declined to 6.2. The contraceptive prevalence rate of modern methods is 13.4 (PAPFAM, 2005). The determinants of high fertility rate and associated population growth require socio-economic development concomitant with investment in health sector strengthening. What does the Government do? Governmentâ&#x20AC;&#x2122;s spending on health services is limited to a current investment of on average 4% per annum. A substantial part of the population refers to the private sector (private hospitals or clinics/doctors, pharmacies) to obtain reproductive health and other services. This results in high outof-pocket expenditure for health, reported to be 57% in selected governates (ILO Assessment of Poverty in 3 governorates in Yemen, 2007). This inordinate burden of
cost on already poor households exacerbates their poverty and health status. As seen in above indicators, many of the health problems in Yemen seem to be caused by a lack of public health intervention. Fifth-year students of the medical college of Hadhramout University have a four-week primary healthcare block in which they should be targeting the community by addressing reproductive health and primary healthcare for women (antenatal care, natal care, post-natal care and family planning) for two weeks; school health for one week; and health education for one week. Increasing health education targeting mothers would also impact the paediatric population. Health education could increase hygiene awareness and healthy habits and promote vaccination coverage for preventable diseases like measles and polio. How should the Government intervene? Improving perinatal and maternal health requires a restructuring of the healthcare system, a lengthy and difficult process. If the general health of the Yemeni is to be improved, interventions must aim at the basic level, to prevent diseases before they occur and to increase the level of health awareness among all groups in the Yemeni population. References Yemen Family Health Survey (2005). UNFPA, UNICEF, WHO Assessment (2005). PAPFAM (2005). International Labour Organization. Assessment of Poverty in 3 governorates in Yemen (2007). Ahlam Saleh Bin Briek | Assistant Professor in Community Medicine, Hadhramout University, Yemen E-mail: ahlambinbriek@yahoo.com
IF THE GENERAL HEALTH OF THE YEMENI IS TO BE IMPROVED, INTERVENTIONS MUST AIM AT THE BASIC LEVEL, TO PREVENT DISEASES BEFORE THEY OCCUR AND TO INCREASE THE LEVEL OF HEALTH AWARENESS AMONG ALL GROUPS IN THE YEMENI POPULATION.
What Would I Change if I Were Minister of Health...?
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It will be interesting over the next decades to watch the effects of my country’s membership of the European Union (EU) on health policy in the Netherlands. In fact, international comments on the established procedure for euthanasia in the Netherlands also came from other EU countries and therefore could not be neglected. If ever again I would be invited to write this column I should be challenged to take the position of member of the European Commission with the portfolio Health and Consumer policy...
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Gerard Majoor | Coordinator Internationalisation, Medical programme, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands Email: g.majoor@oifdg.unimaas.nl
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No doubt due to the liberal climate in the Netherlands, some pressing issues have come up pertaining to problems at the very beginning of life and close to the end. The debate with respect to premature babies is in some way related to the choice
tance of the procedure as earlier established and to attempt to reinstall its proper functioning, at least in the Netherlands.
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My alternative would be to capitalise on prevention of disease and thus on strengthening public health services. For example, recently a new health threat has emerged: obesity, which is in particular strongly on the rise in children. I am confident that health educators working together with youth workers could come up with strategies and plans to fight this trend - and as the Minister of Health I would be ready to invest.
At the other end of the lifeline we may find individuals who, due to unbearable somatic and/or psychological suffering, consistently express their preference to quit life. In the Netherlands a doctor - usually the individual’s family physician - has the possibility to respond to such wish of the patient. However, this physician can only act after consultation with a colleague who must give a second opinion on the case. If both physicians agree that the individual suffers unbearably and lacks any positive perspective, the first physician may assist the individual in committing suicide by providing the necessary drugs. This policy has been quite controversial, not the least because of comments from abroad in which Dutch doctors were accused of substituting God’s decisions and to act as murderers rather than physicians. As a consequence, public prosecutors have been scrutinising cases more closely, which in turn has made physicians reluctant to respond to pleas from suffering individuals. As the Minister of Health I would try to build (international) accep-
Dr. Gerard Majoor
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I know if I were the Minister of Health, my major worry would be the ever-increasing costs of the public healthcare system. Recent ministers have tried to limit those expenses by introducing competition through market mechanisms and by allowing to some extent privatisation of the healthcare system. Knowing the example from the US, I would certainly not continue along that road and I would even reduce possibilities already created by my predecessors.
I made above. Technological advances have increased chances to keep very premature babies alive. The ‘limit’ to attempt rescue of premature babies has been pushed back further and further, from 26 weeks of gestation to perhaps 22 weeks. And although the number of cases may be quite limited, such attempts at rescue bring important consequences in terms of needs for costly technologies and personnel and, most importantly, the chance of survival of a newborn with a life-long need for specialised care. In my view this is an example of an issue where policy cannot be left solely to technologists. As the Minister of Health, in this case I would set the limit on the safe side - to prevent extraordinary spending on technology and super specialised care for a small number of cases.
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Before I kick off, let me admit that my home country the Netherlands has a quite satisfactory healthcare system. There is a mandatory health insurance system with a premium for which - for those without income - can be paid by the national social security system. This health insurance covers all basic needs to treat disease and to maintain health. Everybody in the Netherlands has access to a family physician who can be seen for free and who will pay a home visit if indicated. If referral is needed there are always good tertiary hospitals nearby and advanced care may be provided in one of the country’s eight academic teaching hospitals.
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IMPROVING HEALTH HEALTH PROMOTION
Married Homosexuals; From Denial to Realism
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There are higher rates of HIV infections because of men who have sex with men (MSM) transmitting the disease to their (future) wives, thus having an impact upon women’s reproductive and sexual health. Most men who have sex with men are youth and are an incredibly diverse group, in terms of both their economic circumstances and sexual attitudes and behaviour. They may be more economically disadvantaged than older youth, and often more subject to peer pressure. They are living under socio-cultural-religious contexts, ethnicity, income status, families and discrimination/stigmatisation and social exclusion. Therefore, most of them are either married or will become married. Vulnerable Poverty also compounds the vulnerability of young people to HIV infection. Youth who are poor have an increased risk of infection because they are more likely to be in poor general health and to leave sexually transmitted diseases untreated; they yield to pressure to exchange money or goods for sex; migrate to find work, and thus increase their chances of risky sex; and lack hope for the future. Physical, psychological, and social attributes of adolescence also make young people particularly vulnerable to HIV and other STI. The HIV infection rates among MSMs are high and their behaviours compound the vulnerability of other young adults to HIV infection. National Health Programme? On one hand, Government’s different strategies for a national health programme in terms of sexual health and HIV/AIDS might promote a negative impact among such vulnerable population in the Asia region. On the other hand, due to sociocultural-religious reasons, those behav30
iours are to a large extent invisible, often difficult to access in terms of standard sexual health promotion framework of the nations. Political commitment and appropriate legislative, budgetary, judicial, promotional and other measures for safeguarding individual’s human rights in the context of HIV/AIDS and sexuality is not sufficient. A standard sexual health promotion framework, to change socio-cultural-religious contexts of male/female sexual behaviours is inappropriate. Dr. Lekh Nath Bhandari The youth health framework based on National Reproductive Health 1998, current national planning, concerned world treaties, strategies for sexual health and HIV/AIDS are ineffective to include them in future programmes. There are neither effective informative treatment programmes, nor unity between studies/investigations, nor formal statistics of those sexual minorities. The most vital information, education and counselling are driven underground and statistically unidentified because MSMs go to private hospitals rather than to governmental hospitals, as they look for discreet, proper treatment. AIDS Orphans and Widows Men and women are at not only at greater risk of being infected, but HIV/AIDS also affects man and women as caregivers in the family. The lost productivity of a key demographic group - the young - is compounded by increased healthcare costs and its likely impact on the already fragile healthcare services. The growing number of AIDS orphans and widows may create serious strain on social safety net programmes. It mainly strikes adolescents, young adults, and those in early middle age, killing the very people on whom society relies for production and reproduction.
Government Political and legal forces are the first issues. Government’s high level of commitment and sustained efforts require dynamic leadership and political foresight in order to hasten the transition from denial to realism, from complacency to action and to mobilisation of all resources. This approach can prevent the spread of HIV and minimise its future impact by including MSMs in national health framework. It is important to change the political system and philosophies, change the role of Government from doer to facilitator, and formulate new laws, regulations and deregulations. Also crucial to improving the problem is participatory training for the law enforcement group and socio-cultural forces such as delayed concept of marriage and sex and adoption. Lekh Nath Bhandari | National Vigilance Centre, Nepal Email: banjais@hotmail.com
COMMUNITY ACTION
Health Festival: Health Promotion and Education for the Local Community
Overall it was felt that the festival was a very positive experience for the local community, for the students, for the staff and for the Faculty as a whole.
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Brigitte Krings-Ney, Elis Sabino, Moises Maquina, Josefo Ferro | Universidade Católica de Moçambique, Faculdade de Ciências de Saúde, Departamento de Saúde Familiar e Comunitária, Mozambique Email: brigitte.neykrings@gmail.com
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Health Markets The first health festival in 2008 was a great success. The official opening was done jointly by the Governor and the Bishop of Beira. About 500 people visited this event and we got very stimulating feedback. Not only people of the local community, but also students from secondary schools and nursing schools were curious to get to know the Faculty. Because of its success, a second, equally successful festival was organised in October 2009. It seems likely to become an annual event.
The festivals were well supported by local organisations but in a country like Mozambique with limited resources it is difficult to organise such an event without outside support and we were fortunate to receive generous help from the international partners of UCM.
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The festival was done in close cooperation with the Provincial Directorate of Health, who provided a voluntary HIV counselling and testing centre during the festival. A local theatre group was invited; they performed small drama pieces about cholera prevention and multiple concurrent partnerships. During the festival, the University Clinic was freely accessible.
To promote health in fields such as nutrition and oral health, students offered services like measuring blood pressure, body mass index and urine control for diabetes
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Starting in their first year, students come into contact with the local community in the neighbourhood of the Faculty. On a regular basis, each student visits three families in the township of Inhamudima. It is one of the poorest suburbs in the city of Beira with approximately 20.000 inhabitants (5.500 families). There is a high rate of analphabetism, especially among the adult generation. The majority has no regular income. Most are unemployed; to survive they trade local products such as vegetables, fruits and fish.
More Health for our Community The fourth-year students were actively involved in planning and organising the health festival. The slogan More health for our community was chosen in a democratic process, a logo was designed by students. Groups of three students each chose a topic to present at the health festival. To promote health in fields such as nutrition and oral health, they gave demonstrations of healthy diets, water treatment and mosquito bed nets and offered services like measuring blood pressure, body mass index and urine control for diabetes.
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Training in Family and Community Health UCM medical students in Beira get a fouryear training in Family and Community Health.
In their four years of training, students get to know ‘their families’ quite well, doing health promotion and education, accompanying families during periods of illness. The health festival was an opportunity to invite the families and to greet them.
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The idea was born at a communication workshop: the Faculty of Health Sciences at the Catholic University in Beira, Mozambique (UCM) would organise a health festival in 2008. Different objectives led to the idea of organising this event: • opening the medical school to the public, especially to the local community, • involving fourth-year students in the organisation, • demonstrating the skills students developed during their studies, • completing activities in the Family and Community Health programme, and • collaborating with the Provincial Health Directorate.
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STUDENTS’ COLUMN STUDENTS’ SPEAKERS CORNER
The Big Five
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How do students from all over the world perceive the educational programme at their Faculty, or the educational system in their country? How do they see the future, for their nation and for themselves? And what changes would they make, if they had the chance? We wanted to know. Therefore, we have asked a student five questions.
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This interview was conducted with Areej Mahjoub (21), 3rd-year medical student at Maastricht University, the Netherlands. She is originally from Saudi Arabia, and has come with a group of fellow country students to Maastricht to follow the International Track in Medicine. 1. What is your opinion about innovative educational formats like Problembased Learning (PBL) (or the education format that Maastricht’s Faculty uses)? PBL is a very intelligent method to teach the students simply how to study. It forces, encourages and excites the students for self-studying through presenting problems or cases related to real life. Another advantage is that it makes the student independent in searching the information and does not require the tutor’s full time explanation. 2. What part of your study was the most educational to you, what was the best learning experience in your studies (e.g. internship, research or being ill yourself)? The most educational parts for me were the GP visits, which are carried out in the third year medical programme. In these visits, I had the chance to meet all kinds of patients with different diseases, which I can relate to my theory. I also had the chance to improve my differential diagnosis seeking, and my physical examination
while observing the performance of the physician. 3. What would you change if you were Dean of the Maastricht Faculty? Or on a national level if you were Minister of Education in your country (Saudi Arabia and/or the Netherlands)? If I were the Minister of Education in Saudi Arabia, I would change the content of all the subjects of all studying groups (elementary-university); I would include learning foreign languages at all school levels; I would apply a more interactive teaching system at schools; I would apply PBL at all universities. If I were the Dean of the Maastricht Faculty of Health, Medicine and Life Sciences, I would choose English as a studying language; when the study programme is extremely difficult, give the students a little push (by upgrading their grades), so that they can continue their education; add more opportunities for exchange programmes; create a separate office to aid foreign students with everything; refuse any kind of positive discrimination from faculty employers against the students. 4. Imagine if you were to choose: a practice in a town or in a rural area. What would you choose and why? Say in Africa, I would choose to practice in a rural area because even though the facilities are minimal, I believe that they are in a higher need for physicians and healthcare workers. Thus, I can be of much help and aid when practicing in a rural area. 5. Do you ever get in touch with the community? Unfortunately not, because in Saudi Arabia, voluntary work is limited and narrowed to specific sections (healthcare, environment and agriculture, festival activities, orphans
Ms. Areej Mahjoub
and poor people, young spirit). Most activities require either full-time work or just concentrate to a single event. Thus, I have decided not to participate in such actions. In the Netherlands, I spent most of my time studying, thus, I have no time for community work. Another reason is the language barrier, because my Dutch is not fluent, therefore it is difficult to work as a community worker.
IF I WERE THE MINISTER OF EDUCATION IN SAUDI ARABIA, I WOULD CHANGE THE CONTENT OF ALL THE SUBJECTS OF ALL STUDYING GROUPS (ELEMENTARY-UNIVERSITY).
Network: TUFH Alumni Jelle van den Ameele, Belgium
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Jelle van den Ameele | PhD-student, IRIBHM, Université Libre de Bruxelles; Resident in neurology at Ghent University Hospital, Belgium Email: jelle.vandenameele@ugent.be
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Looking back on these experiences, I am proud to be a ‘Network: TUFH alumnus’ and really grateful to all the people who initiated me into the ideas and vision The Network: TUFH stands for.
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Now, four years later, I must admit I did not follow the ‘canonical’ pathway for an enthusiastic Network: TUFH disciple. Two years ago, I started my formation as a resident in neurology and last year a most ardent desire came true when I started a PhD in developmental and stem cell biology studying embryonic development of the cerebral cortex. Nevertheless, I still feel a ‘Network: TUFH alumnus’. Indeed, I believe a great strength of this network is its openness to everyone, no matter what their background or professional activities
Taking part in this network is still influential on my daily way of living and working. I must admit this currently results in a permanent ‘subcutaneous’ doubt and reflection about the social relevance of my work. However, until now I see this as a desirable consequence, helping me to ask myself relevant questions and guiding me to take the right decisions.
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One year later, when the Conference was held in Ghent, I enjoyed the privilege to be a student member of the organisational committee. Together with many friends
From these experiences we founded the Stufh (Students towards unity for health, see Network: TUFH Newsletter June 2009): a new student organisation at our medical school to bring medical and other students in contact with the less fortunate in our own society through voluntary work, in order to stimulate social consciousness.
are. It rather unites people and institutions with a similar view on how they perform their profession and on how their activities stand amidst society.
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However, it had never occurred to me that these modest personal initiatives, stimulated by some teachers, as well as the many steps towards the implementation of a new medical curriculum, actually happened within the framework of a vision represented by The Network: TUFH. An unpretentious but significant vision, essentially based on values my parents already taught me.
and fellow students we were able to experience the organisation of the Conference from close by, participate actively, and provide as much input as possible in order to make the Conference really student-oriented (see Network: TUFH Newsletter December 2006). The way we, as young students, were involved, taught, listened to and respected by other ‘old’ and experienced participants is something that will always stick in my memory.
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During the few days I spent among all the inspiring Network: TUFH members and sympathizers, I was confronted with and immersed in the founding ideas that unite all these people. As a student I already had been involved in community diagnosis (see Network: TUFH Newsletter June 2004), set up a ‘health education’ project together with some friends in a nearby school in the city of Ghent, and being a student representative I was intensively involved in the curriculum reform our medical school went through.
Dr. Jelle van den Ameele M A R C H
More than four years ago, I landed together with seven other young medical students on the airport of Ho Chi Minh City in Vietnam to attend the 2005 Conference of The Network: TUFH. We were well prepared, brought posters with us to present projects we were proud of, and were eager to spend two weeks in Vietnam. But on the other hand, we were somewhat anxious. We never attended a big international conference before, felt very young and student-like, and coming from a medical curriculum in full transition where much debate was going on, we were unsure about what ‘community- and problem-oriented’ really meant and whether they were unequivocally good qualities of a curriculum.
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MEMBER AND ORGANISATIONAL NEWS MESSAGES FROM THE EXECUTIVE COMMITTEE
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General Meeting 2010 Nepal
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The Network: TUFH will organise its annual international Conference this year in Kathmandu, Nepal. In the past, The Network: TUFH organised, in conjunction with the conference, the Biennial General Meeting (GM) for all Network: TUFH members and other interested in our organisation. In Nepal, the next GM will have a different agenda than in previous years. Due to the transfer of the secretariat from Maastricht University in the Netherlands to Ghent University in Belgium, the legal body of The Network: TUFH will need to change. The current legal status of The Network: TUFH is that of a Dutch association, registered under the original name ‘The Network of CommunityOriented Educational Institutions for Health Sciences’, and with legal statutes dating from 1985. Unfortunately, facilitating an international network, submitted to Dutch Law but based on Belgian territory is - for administrative and juridical reasons - not feasible. Therefore there is a need to establish a new association for The Network: TUFH, under Belgian Law (Title III of the Belgian Law of June 27th 1921 on the Non-Profit Associations, International Non-Profit Associations and Foundations). What is New? Under Belgian Law, a so-called ‘international non-profit association’ will be established with the name ‘The Network: Towards Unity for Health’. This association will need to have a general assembly and an administrative council. The General Assembly of the new international association will consist of all members of the current General Meeting; to be specific all Individual, Associate, Full and Honorary members of The Network: Towards Unity for Health. Also the current EC will maintain its functions and tasks, but within the new legal structure of a Belgian International Non-Profit Association.
In Practice In Nepal, there will be two sessions of the GM. The first one is scheduled on Sunday November 14 at 17.00 hrs and the second session of the GM is scheduled on Wednesday November 17 at 13.30 hrs. During the first session of the GM, the ‘Statutes’ and ‘Rules and Regulations’ of the new association will be presented to you. These statutes and internal rules will be based on the present Constitution and By-Laws of The Network: TUFH, but updated and adapted to Belgian Law. After the presentation, all Full and Associate Members of The Network: TUFH, as stated in the present Constitution, will be asked to vote on the dissolution of the old association. For such a dissolution vote, the Constitution requires a quorum of 50% of all Full and Associate Members either legally represented at the GM or in a postal ballot. A two/thirds majority will be required to dissolve the old association. After the dissolution, The Network: TUFH will continue under its new legal body. The first GM of this new international association will be convened. At this session, the organisation will be composed according to the new statutes, after these have been approved by the GM. Other items on the agenda of the GM will be discussed and voted on.
once every two years at the GM to a person, organisation, institution or group for outstanding contributions to The Network: TUFH. Last time credit went to Dr. Khalifa Elmusharaf from Sudan and in 2005 the TFA was granted to Dr. Vibhore Prasad from the UK. This year, at the GM in Nepal, the third TFA will be handed out. The following criteria for eligibility of the nominee are: • At least for the last four years the nominee has participated in Network: TUFH activities by being a leader and by giving outstanding contributions. • The nominee has been relevant to the advancement of health in his/her/its community, country or region in any of the different areas that The Network: TUFH considers crucial (education, professional societies, health delivery, health policy, and community work). • The nominee should be an ethical human being, organisation, institution or group who/which has had lasting influence on the domain defined under item two.
During the coming months, the new Office of The Network: TUFH will put all available information on the GM online. Please visit www.the-networktufh.org/ conferences/generalmeetings.asp for more information.
The TFA consists of a certificate, an economy ticket to travel to a future Network: TUFH Conference (to be used within three years from the year of award), space in the Newsletter and a world-wide announcement through the Network: TUFH digital Alert. Nominations for the TFA should be accompanied by a letter of support (between 300-350 words) and must be received at the Network: TUFH Office in Ghent, Belgium no later than September 15, 2010.
Nominations for Tamas Fülöp Award At the occasion of the Network: TUFH’s 25th anniversary in 2004, the Executive Committee established the Tamas Fülöp Award (TFA). The TFA is being handed out
Honorary Membership Candidates At the 2010 GM decisions to award Honorary membership to individuals who have rendered exceptional service to The Network: TUFH shall be taken.
We would like to draw your attention to the procedure of proposing candidates for Honorary membership of The Network: TUFH. Any Network: TUFH member can suggest candidates for Honorary membership of The Network: TUFH by writing to the Network: TUFH Office in Ghent, Belgium no later than September 15, 2010. With your proposal we would like to receive a letter (between 300 -350 words) explaining your reasons to propose for Honorary Membership.
Dr. Bjorn Bergdahl
Professor Bergdahl graduated with a degree in medicine from Lund University and was recruited to the internal medicine clinic at the University Hospital of Linköping in 1968. After completing his postgraduate studies, he began to teach medical students in 1977. This was the start of a life-long commitment to medical education. He was the first clinical teacher in Sweden ever to be promoted to the position professor on mainly educational merits. The second problem-based medical curriculum in Europe, after Maastricht, started in Linköping in 1986. Professor Bergdahl was actively involved in creating the new medical programme in Linköping and used all his dedication and perseverance to make sure that the visions became reality.
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His enthusiasm, dedication and the joy he took in his work were sometimes almost overwhelming and until the day before his death he was actively working on an article about his latest project EDIT: web-based PBL scenarios.
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Professor Bergdahl’s dedication to teaching and learning also included his clinical work in cardiology, e.g. patient education in PBL tutorial groups. He was a true visionary who actively supported and involved both colleagues and students. He created a learning community in the Faculty and was a mentor for many young teachers and doctors.
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Problem-based and interprofessional learning, together with a focus on professional development, communication skills and community orientation were the principles on which the new curriculum was based. Professor Bergdahl was part of it all, working hard to implement innovative content and student-centred educational approaches, not just in the medical programme but in all the Faculty’s different health care programmes. He kept on working to promote quality and renewal of teaching and learning until his death. In 2007, the medical programme in Linköping was awarded the distinction ‘Excellent quality in higher education’ by the Swedish Agency for Higher Education.
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Honorary members are exempted from the payment of membership fees and enjoy all common assets of membership. Honorary members have no voting rights.
Professor Björn Bergdahl, M.D., one of the founders of the Faculty of Health Sciences (FHS) at Linköping University, passed away in March 2009. He left us all in grief and disbelief. How would we manage without him?
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For your convenience we have printed below the relevant quotes of the Network: TUFH By-laws concerning Honorary membership: Article 9 1. Individuals who have rendered exceptional service to The Network: TUFH can be granted Honorary membership. 2. Members can propose candidates for Honorary membership to the Executive Committee. 3. Proposal for the granting of Honorary membership shall be put forward before the General Meeting by the Executive Committee. A decision to award an Honorary membership shall be taken at the General Meeting.
A PIONEER IN SWEDISH MEDICAL EDUCATION In Memoriam: Professor Björn Bergdahl, M.D.
We miss him! Mats Hammar | Dean Faculty of Health Sciences, Linköping University, Sweden
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MEMBER AND ORGANISATIONAL NEWS MESSAGES FROM THE EXECUTIVE COMMITTEE
EC Intelligence: Francisco Lamus
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To learn more about the personal beliefs, motivation and goals of our EC Members, we have invited Francisco Lamus to share his thoughts with us.
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While growing to become a full-time associate professor in Family and Community Medicine at the School of Medicine, Universidad de La Sabana, Colombia, I have progressively understood the importance of leadership and collaboration skills as key factors that individuals must pursue, in order to bring together the complex mechanisms that from within a society can initiate processes that may contribute to improve the health and well being of population groups. The Network: TUFH has been a road to travel upon in these issues related to my personal experience. This personal process has taken me from my initial formation as a clinical paediatrician with social interests, to a full-time dedicated citizen, interested in moving forward issues as community health, public and primary health. This through the display of academic, research and service activities. The Network: TUFH provided light when the need to connect personal and collective interests had arisen. More than a change, my transformation has been the product of gaining clarity about what health, well-being, sustainable development and progress need from health professionals. My commitment to this vision of what health should look like has also made me realise a crude paradox: regardless of the fact that issues like primary health, public health, social medicine, family and community medicine, a ‘healthy and even start of life’ are more than reasonable and evidence-based priorities for population groups, it is equally evident that there is a gap that keeps this collective endeavours from moving forward to the top of the agendas of wider
population groups, especially of new generations. The Network: TUFH has provided a rich array of tools, methodologies, concepts and most of all, a world-wide weave of human and social capital also trying to close the gap. Improving the didactic, pedagogic, communication and leadership skills in our new health professionals certainly is the best way to try and move forward in what I consider should be the contribution of organisations like The Network: TUFH, to make a difference in achieving a better health for all. Acknowledging that the core of my professional life has become the fact of being an educator of future health professionals, I have to recognise that I have an important track to walk regarding the improvement, of my day-to-day practice as a health professions educator. Developing the sense of ownership and belonging to the greater ideals that The Network: TUFH represents, has allowed me to explore ways that have unveiled conductivity approaches to health and health education, allowing them to evolve to constructivist and most recently, ‘connectivist’ alternatives of how complex issues of society like health and health education could be handled in more inclusive democratic ways. My commitment with The Network: TUFH follows the track of what I have progressively received since my first encounter with this unique expression of human organisation. Since then, I can look back and watch the track of a personal activist for the rights of the maternal and child populations, an advocate for effective public health policies through a more than ever needed primary health approach, and an explorer in ways to improve the teaching of public and primary health competencies in health professions.
Dr. Francisco Lamus As the acting Latin-American representative to the EC, I acknowledge the new phase of development that the organisation faces. I join the expression of gratitude from all around the globe towards Maastricht University and the team of pioneers that have made this organisation a living organism. I am also certain that ‘now more than ever’ the mission and vision of The Network: TUFH have space to influence world-wide agendas in health and health education policies, programmes and projects. It is through the commitment and action of its constituents that the legacy of Maastricht - and now the challenge of Ghent University - can be taken deep into essential structures of human organisations like health and health education, for this new millennium. It is not an easy challenge but certainly it is worth to live the adventure of walking the walk to make it happen. Francisco Lamus | Member The Network: TUFH EC; Associate Professor, Chief of the Family and Community Medicine Area, Faculty of Medicine, Universidad de La Sabana, Colombia Email: francisco.lamus@unisabana.edu.co
TASKFORCES
Women and Health Taskforce: 2009 Successes
The WHTF looks forward to the impact of the Third Edition WHLP on global communities. The extensive time and effort that taskforce members give to the WHLP, places the WHTF in a promising position for 2010. After an extremely successful 2009, we look forward to working together in the future and welcoming new members into the taskforce. We hope to see everyone in Nepal at the 2010 Network: TUFH Conference where we will release the third Edition of the WHLP.
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For more information on the WHTF and WHLP please see the following: http://bit.ly/85XSIU
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MOVING ON: CHANGES IN INSTITUTIONAL LEADERSHIP The Secretariat received information about changes in leadership with the following Network: TUFH members. We have listed the names of the former and new (Vice-) Deans/ Directors for you: • Dr. Nelson Sewankambo, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda has been replaced by Dr. Stephen Kijjambu, dean@chs.mak.ac.ug • Dr. Fabian Esamai, School of Medicine, Moi University, Eldoret, Kenya has been replaced by Dr. Paul Ayuo, deanmedicine@mu.ac.ke
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Additionally, the conference showcased the announcement for the 2009 minigrant recipients. These grants provide an excellent opportunity for taskforce members to further promote the WHLP directly within their communities. Four members outlined a clear, effective vision for how to implement the WHLP learning modules, and have thus each been awarded a minigrant, ranging from $1,000 to $3000. The 2009 Women and Health Taskforce Minigrant projects are: • Hester Julie, of the University of the Western Cape, South Africa. She will be making use of her grant funds to increase youth awareness surrounding gender violence. • Todd Maja of Tshwane University of Technology, South Africa, has been awarded a mini-grant to further expand the work she began in 2008 with the WHLP into Northern Tshwane. • Sarah Kiguli of Makerere University, Uganda, received a mini-grant in order to introduce the WHLP to 20 Health Professional Training Institutions in the region. • Shakuntala Chhabra of Mahatma Gandhi Institute of Medical Sciences, India will further awareness pertaining to medical emergencies occurring
during pregnancy, labour, and the postpartum period.
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The WHLP must continually be updated so that all information remains current and relevant. One objective was to add additional modules, including Quantitative Methods, Healthy Lifestyles, and Substance Abuse, and to update pre-existing modules. Extensive time and effort in
Providence will allow for the release of the Third Edition of the WHLP at the 2010 Network: TUFH Conference in Nepal.
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This meeting was planned so that members could attend the American Public Health Association Conference held in Philadelphia. Taskforce members were included in many events and recognised for their expertise. This provided an excellent opportunity for the WHTF members to network with other individuals working on Maternal and Child Health issues that they would not meet at a Network: TUFH meeting. The WHTF have made remarkable progress in the improvement and access of adequate healthcare to poor, rural women and children. The WHLP offers a foundation for community workshops and improved curricula for health professionals training institutions. Through the WHLP health professionals and communities learn to better equip themselves with knowledge about gender-related health issues.
Women and Health Taskforce
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After the cancellation of the 2009 Network: TUFH Conference, the Women and Health Taskforce (WHTF) decided to hold their own smaller meeting. Traditionally, Network: TUFH meetings provide opportunities for taskforce members to meet, share their work and experiences, and collaborate on producing the Women and Health Learning Package (WHLP). This cancellation left the WHTF without a needed meeting in order to complete the Third Edition of the WHLP. In collaboration with GHETS, 25 taskforce members attended a workshop in Providence, Rhode Island (USA) from November 12-15. Taskforce members represented many regions including: the Americas, Africa, Eastern Mediterranean, and South-East Asia.
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MEMBER AND ORGANISATIONAL NEWS TASKFORCES
NEWSLETTER NUMBER 02 | VOLUME 28
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Taskforce on Social Accountability and Accreditation: Pushing the New Frontier The taskforce on Social Accountability and Accreditation (TFSAA) began in an attic room at the Network: TUFH Conference in Ghent in 2006 with a workshop exploring the ‘new frontier’ of accreditation as a lever for social change in medical schools. The next year in Kampala a workshop of some 70 people with a subsequent strategic planning meeting established the following priorities: • Formally establish a taskforce within The Network: TUFH. • Review the World Federation of Medical Education (WFME) (www3.sund.ku.dk) standards with a social accountability lens. • Write a peer reviewed paper outlining the issues. • Undertake a research programme to explore the needs in this realm. • Work towards a consensus among established and new accreditors of medical education about a broader concept of accreditation. The TFSAA was formally established in 2007. It met again in Bogota and a sub-committee worked on the WFME standards over the ensuing year, resulting in a well balanced set of suggested modifications of existing standards and the suggestion of a new realm of standards relating, not to the responsibilities of schools for their teaching and research programmes, but the nature and activities of their graduates once they qualify as practitioners. This is the ‘new frontier’ of which the TFSAA speaks and is outlined in the subcommittee’s report. Despite the cancellation of the Network: TUFH Conference in Jordan last year, members of the TFSAA have been very active in advancing the strategic directions established in Kampala. Discussions with the WFME have established that our input is welcome as they begin an intensive review of the established standards and the process of their implementation. Indeed, the President 38
of WFME is an active member of the Steering Committee for the planned Global Consensus Conference (of which more below) and we are exploring synergies for the two processes culminating in their planned 2012 world congress. The primary undertaking for 2010 is the development of a major consensus process entitled: Towards a global consensus on medical education standards based on principles of social accountability accountability. This process is being led by a senior Steering Committee (see Network: TUFH website) and has engaged all of the major international and regional medical education organisations. The detailed outline of the intent can be found on the Network: TUFH website. The response from around the world is remarkably positive and is being actively supported by WHO, WFME, and other organisations with an interest in health human resources for the future. It will culminate in a Global Consensus Conference (GCC) in October at Walter Susulu University in South Africa. The Delphi process planned between now and the summer will define the issues for consideration and the meeting itself will define the degree of consensus and the agreed upon actions to animate that consensus. The TFSAA will meet again in Kathmandu in November at the Network: TUFH Conference and will plan the next stages of its work on the basis of the GCC and the ongoing work with the WFME. This shows promise of influencing the direction of medical education to better address the needs of the society. TASKFORCE INTERNATIONAL EDUCATION: CURTIN UNIVERSITY, AUSTRALIA Curtin University in Western Australia requires its graduates to be industry ready, to take an indigenous, intercultural and international perspective, and to have interdisciplinary experiences. In addition to
these curricula demands, the Faculty of Health Sciences recognises the need to change the way health professionals are educated to prepare graduates for the health and social demands in both Australia and the rest of the world. Interprofessional education (IPE) is one of the key strategies which forms the foundation of many Faculty initiatives, enabling health and social care professionals to learn from each other, to share their knowledge and skills, and to develop the attitudes necessary for collaborative practice. The interprofessional curriculum at Curtin is in its infancy, but thus far the range of activities which have taken place over the past 18 months have been highly successful and have provided educational, practice-based and research opportunities for our students, staff and industry partners. We would be happy to network with anyone else who has or is implementing IPE. Margo Brewer | Curtin University, Australia Email: m.brewer@exchange.curtin.edu.au
Full Membership It is with pleasure that we would like to inform you that the following Full Members have been awarded (a continuation of its) Full Membership: Up to 2014: - Ahfad University for Women, Omdurman, Sudan - College of Medicine, University of the Philippines Manila, Ermita, Manila, Philippines - Faculty of Health Sciences, Linköping University, Linköping, Sweden - Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel - Instituto Superiore di Sanità, Roma, Italy - Institute of Applied Health Sciences (IAHS), University of Science & Technology Chittagong (USTC), Dhaka, Bangladesh - College of Health Sciences, University of Ilorin, Ilorin, Nigeria
ABOUT OUR MEMBERS
Healthy Child Uganda
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brought remarkable innovation and change to medical education both in New Mexico and throughout the world. The curricula of many medical schools are modelled on initiatives Dr. Kaufman has brought forth. In his new role as Vice-President for Community Health, Dr. Kaufman will bring his expertise and experience in community work and collaboration to improving the health of the citizens of New Mexico - a fitting pinnacle for a distinguished career!
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tion and Honours Received; and Value to the University. This honour was highly deserved as Dr. Kaufman has been a Family Medicine Physician, educator, researcher and innovator for over 30 years at the UNMHSC Department of Family and Community Medicine. He is a national and internationally respected leader in family and community medicine and medical education and is perhaps best known for his innovations in Problem-Based Learning and health services delivery to underserved and rural communities. In all of his roles, Dr. Kaufman has been the visionary leader of numerous programmes of local, national and international significance (it is under these models that medical education in New Mexico thrives). For example, he has been Secretary General of The Network: TUFH for eight years. Dr. Kaufman has
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TRIBUTE TO… Arthur Kaufman, M.D., Vice-President for the Office for Community Health was selected by the University of New Mexico’s (UNM) Provost’s Office for the highest honour that UNM can bestow on a faculty member: the rank of Distinguished Professor. Dr. Kaufman is one of two faculty chosen this year and is the third School of Medicine faculty with this rank. He adds this honour to numerous other awards reflecting the importance of his work over the last three decades. Perhaps the most prestigious of those was his selection by the International Family Medicine organisation, WONCA, for the ‘5-Star Family Physician’ International Award of Excellence in Health Care. The criteria for the Distinguished Professor are Scholarly Excellence; Research, Scholarship and Creative Activity; Recogni-
Individual Members • Dr. Ayad M. Al-Moslih, University of Sharjah, Sharjah, United Arab Emirates • Dr. Louella R . McCarthy, School of Medicine, University of Western Sydney, Penrith South DC, NSW, Australia • Dr. Claudia Ehlers, Münster, Germany • Dr. Robert Bella Kuganab Lem, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana • Ms. Marta Aymerich, Faculty of Medicine, Girona University, Girona, Spain
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and enthusiasm. The use of masks, drama and drums were increasingly encouraged, along with instructive stories about malaria, poverty and nutrition. Board games on immunisation, hygiene and antenatal care were developed, translated and drawn on woven plastic rice bags so as to be easily transported. Soon, volunteers were receiving requests for the delivery of health education presentations, not only from their own communities but also from external parties. Local situations in communities, such as the reality of shared water supply for cattle and people, were presented in open-ended flannel board stories that left people openly touched and eager to discuss possible actions. In two of the communities, school children formed story-telling groups in which they applied the same methods and produced their own materials. Through interactive initiatives, health education has come to live in the communities.
Mabira Puppeteers
New Members Full Members • De Waal Foundation, Quito, Ecuador • Institut Arbeit und Technik (IAT), Gelsenkirchen, Germany • Faculty of Medicine, Universidad Mayor de San Simon, Cochabamba, Bolivia
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In our June 2009 edition of the Network: TUFH Newsletter we published about a few successful training modules from fellow members. Now the Uganda Child Health Project introduces to us some of their interactive initiatives: With the key health messages identified in the Healthy Child Uganda manual, the organisation has tried to convey these messages with drama, style and flair in the villages, in order to make them more memorable. A variety of training methods was designed for both teachers and volunteers. However, as health messages have long been associated with telling people what to do, additional efforts were needed to make the messages exciting and to engage the people. The use of puppets, initially introduced as imported hand puppets, caught on quickly. This activity was followed by ‘puppet-making’ workshops that made use of local materials, such as backcloth, banana fibre, clay and plant dyes. Contests between groups were organised too, which sparked off great creativity
Dr. Arthur Kaufman
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MEMBER AND ORGANISATIONAL NEWS
THE NETWORK TOWARDS UNITY FOR HEALTH
ABOUT OUR MEMBERS
A Passion for...
Newsletter Volume 28 | no. 2 | March 2010 ISSN 1571-9308
The passion of Yoka PinckersCerfontaine, Secretariat The Network: TUFH, the Netherlands: I grew up on a farm, and when I was four, my brother was given a black Shetland pony. My brother didn’t show much interest in the pony, which we had named Sjeng, but I was enthusiastic from the start. Unfortunately, Sjeng wasn’t a very sweet-natured pony and didn’t appreciate all the attention I wanted to give him.
Editor: Marion Stijnen Language editor: Sandra McCollum The Network: Towards Unity for Health Publications P.O. Box 616, 6200 MD Maastricht The Netherlands Tel: 31-43-3885633, Fax: 31-43-3885639 Email: secretariat@network.unimaas.nl www.the-networktufh.org
Mrs. Pinckers-Cerfontaine
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After two years of practising on the back of my wooden hobby horse and whining to my parents, I was finally allowed to take horse-riding lessons at the local riding school. When I was seven, we sold Sjeng and I got a new pony. Her name was Daisy, and she was my first love. In the meantime, my parents had stopped farming, and all the cows were sold. My father had 14 horse stalls built and began stabling horses. He even bought a second horse, named Sivollo, who is now 33 years old and still lives with us. Several girls my age stabled their horses and ponies with us. We quickly became good friends, and spent all our free time with the horses. We often rode outdoors, competed with each other, brushed the horses until they shone, and cleaned the tack. Looking back, I think the horses must have been thankful when the eight weeks of summer holidays were finally over, so they could get a little peace. My mother even had to come and fetch me from the stables more than once, because I had fallen asleep lying next to Daisy, or even sitting on her back. On my eleventh birthday, we started a pony club, and now, twenty years on, it’s still going strong and has grown into an association with more than 60 members. Because I wanted to ride in official competitions, I also joined a national equestrian association. By the time I was 14, I had outgrown Daisy, and we sold her. That was
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a terrible feeling. Up to the age of 16 I had several horses with which I competed (mostly in jumping competitions), but none of them was a friend like Daisy had been. I had to train for two hours almost every day, and I quickly lost the fun I’d had in riding. So I decided to stop competing and look for another horse. One day, my father took me to see a friend who had a number of purebred Arabians which he trained for racing. Once I got there, I took one look at Magic Fire and it was love at first sight. I could finally just ride through the woods with my friends again, and on Magic, it was fun again. In the weekends I worked at the stables of my father’s friend. I cleaned out the stalls and cared for the horses, and after a while, I was allowed to help train the horses, and even ride on them. Racing horses was nothing like dressage and jumping, and the speed with which the horses ran gave me a huge adrenalin rush. Unfortunately, I was too big and heavy to become a professional jockey. I started looking around for a new challenge, which I found in Western Riding. I enjoyed it for a while, but the specialties “Pleasure” and “Reining” weren’t exciting enough for me. Cattle driving, either “Cutting” or “Team Penning,” that was the real thing. But for that, you need a horse with “cow sense”. Magic just didn’t have it, and I didn’t want to sell him.
Finally I decided to start riding for fun again. I regularly go riding together with a group of friends who I have known for almost twenty years, and at least once a year we organise a horse-riding holiday. The highlight was our holiday to Ireland in 2006, where we trekked on horseback. Despite the fact that I am now a mother with a busy job, I still try to go riding with Magic at least twice a week. That feeling of freedom I get galloping through the woods and fields never fails to relax me. It goes without saying that I hope my daughter will take over my passion for horses when she’s old enough. But of course, that choice is up to her.
DESPITE THE FACT THAT I AM NOW A MOTHER WITH A BUSY JOB, I STILL TRY TO GO RIDING AT LEAST TWICE A WEEK.