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Teaching Public Health to Undergraduate Medical Students Using Problem Based Learning

*Khan MK,1 Hoque ME,2 Ferdous J,3 Hassan MR,4 Kabir S,5 Basher MS,6 Ahmed MS7

[SSNI Med Col J 2016 Jan; 1 (1):45-54] Key words: Public health, problem based learning, undergraduate medical students 1. *Dr. Mohammad Kamruzzaman Khan, Lecturer, Department of Community Medicine, Mymensingh Medical

College, Bangladesh. kamruzzaman.mihir@gmail.com 2. Dr. Md. Hafiz Ehsanul Hoque, Lecturer, Department of Community Medicine, Sylhet M A G Osmani Medical

College, Bangladesh. ehsandec20@gmail.com 3. Dr. Jannatul Ferdous, Medical Officer, OPD, Ophthalmology, Mymensingh Medical College Hospital,

Bangladesh. jannat.bakul.mmc@gmail.com 4. Dr. Mohammad Rashedul Hassan, Lecturer, Department of Community Medicine, Mymensingh Medical College,

Bangladesh. mrh.russel@gmail.com. 5. Dr. Shikha Kabir, Lecturer, Department of Community Medicine, Mymensingh Medical College, Bangladesh.

drskabir1971@gmail.com 6. Dr. Md. Shahidul Basher, Professor and Head, Department of Community Medicine, Mymensingh Medical

College, Bangladesh. drmsbasher@gmail.com 7. Dr. Md. Shibbir Ahmed, Professor and Head, Department of Community Medicine, Sylhet M A G Osmani Medical

College, Bangladesh. dr.shibbir@gmail.com *For correspondence

The importance of teaching public health to medical students has long been established. Medical colleges should teach public health to make future doctors equipped with adequate public health knowledge and skills. Problem Based Learning (PBL) is an instructional method that helps to maintain students’ intrinsic interest in the subject matter promotes group work and helps students become self-directed learners. The objective of the study was to determine the effectiveness of PBL in comparison to Traditional Learning (TL) in teaching public health to undergraduate medical students and to assess the attitudes of students regarding TL and PBL. The Quasi-Experimental study was conducted among 74 students of 4th year MBBS of Sylhet M A G Osmani Medical College. Intervention and control group were taught selected topics of maternal and child health and family planning (MCH & FP) using PBL and TL methods, respectively. Similar short answer questions and problem based questions were used to assess the performance of both groups after intervention. Students’ attitude towards PBL and TL was evaluated using a self-administered semi-structured questionnaire. The mean score of PBL group (27.82) was significantly higher than TL group (23.03). The difference between mean score of two groups was statistically highly significant (p = 0.001). Among the good score (above mean+1SD) attaining students 81.3% were from PBL group, whereas 18.8% were from TL group that differed significantly (Chi-Square test; p = 0.005). Most of the students of intervention group agreed that PBL developed their interest in learning, developed problem solving, analytical and communication skills and motivated them for self directed learning. Three-fourth (73.7%) of the students of intervention group agreed that PBL is superior to TL. The results of the study revealed that PBL is more effective than TL in teaching public health to undergraduate medical students. Medical colleges of Bangladesh should consider using of more effective and innovative teaching method like PBL.

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Introduction he importance of teaching public health to medical students has long been established.1 Public health is

often poorly represented in medical curriculum and is poorly taught or given less importance by students and doctors.2-7 The good medical practice requires a population perspective and understanding of epidemiological principles. Medical College should teach public health to ensure that the future doctors will be adequately equipped with public health knowledge and skills.8 Problem based learning (PBL) method is one of the innovative methods in public health course that has been progressed to recent decades as an alternative to learning by the traditional methods.9 It gained popularity as a teaching method in medical schools of United Kingdom, United States of America, Australia and many other coutries.10 PBL is a learner-centered instructional method that enhances students’ ability to analyze, synthesize, and evaluate problems. PBL can be described as a teaching strategy in which students confront contextualized, ill-structured problems and strive for meaningful solutions.11 PBL is an instructional method that utilizes real problems as the primary pathway of learning.12 PBL requires a greater, deeper level of students’ involvement in the class. It results in greater students’ learning.13 PBL includes problems that can be solved in many different ways and have more than one solutions.14 The problems help to maintain students’ intrinsic interest in the subject matter, emphasize learning as opposed to recall, promote group work and help students become self-directed learners.15 PBL integrates and develops all three domains of learning as described by Bloom, including the cognitive (mental and intellectual skills), affective (feelings and attitudes) and the psychomotor (skills).16

Recent health sector reforms may have increased the need for doctors to receive public health education.8 In order to achieve the Millennium Development Goals (MDGs) and improve the health standards, there is a demand to reform medical colleges’ curriculum and educational methods to enable them to provide integrated health care services.17, 18 Therefore, medical educations are being encouraged with new learning methods to expanded needs.19 Evidences demonstrate that graduates of PBL curricula have superior professional competencies in comparison with graduates of traditional curricula. Studies in this area have been mostly carried out in other countries. In the medical colleges of Bangladesh, public health is being taught mostly using traditional lecture and tutorial based learning which is not the most effective teaching strategy to stimulate thought and enhance problem-solving skills. Day visit and field site training program have been introduced in the undergraduate medical curriculum, which covers a very few areas of curriculum. Undergraduate medical students made criticisms of their medical education, particularly overcrowding of the curriculum, factual overload, an emphasis on passive learning and paucity of learning based on exploration and enquiry.20 Now, it is the time to think about the use of more active, innovative teaching methods such as PBL. This study identified the effectiveness of PBL in teaching public health to undergraduate medical students and assessed students’ attitude regarding PBL and TL in the medical curriculum. Methods A Quasi experimental study was conducted among randomly selected 74 students of 4th year MBBS of Sylhet M A G Osmani Medical College during the period of June 2014 to November 2014. From the Five

T

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Batches of 4th year MBBS students two batches was randomly selected and enrolled in the study. One batch having 38 students was then randomly selected as experimental group. Another batch having 36 students was selected as control group. PBL course module was developed on selected topics of public health (MCH & FP). Students of experimental group were oriented with PBL course. Four teachers were oriented about the PBL course. Selected topics were taught in eight traditional lecture classes (1 hour each) for both groups. The topics were also taught in eight PBL tutorial classes (2 hours each) in experimental group and in eight traditional tutorial classes in control group. At the end of the course, a written examination of 50 marks was taken for the assessment of the performance of the students. A self-administered semi-structured questionnaire was used to collect the information from the students of PBL group regarding their attitudes towards traditional learning and problem based learning. Data input in Microsoft Excel was done twice to see the consistency and then cleaned. SPSS 17 version was used to analyze data. The independent sample t test was used for comparing the scores of PBL and Traditional Learning (TL) group. Cross tabulation was done to compare the obtained scores between intervention and control group and Chi-square test was performed. No physical or psychological risk was associated with the study. Consent from the authority and participants was taken prior conducting the study. Ethical clearance was obtained from the Ethical Committee of Sylhet M A G Osmani Medical College. Results A written examination with similar problem based questions and short answer questions of 50 marks were conducted to assess the

performance of the students of both groups after intervention. Mean score was 27.82 and 23.03 in PBL group & TL group respectively. Standard deviation was 7.38 in PBL group and 7.63 in TL group (Table I). The difference between mean score of PBL group and TL group is 5.79. The independent sample t test was used for comparing the groups and the difference was found highly significant statistically (p = 0.001, Table II) Categorization of obtained score of the students in the examination was done as follows: Poor Score: Score below mean (25.0)

minus 1SD (7.99) (<mean-1SD) i.e. <17.01.

Average Score: Score in between mean plus minus 1SD (mean+/-1SD) i. e. 17.01 to 32.99.

Good Score: Score above mean plus 1SD (>mean+1SD) i. e. >32.99.

Among the poor scorers more than four-fifth (81.8%) were from the TL group. On the other hand among the good scorers more than four fifth (81.3%) were from the PBL group. Chi-Square test was done and the difference in score categories was found highly significant statistically (p = 0.005; Table III). Students’ attitude towards PBL and TL was assessed using a self-administered semi-structured questionnaire from the students of intervention (PBL) group. Maximum (85.9%) students of intervention group either agreed or strongly agreed that PBL developed their interest in learning (Figure 1). Maximum (92.1%) students agreed that PBL developed their problem solving skills; more than three fourth (78.9%) students stated that PBL motivated them for self directed learning; 81.6% students agreed that PBL

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sharpened their analytical skills. Almost every student (94.8%) agreed that PBL developed his or her ability to work as team member. 81.6% students agreed that problem serves as a stimulus for learning and development of problem solving skills in an authentic way (Table IV). Most of the (89.5%) students either strongly agreed or agreed that PBL improved their communication skills (Figure 2). Three fourth (75.6%) of the students stated that traditional learning is teacher centered and leads to passive learning. Maximum students (89.5%) agreed that traditional learning is text based (Table V). Almost all students (97.4%) either strongly agreed or agreed that active participation of students is more in PBL than TL. They also agreed that teacher student interaction is more in PBL than TL (Table VI). Three-fourth (73.7%) of the students ranked PBL superior to TL (Figure 3). Findings of the qualitative portion of the study showed that every student likes the group work in the PBL most and they think it will be useful in their real life. In addition to this some students like teacher-student and student-student interaction, presentation and open discussion in the class. Some students mentioned that in PBL class they were able to learn from different sources other than text books notably learning from internet which broaden their capability of thinking. Overall PBL was interesting and enjoyable to them. However, some students of PBL group reported that duration of class was long (2 hours) and they had to work a lot. Some students mentioned, teaching learning facilities including audio-visual aids, reference books and internet need further improvement.

Table I: Comparison of scores between PBL group and TL group

PBL group

(n = 38) TL GROUP

(n = 36)

Minimum score

10.00

5.00

Maximum score 42.00 38.00

Median 28.00 20.00

Mean score 27.82 23.03

Standard deviation

7.38

7.63

Table II: Independent sample t test to compare the mean scores Mean difference t Df* p value

5.79

3.32

72

0.001

*df = degree of freedom

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Table III: Comparison of scores between PBL group and TL group Score

Total Poor (below mean -

1SD) Average (Mean +/-

1 SD) Good (more than

mean + 1SD) Group PBL Count 2 23 13 38

% within group 5.3% 60.5% 34.2% 100.0% % Overall 18.2% 48.9% 81.3% 51.4%

TL Count 9 24 3 36 % within group 25.0% 66.7% 8.3% 100.0%

% Overall 81.8% 51.1% 18.8% 48.6% Total Count 11 47 16 74

% in both groups 14.9% 63.5% 21.6% 100.0% % total 100.0% 100.0% 100.0% 100.0%

*n = 74; mean = 25.0; SD = 7.99; Chi-Square value 10.68; p = 0.005

Figure 1. Attitude of the students towards PBL- developed interest in learning

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Table IV: Attitude of the students towards PBL

*n=38

Figure 2. Attitude of the students towards PBL- Communication skills

Statement

Strongly agree (%)

Agree (%)

Neutral (%)

Disagree (%)

Strongly disagree

(%)

PBL developed my problem solving skills 28.9 63.2 5.3 2.6 0 PBL motivated me for self directed learning 28.9 50.0 7.9 13.2 0 PBL sharpened my analytical skills 15.8 65.8 13.2 2.6 2.6 PBL developed my ability to work as a team member 47.4 47.4 2.6 0 2.6 Problem serves as a stimulus for learning and 13.2 68.4 15.8 2.6 0 development of problem solving skills in an authentic way

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Table V: Attitude of the students towards traditional learning

n=38, *missing 1 Table VI: Attitude of the students toward PBL in comparison to TL

n=38

Figure 3. Ranking PBL in comparison to TL

Statement

Strongly agree (%)

Agree (%)

Neutral (%)

Disagree (%)

Strongly disagree

(%) Traditional learning is teacher centered and leads to passive learning* 35.1 40.5 18.9 5.4 0 Traditional learning is generally text based

42.1

47.4

5.3

2.6

2.6

Statement

Strongly agree (%)

Agree (%)

Neutral (%)

Disagree (%)

Strongly disagree

(%) Active participation of students is more in PBL than TL 55.3 42.1 2.6 0 0 Teacher student interaction is more in PBL than TL 71.1 26.3 0 2.6 0

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Discussion This quasi-experimental study conducted among two groups of 4th year MBBS students of Sylhet MAG Osmani Medical College to determine the effectiveness of PBL in studying public health. This study revealed that students who participated in the PBL classes performed significantly better than the students of TL group. The mean scores of students in the PBL group were significantly higher than those in the TL group (P=0.001). The majority of the good score attaining students (81.3%) were from PBL group. The results of this study are consistent with those of Gibson DR, Campbell RM26 and Yang ND27 that reported improved learning and self-confidence among PBL students compared to lecture students. Similarly Koleini et al28 showed that there was a significant difference between the TL and PBL in that the PBL may lead to better learning than to TL. In the study of Gurpinar E et al29 of Turkey the mean score in PBL group was 4.5 points higher than lecture based learning (LBL) group. However, a research in Pakistan showed no significant differences between the test scores by PBL and LBL group; but PBL received significantly higher student rating (p<0.05).30 Another experience during pharmacology course in Germany showed that students in PBL were more successful than students in LBL even in standardized national tests.31 In several of the Clerkship performance measures, the PBL students performed significantly better and in no circumstances did they perform worse than the standard curriculum.32 In the section of students’ attitude towards PBL, this study revealed that the majority of the students agreed that PBL developed their interest in learning, developed problem solving, analytical and communication skills and motivated them for self directed learning.

PBL developed their ability to work as a team member. They also mentioned that the problem serves as a stimulus for learning and development of problem solving skill in an authentic way. Other studies are also supporting this findings.33-35 Shamsan B and Syed AT also found similar finding among medical undergraduates in Saudi Arabia.36 Regarding attitude towards TL majority of the students agreed that the TL is teacher centered and leads to passive learning and TL is generally text based. They also agreed that active participation of students and teacher student interaction in the class is more in PBL than TL. Three fourth (73.7%) of the students of intervention group agreed that PBL is better than TL and considered it superior to TL in teaching Public Health. This findings are consistent with findings of others study regarding PBL.36, 37 Overall, PBL was interesting and enjoyable to them. However, some students mentioned, teaching learning facilities including audio-visual aids, reference books and internet need further improvement. Some students of PBL group also reported that duration of class was long and they had to work a lot. Similar observations were also seen among medical undergraduates in Saudi Arabia.36 Conclusion The results of the study revealed that students of PBL group were scored better in the examination. The study also revealed that PBL is more effective than TL in teaching public health to undergraduate medical students. Moreover, majority of the students of intervention group agreed that PBL is better than TL and considered it superior to TL. Medical Colleges of Bangladesh should think about the use of more effective and innovative teaching method like PBL in teaching Public Health.

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Acknowledgements The study was conducted under the research fellowship supported and funded by USAID’s Next Generation of Public Health Experts Project (NGPHEP), James P Grant School of Public Health (JPGSPH), BRAC University. I would like to thank Professor Sabina Faiz Rashid, Dean, JPGSPH, and Chief of Party, USAID’s NGPHEP and Khadija Leena, Project Coordinator and Priscilla Heffelfinger of USAID’s NGPHEP for their encouragement and support. References 1. The Interdepartmental Committee on

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