Systematic development and refinement of a contextually relevant strategy for undergraduate medical ethics education: a qualitative study.

BACKGROUND: Delivery of medical ethics education is complex due to various reasons, compounded by the context-dependent nature of the content. The scarcity of relevant resources in the contexts of some developing countries adds a further layer of difficulty to ethics education in these contexts. We used a consultative approach with students, teachers and external experts to develop a practical approach to medical ethics education. This study aimed to develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia. METHODS: The study utilised an explorative qualitative methodology to seek views of students and faculty of Rabigh Faculty of Medicine, Saudi Arabia, and international experts in the field of ethics and education to review and enhance a new ethics learning strategy which included a workbook-based tool. Three focus groups with 12 students, in-depth interviews with four faculty members and qualitative feedback from eleven external experts enabled the study participants to objectively critique the WBEL and provide feedback to enhance its quality. Thematic content analysis of the data was done to draw inferences which were used to refine the educational strategy. RESULTS: The analysis generated twenty-one sub-themes within four main themes: design features, content, teaching methods and assessment. These findings helped to design the educational strategy to improve its effectiveness in the given context. CONCLUSION: The study drew on the views of students, faculty and external experts to systematically develop a novel approach to ethics education for countries like Saudi Arabia. It also demonstrated the use of the consultative approach for informing a culturally relevant educational strategy in the Middle East context.

Effectiveness of media awareness campaigns on the proportion of vehicles that give space to ambulances on roads: An observational study.

BACKGROUND AND OBJECTIVE: The findings of the Health Care in Danger project in Karachi suggests that there is presence of behavioral negligence among vehicle operators on roads in regards to giving way to ambulances. A mass media campaign was conducted to raise people's awareness on the importance of giving way to ambulances. The main objective of this study was to determine the effectiveness of the campaign on increasing the proportion of vehicles that give way to ambulances. METHODS: This was a quasi-experimental study that was based on before and after design. Three observation surveys were carried out in different areas of the city in Karachi, Pakistan before, during and after the campaign by trained observers who recorded their findings on a checklist. Each observation was carried out at three different times of the day for at least two days on each road. The relationship of the media campaign with regards to a vehicle giving space to an ambulance was calculated by means of odds ratios and 95% confidence intervals using multivariate logistic regression. RESULTS: Overall, 245 observations were included in the analysis. Traffic congestion and negligence/resistance, by vehicles operators who were in front of the ambulance, were the two main reasons why ambulances were not given way. Other reasons include: sudden stops by minibuses and in the process causing obstruction, ambulances not rushing through to alert vehicle operators to give way and traffic interruption by VIP movement. After adjustment for site, time of day, type of ambulance and number of cars in front of the ambulance, vehicles during (OR=2.13, 95% CI=1.22-3.71, p=0.007) and after the campaign (OR=1.73, 95% CI=1.02-2.95, p=0.042) were significantly more likely give space to ambulances. CONCLUSION: Mass media campaigns can play a significant role in changing the negligent behavior of people, especially when the campaign conveys a humanitarian message such as: giving way to ambulances can save lives.

Accuracy of portrayal by standardized patients: results from four OSCE stations conducted for high stakes examinations.

BACKGROUND: The reliability in Objective Structured Clinical Exams (OSCEs) is based on variance introduced due to examiners, stations, items, standardized patients (SP), and the interaction of one or more of these items with the candidates. The impact of SPs on the reliability has not been well studied. Accordingly, the main purpose of the present study was to assess the accuracy of portrayal by standardized patients. METHODS: Four stations from a ten station high-stakes OSCE were selected for video recording. Due to the large number of candidates to be evaluated, the OSCE was administered using four assessment tracks. Four SPs were trained for each case (n = 16). Two physician assessors were trained to assess the accuracy of SP portrayal using a station-specific instrument based on the station guidelines. For the items with disagreement a third physician was asked to review and the mode was used for analysis. Each instrument included case-specific items on verbal and physical portrayal using a 3-point rating scale ("yes", "yes, but" and "not done"). The physician assessors also scored each SP on their overall performance based on a 5-item anchored global rating scale ("very poor", "poor", "ok", "good", and "very good"). SPs at location 1 were trained by one trainer and SPs at location 2 had another trainer. All SPs were employed in a high-stakes OSCE for at least the second time. RESULTS: The reliability of rating scores ranged from Cronbach's alpha of .40 to .74. Verbal portrayal by SPs did not significantly differ for most items; however, the facial expressions of the SPs differed significantly (p < .05). An emergency management station that depended heavily on SPs physical presentation and facial expressions differed between all four SPs trained for that station. CONCLUSIONS: Variation of trained SP portrayal of the same station across different tracks and at different times in OSCE may contribute substantial error to OSCE assessments. The training of SPs should be strengthened and constantly monitored during the exam to ensure that the examinees' scores are a true reflection of their competency and devoid of exam errors.

Temporal stability of objective structured clinical exams: a longitudinal study employing item response theory.

BACKGROUND: The objective structure clinical examination (OSCE) has been used since the early 1970s for assessing clinical competence. There are very few studies that have examined the psychometric stability of the stations that are used repeatedly with different samples. The purpose of the present study was to assess the stability of objective structured clinical exams (OSCEs) employing the same stations used over time but with a different sample of candidates, SPs, and examiners. METHODS: At Time 1, 191 candidates and at Time 2 (one year apart), 236 candidates participated in a 10-station OSCE; 6 of the same stations were used in both years. Generalizability analyses (Ep2) were conducted. Employing item response analyses, test characteristic curves (TCC) were derived for each of the 6 stations for a 2-parameter model. The TCCs were compared across the two years, Time 1 and 2. RESULTS: The Ep2 of the OSCEs exceeded.70. Standardized thetas (θ) and discriminations were equivalent for the same station across the two year period indicating equivalent TCCs for a 2-parameter model. CONCLUSION: The 6 OSCE stations used by the AIMG program over two years have adequate internal consistency reliability, stable generalizability (Ep2) and equivalent test characteristics. The process of assessment employed for IMG's are stable OSCE stations that may be used several times over without compromising psychometric properties.With careful security, high-stakes OSCEs may use the same stations that have high internal consistency and generalizability repeatedly as the psychometric properties are stable over several years with different samples of candidates.

Problems and issues in implementing innovative curriculum in the developing countries: the Pakistani experience.

BACKGROUND: The Government of Pakistan identified 4 medical Colleges for introduction of COME, one from each province. Curriculum was prepared by the faculty of these colleges and launched in 2001 and despite concerted efforts could not be implemented. The purpose of this research was to identify the reasons for delay in implementation of the COME curriculum and to assess the understanding of the stakeholders about COME. METHODS: Mixed methods study design was used for data collection. In-depth interviews, mail-in survey questionnaire, and focus group discussions were held with the representatives of federal and provincial governments, Principals of medical colleges, faculty and students of the designated colleges. Rigor was ensured through independent coding and triangulation of data. RESULTS: The reasons for delay in implementation differed amongst the policy makers and faculty and included thematic issues at the institutional, programmatic and curricular level. Majority (92% of the faculty) felt that COME curriculum couldn't be implemented without adequate infrastructure. The administrators were willing to provide financial assistance, political support and better coordination and felt that COME could improve the overall health system of the country whereas the faculty did not agree to it. CONCLUSION: The paper discusses the reasons of delay based on findings and identifies the strategies for curriculum change in established institutions. The key issues identified in our study included frequent transfer of faculty of the designated colleges and perceived lack of: Continuation at the policy making level. Communication between the stakeholders. Effective leadership.

Assessing clinical communication skills in physicians: are the skills context specific or generalizable.

BACKGROUND: Communication skills are essential for physicians to practice Medicine. Evidence for the validity and domain specificity of communication skills in physicians is equivocal and requires further research. This research was conducted to adduce evidence for content and context specificity of communication skills and to assess the usefulness of a generic instrument for assessing communication skills in International Medical Graduates (IMGs). METHODS: A psychometric design was used for identifying the reliability and validity of the communication skills instruments used for high-stakes exams for IMG's. Data were collected from 39 IMGs (19 men--48.7%; 20 women--51.3%; Mean age = 41 years) assessed at 14 station OSCE and subsequently in supervised clinical practice with several instruments (patient surveys; ITERs; Mini-CEX). RESULTS: All the instruments had adequate reliability (Cronbach's alpha: .54 - .96). There were significant correlations (r range: 0.37 - 0.70, p < .05) of communication skills assessed by examiner with standardized patients, and of mini-CEX with patient surveys, and ITERs. The intra-item reliability across all cases for the 13 items was low (Cronbach's alpha: .20 - .56). The correlations of communication skills within method (e.g., OSCE or clinical practice) were significant but were non-significant between methods (e.g., OSCE and clinical practice). CONCLUSION: The results provide evidence of context specificity of communication skills, as well as convergent and criterion-related validity of communication skills. Both in OSCEs and clinical practice, communication checklists need to be case specific, designed for content validity.

Reflections by potential health care providers on a research methodology course taught under a primary health care centre: An experience of inter-professional education.

OBJECTIVES: Public health research demands a collaborative approach in working with communities to combat expected challenges in the field. Therefore, to improve primary care services, a training programme on research methodology, focusing on the principles of inter-professional education (IPE), was introduced at Karachi Medical and Dental College. The objectives of this study were to assess the level of learning by participants in the domain of communication and to explore participants' opinions and evaluations of the training programme. METHODS: A total of 96 participants, including faculty members, medical students, social works students and health technicians in the research methodology course, were selected during March to September 2010. The study employed mixed method research in which communication competencies and participants' perceptions, as captured by course evaluations, were analysed, and findings were triangulated. RESULTS: The results showed that 87% of faculty enjoyed contributing to 'inter-professional relationships' and that 'teamwork' skills in community-focused areas improved among 90% of students. As many as 78% of students and 70% of faculty members identified 'active listening' and 'communicating information to families', respectively, as being learned to a lesser extent. These findings were defended by their deliberations on course evaluation. CONCLUSION: Learning through inter-professional relationships was found to be most effective among faculty, whereas learning through teamwork was found to be most effective among students. Moreover, it was found that information was better communicated to families by students than by faculty staff.

Problem based learning in medical education: theory, rationale, process and implications for pakistan.

Historically, lectures were the medium to transfer cognitive information to the learners in medical education. Apprenticeship training, labs, bedside teaching, tutorials etc. were used to impart psychomotor and affective skills. It was assumed that the learner will assimilate all this knowledge and will be competent to apply this learning in practical life. Problem-based learning (PBL) emerged due to problems in building the appropriate competencies in the medical graduates and is a relatively newer mode of transfer of knowledge. This paper will deal with problem-based learning which took the world with storm in the 80's and most institutions in the world started using different variants of PBL. This paper attempts to define and explore the theoretical basis and historical background of PBL. The paper will systematically review literature and argue about the advantages and disadvantages of PBL and the implications of its implementation in Pakistan.

Effect of Leadership Styles on Job Satisfaction Among Critical Care Nurses in Aseer, Saudi Arabia.

OBJECTIVE: To evaluate the effect of transformational and transactional leadership styles of head nurses on the job satisfaction of staff nurses in critical care units (CCU) of a tertiary care hospital. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Critical care units at Aseer Central Hospital (ACH), Abha, Saudi Arabia, from July to December 2012. METHODOLOGY: The multifactor leadership questionnaire (MLQ-5X) and job satisfaction survey with demographics were used. Staff nurses (N=89) reporting to 8 nurse leaders responded as per the requirements of MLQ-5X and also filled the job satisfaction survey. ANOVA, correlation coefficient (Pearson r) and multiple linear regression were used for analyses. RESULTS: All nurse leaders demonstrated a combination of transactional (TA) and transformational (TF) style of leadership. Nurses working under leaders with a TF style demonstrated significantly (p < 0.05) higher job satisfaction. The operating conditions were related negatively to the style of leadership. Pay, fringe benefits and nature of work were not related to the style of leadership. The nurses were moderately satisfied with their work and 23% of the variation in nurses' job satisfaction could be explained by the head nurses 6 leadership facets with positive effect of professional support, intellectual motivation, management by correction and their laissez faire style. CONCLUSION: The study emphasized the importance of TF style of head nurses for increasing staff nurses' job satisfaction. It is suggested that nurse leaders should be trained in TF style of leadership and provided more support and training for effective management of CCU.

Comparison of an integrated problem-based learning curriculum with the traditional discipline-based curriculum in KSA.

OBJECTIVE: To compare the integrated problem-based learning (PBL) curriculum of the third year medical students of KSU at the Al-Qaseem campus with the traditional discipline-based teaching curriculum of students of Riyadh campus. DESIGN: A comparative cross-sectional study. PLACE AND DURATION OF STUDY: Al-Qaseem and campuses of King Saud University (KSU). A structured questionnaire was used for comparing the students of third year at both campuses of KSU. The student's learning behaviours and their liking for teaching methodologies was evaluated from March to June 2003. SUBJECTS AND METHODS: There were 138 3rd year students of Riyadh campus (59 females and 79 males) and 65, of Al-Qaseem campus (17 females and 48 males) (N = 203). Fifty-eight percent of students' at Al-Qaseem campus went to the library two or more times compared to 3.4% of the Riyadh campus (P = 0.000), 18.5% of Al-Qaseem campus used Journals (P = 0.000), and 86% did self-learning (P = 0.000), which was much higher than the students' at Riyadh campus. RESULTS: Almost 75% students at Al-Qaseem campus were satisfied with their system of education compared to 20% at Riyadh campus (P = 0.000). Sixty-nine percent students at Al-Qaseem campus answered problem-solving questions correctly versus 7.25% of the students at Riyadh campus. The students of both campuses liked group teaching almost equally and thought it makes them remember better. The Al-Qaseem campus students liked PBL, clinical skills lab, tutorials, and also lectures delivered at the college. CONCLUSION: PBL improved the students' usage of learning resources, problem-solving abilities and they were satisfied with their learning and the curriculum.

Health and safety measures available for young labourers in the cottage industries of Karachi.

OBJECTIVE: To determine the health problems faced by labourers, 18 years and under, working in the cottage industries of Karachi and know the safety measures available and utilized at these places. DESIGN: Cross-sectional study using two-stage cluster sampling. PLACE AND DURATION: From February 2002 to March 2003, 95 cottage industries from 10 different locations of five districts of Karachi were included. SUBJECTS AND METHODS: All workers, 18 years and below, present were interviewed. The environmental and safety gadgets present at the industry were inspected by the surveyors and the manager was interviewed for presence of health and safety benefits for the workers. RESULTS: A total of 280 workers were interviewed, 26 (9.3%) children were between 9-12 years, 82 (29.3%) were between 13-15 and 172 (61.4%) were between 16-18 years of age. Health benefit was given to only one 13-year-old worker in silk industry; appropriate gadgets were absent in 93 (97.8%) industries, present only in 2 industries (one silk and one loom). First Aid box was present in only one loom industry. Two hundred and forty workers (85.7%) were unaware of the materials they were using. One hundred and ninety-three (69%) children were working in improper light, 199(71%) workers experienced high level of noise, 232(83%) were working in high temperature and 155(55.3%) were working with improper ventilation. Health problems faced included joint pains (n=64, 22.85%), backache (n=85, 30.35%), vertigo (n=48, 17.14%), numbness of fingers (n=77, 27.5%) and fatigue experienced by 143 (51.07%) children. CONCLUSION: The children and adolescents employed in cottage industry are suffering from health problems due to lack of knowledge on their part, and improper ergonomics, environmental and safety conditions at the workplace. The cottage industry should be regulated and brought under labour law. The health sector non-governmental organizations should make concerted efforts for the rehabilitation of this workforce by creating awareness and providing opportunities for education and development of skills.

Hospital waste management in the teaching hospitals of Karachi.

OBJECTIVE: To evaluate the current practices of segregation approaches, storage arrangements, collection and disposal systems in the teaching hospitals of Karachi. METHODS: A cross-sectional survey was conducted in eight teaching hospitals of Karachi, using convenient sampling technique. The instrument of research was a self administered questionnaire, with four sections, relating to the general information of the institution, administrative information, information regarding Health Waste Management personnel and a check-list of Hospital Waste Management activities. RESULTS: Out of eight hospitals visited 2 (25%) were segregating sharps, pathological waste, chemical, infectious, pharmaceutical and pressurized containers at source. For handling potentially dangerous waste, two (25%) hospitals provided essential protective gears to its waste handlers. Only one (12.5%) hospital arranged training sessions for its waste handling staff regularly. Five (62.5%) hospitals had storage areas but mostly it was not protected from access of scavengers. Five (62.5%) hospitals disposed off their hazardous waste by burning in incinerators, two (25%) disposed off by municipal landfills and one (12.5%) was burning waste in open air without any specific treatment. No record of waste was generally maintained. Only two (25%) hospitals had well documented guidelines for waste management and a proper waste management team. CONCLUSION: There should be proper training and management regarding awareness and practices of waste disposal. Research must be undertaken to seal existing gaps in the knowledge about hospital waste management. The hospital waste management guidelines enacted on 7th June 2004 should be followed and regulated by law enforcement agencies rigorously.

Association of anemia with parasitic infestation in pregnant Nepalese women: results from a hospital-based study done in eastern Nepal.

BACKGROUND: Anemia is a major contributor to maternal deaths in developing countries. Association of anaemia with helminthic infestations has been seen in the world and by eliminating it, anemia may be reduced with positive effects on maternal outcome. METHODOLOGY: A comparative cross-sectional study was done to assess the association of anemia with parasitic infestation, and other significant risk factors in eastern Nepal. One hundred and twelve pregnant women with and without anemia were enrolled in the study at the antenatal clinic at Dhankuta District Hospital, Nepal from May 2001 to July 2001. The data on social and demographic variables was collected through a structured questionnaire. Hemoglobin estimation and stool examination for parasitic infestation was done for all these women. RESULTS: Anemia was found in 66 (58.91%) women and 52 (46.5%) had helminthic infestation. Anemia was significantly related to hookworm infestation. There was a highly significant relationship between education and the knowledge of women regarding effect of helminthic infestations (P<0.000), transmission and spread of infestations (P < 0.000). The knowledge of women regarding effect of helminthic infestation was significantly (P < 0.001) related to the occurrence of parasitic infestations but its association with anaemia was not significant. CONCLUSION: Hookworm infestation in pregnancy was significantly related with anaemia. Hence all women coming to antenatal clinics should be screened for hookworm infestation. The antenatal care should include de-worming with correction and prevention of anaemia.

Introducing problem-based learning in a medical school with traditional/conventional curriculum.

BACKGROUND: Globally, over the last two decades, medical education and its learning strategies are being made more prone to problem-solving in order to produce better clinicians. The medical curriculum has not changed in Pakistan since its inception and that is reflected in the form of inadequacies in health delivery system. There is a dire need of creating relevance between medical education/training and medical practice in order to introduce an effective health care system. OBJECTIVE: This study is particularly aimed at evaluating the effect of problem-based learning (PBL) in a group of students accustomed to conventional teaching and to assess any change in students attitudes/learning abilities after repeated PBL interventions. DESIGN: An interventional study. SUBJECTS AND METHODS: Response of 32 students of fourth year MBBS of Karachi Medical and Dental College was recorded against two PBL exercises in September 2002. RESULTS: A significant change in the study trend and analytical ability (p < 003) was shown in the two PBL sessions. The students who liked PBL were 33% more prone to practice group-study (OR = 1.33 and 95% CI=1.28, 1.39) than those who preferred other modalities of teaching. The final professional grades of these students were significantly higher than those in the previous years (p < 0.000). CONCLUSION: A strong association between liking for PBL and group study was found and the analytical performance and thought process of students were significantly improved after the second PBL session.

Assessment of immunization service in perspective of both the recipients and the providers: a reflection from focus group discussions.

BACKGROUND: A number of evaluations of the EPI program have been carried out either at a small scale or countrywide in order to identify statistical figures but very few of them reflect population opinions. This study was conducted with an objective to assess the immunization services available through expanded program of immunizations (EPI) and national immunizations days (NIDs) and to determine the reasons for incomplete immunization. METHODS: This study is qualitative, based on eight Focus Group Discussions (FGDs) with mothers and fathers as recipients while lady health visitors and vaccinators as service providers. RESULTS: Majority of the mother and fathers were aware of the importance of immunization. Overall the failure of immunization was related to low income, inaccessible government dispensaries and occupancy in house hold work. Almost all mothers and fathers were of the opinion that the private clinics are giving service at a higher cost for quality vaccines than that of government dispensaries. Majority of fathers and mothers are ignorant of the advantages of antenatal immunization. Vaccinators and Lady Health Visitors had adequate knowledge and were partly satisfied with the services they provide. Vaccinators identified the need of local vaccinators and well--run vehicles in order to increase immunization rate. CONCLUSION: The quality of immunization services is compromised at the recipient level mainly due to lack of motivation and prevailing doubts about immunization importance. The service providers thought that the problem of incomplete vaccination particularly for females and misplacement of cards. Hence solving the problems of the providers at all levels combined with media campaigns to modify rigid behaviour of recipients can significantly improve the immunization coverage in Pakistan.