|Year : 2007 | Volume
| Issue : 3 | Page : 195-197
Community-based medical education: The Nepal experience
AK Sharma1, BK Yadav2, GC Pramod2, IS Paudel2, ML Chapagain3, S Koirala4
1 Department of Community Medicine, University College of Medical Sciences, Shahdara, Delhi, India
2 Department of Community Medicine, BP Koirala Institute of Health Sciences, Ghopa, Dharan, Nepal
3 Department of Medical Education, BP Koirala Institute of Health Sciences, Ghopa, Dharan, Nepal
4 BP Koirala Institute of Health Sciences, Ghopa, Dharan, Nepal
|Date of Submission||01-Sep-2005|
|Date of Acceptance||11-Aug-2007|
A K Sharma
Department of Community Medicine, University College of Medical Sciences, Shahdara, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma A K, Yadav B K, Pramod G C, Paudel I S, Chapagain M L, Koirala S. Community-based medical education: The Nepal experience. Indian J Community Med 2007;32:195-7
|How to cite this URL:|
Sharma A K, Yadav B K, Pramod G C, Paudel I S, Chapagain M L, Koirala S. Community-based medical education: The Nepal experience. Indian J Community Med [serial online] 2007 [cited 2015 Nov 29];32:195-7. Available from: http://www.ijcm.org.in/text.asp?2007/32/3/195/36826
| Introduction|| |
Exposure to the communities in rural setup during undergraduate teaching of medical students may help them in appreciating the primary health-care needs of the community. Community-based training enables students to understand the needs of communities, to relate theoretical knowledge to practical training in a primary-care context, to continuously confront reality and to help them to acquire competence in areas relevant to community health needs.  This method of teaching and training of medical students has been recognized at various levels.  The BP Koirala Institute of Health Sciences, a medical university in eastern Nepal, has adopted a community-based and community-oriented medical education with problem-based learning in selected pre-clinical subjects.
Since the community-based teaching is being introduced for the first time, this study was undertaken to achieve the following objectives:
- To study the perceptions, attitudes and expectations of the students towards community-based medical education and
- To understand the community's perception of, and response to, interaction with undergraduate medical students.
| Materials and Methods|| |
This study was carried out on the 5 th semester MBBS students during their community-based family health exercise in 1999-2000. Each student visited one allotted family in a rural area, once in a fortnight for 6 months. Visits were preceded by a briefing session by a faculty member. The students interacted with each member of the family. They collected information about morbidity, mortality, nutritional status, socioeconomic condition, environmental sanitation, family planning practices, social and cultural beliefs and taboos influencing health and health-seeking behavior. The students also disseminated correct knowledge regarding various health practices as relevant to the respective families.
A pre-tested questionnaire was used to assess the attitude, perceptions and expectations of the students. The questionnaire was administered before the first visit to the community and again after the last visit during the exercise. It also included questions regarding frequency of visit, duration of exercise and optimum number of families to be visited by each student. There were seven questions related to measurement of attitude. The attitude questions had five possible answers varying between most positive and least positive response (e.g., Question: The exercise was (1) very useful, (2) useful to some extent, (3) not useful, (4) useless and (5) no response, with most positive score being +5 and least positive score being +1. The minimum and maximum possible scores were +7 and +35. The obtained score at the beginning were termed as 'pre' and at the end of the exercise were termed as 'post.' A similar set of questionnaire in local language was also administered to the families, at the beginning and end of the exercise, allotted for this exercise. To eliminate interviewer bias, family members were interviewed by the social scientists (coauthors of this research paper) of the department of community medicine. In the questionnaire for the family members, considering the low level of literacy in the community, the attitude questions were not put to any scale.
The pre- and post-scores were compared using Wilcoxon Signed Rank Test. Rest of the analysis was performed using chi-squared tests. SPSS v10.0 software was used for data entry and analysis.
| Results|| |
The batch of students participating in the study consisted of 30 male and 9 female students. Of these, 33 (84.6%) received their school level education in English medium, and remaining 6 (15.4%) received it in Nepali medium; 34 (87.2%) students were from urban background, and majority (89.7%) were in the age group of 20-22 years.
The questions relating to measurement of attitude are given in [Table - 1]. The overall mean score before and after the exercise were 26.92 (±3.10) and 24.54 (±4.87) respectively. The difference was not statistically significant ( P > 0.05). Since the sample did not have normal distribution, Wilcoxon Signed Ranks Test was used to compare the paired results for each question. The change in attitude was negative for all the seven questions. However, statistically significant change was observed regarding usefulness of the visits, recognizing the visit as a possible interference in life of villagers.
The students were also asked to give their opinion regarding suitable duration of this exercise, optimum frequency of visits to the family and number of families that the students would like to visit during the exercise. At the end of the exercise, majority of the students were not in agreement with the existing duration of the exercise. A quarter of them wanted it for only 1 month, but another third wanted it for a year or more. Only half of the responding students considered once-a-fortnight visits as optimum. About 30% wanted the frequency to be increased to once a week, and only 7% wanted it to be reduced to once a month. At the beginning of the exercise, 77% students wanted more than one family to be allotted to them, but later only 65% thought so. However, this change was not statistically significant.
The response of the families visited by the students is given in [Table - 2]. The visit by the students was liked very much by 35% of the respondents, but only 23% felt that it is very useful. Students were not found suitable for solving the health-related problems of the families by most of the respondents in the community.
| Discussion|| |
Family health exercise is introduced in the syllabus of Community Medicine to give adequate exposure to the students about the family and its surrounding environment so that they can appreciate the health needs of the community from a broader perspective. In our study, we found that students showed greater enthusiasm about the activity before actually undertaking it. They appeared more comfortable about visiting the families and expressed greater confidence about providing health education to the families. But after the exercise the attitude took a downward turn, and lack of confidence also became visible. The students found themselves unable to meet the health-care needs and education-related demands of the villagers. Some of the students found the exercise "boring" and "a waste of time." It was observed by the researchers that some of the students did not take much interest in the activities. This can be attributed to incomplete understanding of the activities and inability of the teachers to emphasize the importance of the exercise. In the international literature, it has been reported that community-based training in Family Medicine is highly valued by students and has distinct advantages in providing medical students with the necessary training for the rendering of primary health-care services. 
Several obstacles were also faced by Nazareth et al., in South Africa, when they tried to introduce medical education in the community.  But in their case the students' attitudes were more positive, contrary to findings in our study.
It is also observed that students had more unrealistic assessment of the expectations of the villagers. Before going to the community, they expressed high level of confidence in tackling the expectations of the villagers, which was diminished at the end of the exercise. But this should not be interpreted as lack of interest on the part of students because a larger number of students wanted the frequency of visits to the families and duration of this exercise to be increased from the current level. The students observed that at times they were at a loss about how to tackle the problems in the family.
A similar data was collected from the families visited by the students. During discussion with students, it was noted that villagers were expecting free medicines and special privileges at the institute's hospital in return for the help rendered by them in conducting family health exercise. But at the end of the exercise since no such benefits were available to them, the expectations turned into disappointments. About three-fourths of the families had said during pre-test that they liked the visits by the students very much, but only 35% felt the same at the end of the exercise. Opinion regarding utility of the visit also showed a negative trend during post-test. This exercise is primarily aimed at training of the students; participation of the community is passive. In order to retain interest of the families, they should be provided health-care services at the village level. William et al. have also observed that communities generally do not receive valued outcomes in exchange for participation in the community-based education process. 
| Conclusions|| |
It may be concluded that the family exercise did not have the desired positive impact on the students' attitude towards family health, and the intended objectives were not fulfilled adequately. The expectations of the community are to be given due emphasis. A basic health-care service for the villagers needs to be introduced. Giving certain special privileges to the community for treatment at the institute's hospital may also have a positive impact.
| References|| |
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|2.||Harden RM, Sowden S, Dunn WR. Educational strategies in curriculum development: The SPICES model. Med Educ 1984;18:284-97. [PUBMED] |
|3.||Mash B, de Villiers M. Community based training in family medicine: A different paradigm. Med Educ 1999;33:725-9. [PUBMED] [FULLTEXT]|
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|5.||Williams RR, Reid SJ, Myeni C, Pitt L, Solarsh G. Practical skills and valued community outcomes: The next-step in community-based education. Med Educ 1999;33:730-7. |
[Table - 1], [Table - 2]
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