Year : 2021 | Volume
: 46 | Issue : 2 | Page : 173--177
Strengths, weaknesses, opportunities, and threats analysis of competencies and building skill pyramid in the subject of community medicine
Former, Professor and Head, Department of Community Medicine, Pt. B.D Sharma, PGIMS, Rohtak, Haryana, India
Prof. Sunder Lal
House No: 779, Sector-17, HUDA Jagadhri, Yamuna Nagar - 135 003, Haryana
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Lal S. Strengths, weaknesses, opportunities, and threats analysis of competencies and building skill pyramid in the subject of community medicine.Indian J Community Med 2021;46:173-177
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Lal S. Strengths, weaknesses, opportunities, and threats analysis of competencies and building skill pyramid in the subject of community medicine. Indian J Community Med [serial online] 2021 [cited 2021 Jun 14 ];46:173-177
Available from: https://www.ijcm.org.in/text.asp?2021/46/2/173/317099
In the subject of community medicine, the new MBBS regulations identified twenty broad topics with 106 core competencies. Out of these, 88 (83%) are related to domain of knowledge (knows and know how), whereas 18 (17%) are related to skill domain (shows and shows how and performs). At the end of the course, the student should be able to demonstrate and or perform these skills himself or herself. Building these skills in community medicine is an enormous task and a challenge indeed. The present communication makes an attempt to analyze the strengths, weaknesses, opportunities, and threats of core competencies and focuses on building skill pyramid through learning by doing. Its purpose is to disseminate nationwide various approaches with explicit learning objectives of each skill to facilitate acquisition of these skills. Further, this will help and contribute to achieving institutional and national goals relevant to the subject of community medicine. The whole focus is enabling the faculty to implement these new regulations by restructuring their training program. The teachers/faculty must reinvent themselves to refine and practice these competencies.
Strengths, Weaknesses, Opportunities, and Threats Analysis of Competencies
Undoubtedly, their intrinsic strengths are humanistic learning relevant to the global medical education trends by adhering to ethical practices. They give an impetus to improved doctor–patient relationship and the acquisition of effective communication skills. They encourage self-directed learning by choosing a subject of interest by the learner and exposure to clinical experience in the very 1st year of the MBBS course. Clear directions are there for integrated teaching by way of horizontal and vertical integration. Learning is outcome-based under new regulations. Specific core competencies to be acquired span over the years. Domains of learning, methods of learning as well as methods of assessment have been explicitly stated.
Overall, the system of medical education has not been prepared adequately to implement the new regulations. Bottlenecks, such as inadequate physical facilities/infrastructure to accommodate a large number of students, shortage of staff, logistic problems (transport and equipment's) and inadequate training/continued education of the faculty needs to be addressed on a priority basis. Nonavailability of learning resource material i.e., textbooks based on competency learning, is another impediment.
Revised curriculum provides a unique opportunity to medical faculty to restructure their teaching program, to develop learning resource material, promote problem-based learning, prepare relevant case studies, develops skill labs, integrate teaching and learning with health-care delivery system, use real-life situations and live data, exploit modern technologies, develop field practice areas to bring field experiences to a classroom setting, involve program officers of state/district in teaching program to achieve competency-based learning. Further, it provides an opportunity to transform conventional field visits to specific skills (revision of skill sets) to be acquired with clear-cut objectives and ensuring the achievement of relevant learning objectives.
New regulations specify skill domains relevant to first nine broad topics only and for the rest of the 11 broad topics (related to Indian Public Health Standards, management skills, health economics, and financing of health care) no skill has been specified, which is a serious omission. Excessive reliance on simulated models and use of computers/laptop-based learning may confine faculty and students alike to classroom setting, leading to progressive loss of community contacts/interactions which are vital to the discipline of community medicine. Under the new regulations, 83% of learning is through didactic teaching and only 17% is skill-based learning. This imbalance needs to be rectified. Formative and summative assessment of students focuses primarily on knowledge domain and ignores evaluation of skill domain. Change is difficult to accept; faculty may not impart skill-based training and impart only didactic training. All these threats must be converted to opportunities and weaknesses into strengths by continued education program for faculty.
Way Forward to Build Skill Pyramid in Community Medicine
CM 1.9 – Demonstrating the role of effective communication skills in health
In the subject of community medicine, “the patient” is community not an individual. Listening to community you serve is most important skill. Community is an important human resource in health. All ministries and departments converge at the level of village and urban ward. Objective of this skill is to arrive at a community diagnosis. Listening to community and its leaders-elected and nonformal is the first step in community diagnosis. Listen to people's demands, their chief complaints, concerns, felt needs, their priorities, health-seeking behavior, beliefs, customs, and best practices. How do we do it? Let students interact with village/urban slum community, organized listening groups such as Village Health Sanitation and Nutrition Committee, Mahila Arogya Samiti, Accredited Social Health Activist (ASHAs), Anganwadi Workers (AWWs), Health workers, and School teachers. Listening can be combined/concurrent with transect walk in the community
Speaking: This is the second most important communication skill. What to speak, how to speak, when to speak, and with whom to speak are essential elements of this skill. Let students prepare health messages/posters (practice writing skills) based on community interactions and transect walk, relevant to a specific problem. Messages thus prepared can be communicated to target community or group of potential beneficiaries or to allotted families. Message must be specific and address the concern of the people or group
Expected outcome: Student contacts and interacts with community/households and families in rural or urban slums. Minimum frequency of contacts to be determined locally as per need
CM 1.10 – Demonstrate the important aspects of doctor–patient relationship
Objective of this skill is to abide by the prescribed ethical and legal codes of conduct and practice to improve the quality of relationship between providers and the community. Doctor is bound by medical ethics of Hippocratic Oath, Nuremberg code of ethics in medical research, Declaration of Helsinki, and duties of physician to their patients as per the Medical Council of India. In public health patient is “Community.” A typical rural health center is responsible to a defined population of 30,000 and urban health center to 50,000 population. The way in which providers of public health services are connected with community they serve is known as community relationship. In community medicine, the households, families, community, Village Health Sanitation and Nutrition Committees, ASHAs, and AWWs are connected with dynamic health system of subcenters (Health and Wellness Centers), Primary Health Centers (PHCs), Community Health Centers (CHCs), and District hospitals to provide continuum of comprehensive primary health care across life cycle. The system maintains sustained contacts with the families and the community leading to community participation and satisfaction as also increased use of public health services at all these levels. These interactions and sustained contacts must be demonstrated to the students. Most textbooks of community medicine do not have a chapter on Medical Ethics and Research. Hence, the UGs and faculty are deprived of this information
Expected outcome: Student contacts health workers and health volunteers, identifies their nature and frequency of contacts with rural or urban community, or else elicits these contacts directly from people and documents in their practical notebook for self-assessment
CM 2.1: Performing Clinico-sociocultural and demographic assessment of the individual, family, and community CM 2.2: Demonstrate correct assessment of socioeconomic status (SES) CM 2.3: Demonstration of barriers to good health and health-seeking behaviors
Objective of these skills is to identify deprived families/population or vulnerable population for prioritization of health services and services related to health determinants, apart from identification of barriers in good health.
The students perform and document these skills in the allotted family/families by using Household Survey Format currently being used in health-care delivery system, Integrated Child Development Scheme program, and screening tool of RBSK. Student can assess the SES using the format on standard of living index, revised Kuppuswamy's method of social classification, or Udai Pareek's method. SES status determines the level of well-being of an individual, family, and community as also utilization of public health services. Relate these observations/information gathered by the students to National Demographic goals, Universal immunization program, RMNCH+A, National program of elderly, and noncommunicable diseases (NCDs) program. Students can interact with nonusers or partial users of health services in the family or in the community to elicit barriers to good health and health-seeking behaviors.
Expected outcome of CM 2.1 to 2.3: the student identifies deprived families/households/individuals and major barriers in health and health-seeking behavior in allotted families such as health illiteracy, poverty, availability, access, and acceptability of health service.
CM 3.7: Identifies vectors of public health importance and their life cycle and control measures.
The objective of this competency is to identify breeding places and bionomics of vectors and application of integrated vector control measures to control and elimination of vector-borne diseases in the community. This skill can be acquired by study of insects/slides under dissecting or ordinary microscope and more effectively by demonstrating the breeding places and collecting the larval stages of insect and their development to the adult stage. This experiment is to be done by the students under the guidance of the faculty
Expected outcome: The student identifies common vectors of diseases and their breeding places, bionomics, and their control measures
CM 4.3: Demonstrates steps in evaluation of health promotion and education program
The objective of this skill is to assess health communication needs or gaps in health promotion/education programs and health services for planning effective behavior change communication strategy besides comprehension of national communication strategy for various national health programs. One of the pivotal public health approaches is to promote healthy behaviors through massive health education programs and healthy public policies to generate awareness leading to change in attitude and adoption of healthy behaviors. How we demonstrate the effect of health education programs is a challenging task
The knowledge can be assessed by collecting information on a standard questionnaire developed under national health program or developed by the students. For example, comprehensive knowledge of HIV/AIDS under National AIDS Control Program means (i) knowing any two methods of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful uninfected partner), (ii) rejecting two most common local misconceptions about transmission, (iii) being aware that healthy-looking person can be infected with HIV. The attitudes can be assessed by Likert's scale. Practices can either be observed such as breastfeeding, infant and young child feeding, and personal hygiene or elicited by interviewing potential beneficiaries of a service program. This requires a cohort exposed to sustained health education program, for example, school students, pregnant and lactating mothers, and beneficiaries of national health programs such as family planning, tuberculosis, malaria, NCDs, and NACP. Teachers can develop data-based case studies as also an evaluation of a poster, a pamphlet, or a health message. Textbooks seldom describe planning, implementation, and evaluation of health promotion/education program.
Expected outcome: The student formulates health messages and demonstrates best health practices in the allotted family/in schoolchildren or else he classifies health behaviors into harmful, harmless, and healthy behaviors/best practices as observed in the community or family, to assess their communication needs
CM 5.2: Demonstrate correct method of performing a nutritional assessment of an individual/family and community by using appropriate method
The learning objective of this skill is to improve the nutritional status of the community by improving dietary practices. This skill can be acquired in family studies. The nutritional status of most vulnerable – young children under 5 years of age, pregnant and lactating mothers can be assessed by the students by clinical examination to detect clinical signs of malnutrition which appear very late or by anthropometric measurements such as weight and height for age and weight for height besides midupper arm circumference, and body mass index, which can detect invisible malnutrition. Point of care tests such as hemoglobin estimation of schoolchildren and pregnant women for anemia and biochemical tests (only for research purposes) can be done. Dietary surveys are conducted to assess dietary intake of most vulnerable or a family and in community. These surveys are done by standardizing the commonly used household utensils for volume or quantity. Amount of food items consumed on previous day (24 h recall method) is determined on standard forms developed by the National Institute of Nutrition. Quite often these surveys are cursory and ignore standard procedures. Faculty members must have adequate training on anthropometric measurements and calibration of equipment. Cooking practices are also observed along with consumption of iodized salt tested by salt testing kit. The food consumption in young children of 6–23 months of age can be assessed by three core indicators of minimum dietary diversity, meal frequency, and acceptable diet (proportion of children consuming four or more food groups, proportion of children consuming solid/semisolid foods for a minimum number of times, and minimum acceptable diet as per the WHO recommendations). Dietary diversity is a proxy for nutrient adequacy of the diet
Expected outcome: The student calibrates weighing scale, ascertains correct age, weighs young children, plots weight on growth chart as per age, interprets the result, and explains the results and desired actions to mothers
CM 5.4: Planning and recommending a suitable diet to individual and families
Based on the findings of dietary surveys, the diet of family or individual can be improved by improving cooking practices and recommending affordable and acceptable food items available locally or in home
Expected outcome: The student carries out a dietary survey on minimum dietary diversity and meal frequency of young child of 6–23 months of age in the allotted family and formulates/demonstrates diet for the child, tests iodine content of the salt by qualitative method, and standardizes the commonly used utensils for volume or quantity
CM 6.1: Formulate a research question for the study
The objective of this skill is to develop scientific temper among students to pursue research in any area of medicine. First of all, students identify a pressing health problem and then convert it into an answerable research question. Example of problem/topic-problem of anemia in adolescents/peer group, overweight and obesity, and dental caries in adolescents. Student's research topic should not be too ambitious because of the constraint of time and resources. Further, it should be feasible, interesting, novel, ethical, and relevant. It should focus on action and operational research. Framing a research question requires thorough review of literature from library, journals, and the use of computers
Expected outcome: The student completes at least one feasible assigned project in the area of action/operational research
CM 6.2: Demonstrate the method of data collection, classification, analysis, interpretation, and presentation of statistical data
The learning objective of this skill is: how to manage data to generate information for action and use of data for planning, monitoring, evaluation, and decision-making. Common data collection methods are interviews, health examination (clinical signs) including anthropometric measurements, laboratory tests, and imaging. Gender-specific qualitative and quantitative data can be collected from peer group by students by interview and measurements. They classify, analyze, and interpret these data themselves and present these data by frequency tables and appropriate diagrams. If data are collected from other sources, it must relate to a national health program. Avoid use of hypothetical data
CM 6.3: Demonstrate the application of elementary statistical methods including tests of significance in various study designs.
One can demonstrate tests of various studies on qualitative and quantitative data collected from sample of MBBS class students. In simulation exercises always give data relevant to a specific national health program or else use National Family Health Survey (NFHS)-4, National Health Profile data, or data of Comprehensive National Nutritional Survey
CM 6.4: Demonstrate common sampling techniques and simple statistical methods: frequency distribution, measure of central tendency, and dispersion
Sampling techniques can be demonstrated by drawing a desired sample size from a MBBS class (universe) by simple random or systematic random sampling technique. The sample can also be drawn from schoolchildren (universe) for goiter survey by cluster sampling technique. Measures of central tendency and dispersion can be generated from students data or aggregating data of family studies
Expected outcome of CM6.2 to 6.4: The student draws a desired sample size from a peer group, collects data from peer group, calculates measures of central tendency and dispersion, prepares 2 × 2 table, and applies appropriate test of significance by the use of computers (statistical softwares) for rapid processing of data
CM 7.4: Define, calculate, and interpret morbidity and mortality indicators based on given set of data.
The objective of this skill is to develop epidemiological skill for assessing disease burden in community, assessing health-care needs, planning, monitoring and evaluation of impact of interventions under various national health programs. Emphasis should not be to just calculate rates but always stress on their applications. The given set of data on morbidity and mortality must relate to various national health programs as published in National health profile, NFHS, Surveillance data, recent outbreak data (such as COVID-19 pandemic data) or a data of a facility – subcentre, PHC, and CHC. SRS data on mortality and causes of death statistics (million death study on causes of death) or infant and maternal mortality data could also be used
Expected outcome: The student calculates incidence/attack rate, prevalence, mortality rates, and interprets these rates in the context of national goals for sustainable development
CM 7.6: Enumerate and evaluate need for screening tests
The learning objective of this skill is to rapidly select at-risk persons or risk factors or risk behaviors as early markers of unfavorable outcome (disease). Screening is usually done in apparently healthy persons. Screening of blood for its safety, screening, and early intervention of children from 0–18 years of age for 4Ds, screening of antenatals to identify high-risk pregnancies, and population-based screening of men and women over 30 years of age for oral, breast, and cervical cancer, screening of persons above 50 years of age for cataract are in place under various national health programs. Use data of these programs to demonstrate the evaluation of screening tests. Point of care tests at subcenter and PHC are available (hemoglobin testing, blood glucose, Widal test/Tyhi-d, universal screening of antenatal for syphilis, and HIV and VIA for early detection of cervical cancer) for screening programs. Demonstrate the evaluation of these screening tests in terms of their sensitivity, specificity, and predictive value by developing suitable exercises linked with ongoing national health programs
Expected outcome: The student calculates sensitivity, specificity, and predictive value of a test on data set as elaborated above
CM 7.7: Describe and demonstrate the steps in the investigation of an epidemic of communicable disease and principles of control measures
The learning objective of this skill is to learn epidemic-prone diseases, warning signals of an epidemic, and strategies of containment/spread and prevention of an epidemic of similar nature in future. Demonstrate the methods of detection of outbreak/epidemic such as rumor register, its columns, and contents, reviewing routine surveillance reports under Integrated Disease Surveillance Project (IDSP), weekly reporting formats “ S,” “P,” and “L” forms, media reports, and laboratory results. Demonstrate the first information report on Form C, case-based reporting format and line listing format as also epidemic curve. Link this skill with IDSP program for investigation and control of common epidemics of CCDs, for example, food poisoning, diarrheal diseases/cholera, measles, dengue, chikungunya, and JE, Use training manual of IDSP and case studies on epidemic investigations besides manuals on control measures of epidemic developed by National Centre for Disease Control
Expected outcome: The student prepares a histogram to show epidemic curve (time analysis), draws an incidence map (place analysis), and prepares a table of age and sex of affected persons in the population (person analysis) of any epidemic/outbreak case study data provided by faculty
CM 8.6: Educate and training of health workers in disease surveillance, control, treatment and health education for CCDs and NCDs.
The objective of this skill is to learn how to train and educate paramedical health teams on the job and for continued education, to achieve goals of public health surveillance. The other objective is to learn the role of health workers in syndromic surveillance of CCDs and risk factors surveillance of NCDs, and basic response to outbreaks of CCDs. The health workers (male and female), ASHAs, AWWs, community informants, and link workers are in regular contact with the community and households/families. They provide outreach immunization and home-based services. They come to know the unusual events first of all. These workers have been assigned the task of “syndromic surveillance” and surveillance of risk factors of NCDs. Weekly filled up reporting “S” forms can be demonstrated to students to capture the syndromes being reported and action initiated by these workers. Faculty members facilitate the acquisition of this skill if they integrate their teaching program with district surveillance officer/district epidemiology unit and get involved in training program of IDSP. Use district/state-level surveillance officers for UG training program to the extent possible
Expected outcome: The student identifies syndromes under surveillance and records the contents of training of health workers under IDSP and interprets the quality of data collected by workers on form “S” for training needs assessment
CM 9.2: Define, calculate, and interpret demographic indices including birth rate, death rate, and fertility rate
The objective of this skill is to learn the impact indicators of various national health programs/interventions over the time. Live data of SRS, NFHS-5, recent National Health Profile, recent Health and Family Welfare Statistics in India or routine reports of subcenter/PHC can be helpful to develop this skill. It should not be pursued as a pure hypothetical or theoretical statistical exercise for compliance. Teachers can collect reports from subcenters or Anganwadis or ASHAs on population size, births, deaths over a period of 1 year and students can work on these data or else the data of adopted field practice area can be used. Live data such as couple protection rate, parity-wise data, and data on eligible couples of a subcenter can be used. For population trends, its distribution, age and sex composition, sex ratio, density, and natural growth rate can be learned by use of census data
Expected outcome: The student prepares population and vital statistics profile of India from census data, determines sex ratio, calculates demographic indices from a given data set, and interprets in the context of national demographic goals by 2025.
Core skills in epidemiology, biostatistics, demography and vital statistics, applied nutrition, social and behavioral sciences, environmental sciences, reproductive biology, communication, and community relationships are best learned in the community by use of real-life situations/live data of national health programs and routine reports of the health facility. Student documents his/her learning experience/skills acquired in their practical notebook for self-assessment.
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