Submitted: 25 October 2023
Accepted: 3 April 2024
Published online: 1 October, TAPS 2024, 9(4), 71-75
https://doi.org/10.29060/TAPS.2024-9-4/CS3161

Sulthan Al Rashid¹, Syed Ziaur Rahman², Santosh R Patil³ & Mohmed Isaqali Karobari⁴

¹Department of Pharmacology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), India; ²Department of Pharmacology, Jawaharlal Nehru Medical College, Aligarh Muslim University, India; ³Department of Oral Medicine and Radiology, Chhattisgarh Dental College & Research Institute, India; ⁴Dental Research Unit – Centre for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), India

I. INTRODUCTION

Concept maps serve as teaching and learning tools that appear to assist medical students in cultivating critical thinking skills. This is attributed to the adaptability of the tool, acting as a facilitator for knowledge integration and a method for both learning and teaching. The extensive array of contexts, purposes, and approaches in utilising Concept maps and tools to evaluate critical thinking enhances our confidence in the consistent positive effects (Fonseca et al., 2023).

In the realm of medical education, employing concept maps as a learning strategy can prove to be beneficial (Torre et al., 2023). Concept maps, visual representations of learners’ understanding of a set of concepts, have proven to be valuable tools in medical education (Novak & Cañas, 2008). The integration of concept maps as a teaching strategy allows for the depiction and exploration of the relationships among various medical concepts (Ruiz-Primo & Shavelson, 1996). In our instructional approach, instructors employ concept maps during lectures (Appendix 1), emphasising the interconnectedness of key concepts. Students actively participate in creating their own concept maps, facilitating collaborative learning. This flexible approach accommodates diverse learning styles, with students using both concept map notes and textbooks. The final evaluation includes an assessment of students based on their application of concepts outlined in the concept maps, contributing to a well-rounded and adaptable learning experience in medical education.

In this study, we aimed to assess the impact of utilising the concept map teaching technique in conjunction with concept map notes on the academic performance of students.

II. METHODS

In the field of medical education, the adoption of Competency-Based Medical Education (CBME) introduced by the National Medical Commission (NMC) for the MBBS 2019 batch has led to the implementation of various innovative teaching approaches. This research, conducted with the approval of the Institutional Review Board (IRB) under the reference number 020/09/2023/Faculty/SRB/SMCH, focuses on comparing the academic outcomes of two MBBS batches of Saveetha Medical College and Hospital.

We evaluated the first-year results of the 2020 MBBS batch, which did not receive concept map teaching, and compared them with the first-year results of the 2021 MBBS batch, where concept map teaching was implemented. Students are encouraged to create concept map notes on A3 white sheets, as illustrated in Appendix 2. Furthermore, “subject-wise Saveetha Maps” were developed, incorporating handwritten notes taken by students on each topic.

Generally, it was advised to all the included students to carry on with the books and concept map notes. Furthermore, if they encounter any difficulty in referring the books, they are advised to make use of the concept map notes. In our educational setup, we promoted the combined use of concept maps notes and books for all the students. All students received their compiled handwritten notes, which include all the topics included in their particular subject, as a part of the final evaluation during summative assessment at the end of academic year, and their performance was examined by the examiners.

III. RESULTS

Performance of both the 2020 MBBS batch and the 2021 MBBS batch was assessed. To compare the percentages of first-year results of the 2020 MBBS batch (without concept map) and first-year results of the 2021 MBBS batch (with concept map), a t-test was used, and the results were highly significant (P <0.001) (Table 1 and Appendix 3).

Submitted: 31 January 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 68-70
https://doi.org/10.29060/TAPS.2024-9-4/PV3238

Ardi Findyartini^1,2 & Azis Muhammad Putera²

¹Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia; ²Medical Education Center, Indonesian Medical Education and Research Institute, Faculty of Medicine, Universitas Indonesia, Indonesia

I. ON PROFESSIONAL IDENTITY FORMATION

Professionalism in medicine can be considered as attributes, behaviours, and identity of the professionals who put the needs of their patients and the community they serve above their individual needs. The concept of professionalism is dynamic and might be perceived differently over time, in different contexts, and by different fields, although some ground values like excellence, competence, and altruism might persist. 

Identity formation is an inseparable part of professionalism as it underlines the importance of “being” in addition to the essence of “behaving”. Professional identity formation (PIF) in medical education is both an active psychological process conducted by individuals in internalising their values and others’ expectations. It is also a dynamic socialisation process allowing an individual to be part of the professional community with increasing roles and recognitions. This applies for both medical students who grow to become medical professionals and for medical teachers who probably juggle their different identities as clinicians/researchers to be able to enact their roles as teachers (Cruess et al., 2014).

There is no “one-size-fits-all” rule as to how their PIF should be navigated, as PIF is a journey unique to each individual. The students need to be supported to form their identity from the stage where they just follow the rules to become individuals who can internalise values and expectations from their professional community as an integral part of themselves. The medical teachers, on the other hand, still have to develop their professional identities as teachers and educators in addition to their other identities.

II. CULTURE: WHY DOES IT MATTER?

Given the importance of individual and socialisation processes in PIF, we suggest that it is time for us to consider the influence of cultural factors in students’ and teachers’ PIF. It has been well-established that culture plays a pivotal role in how education is designed, developed, and delivered systematically. However, the frameworks by which medical curricula and faculty development programs are developed, as well as literature informing the commonly understood concepts of PIF, often stem from Western countries. Recent understanding of culture, professionalism, and PIF acknowledges that professionalism is context-specific, with notable differences between norms adopted by the contemporary Western world and in non-Western settings (Al-Rumayyan et al., 2017). Herewith, we use Hofstede’s cultural framework to discuss this matter, where countries are characterised by spectrums of hierarchy, collectivism, uncertainty avoidance, long vs short term orientation, femininity vs masculinity, and self-indulgence and restraint (Hofstede, 2001).

For instance, our research highlights the importance of culture in the PIF of medical teachers. Four main factors seemed to influence the PIF of medical teachers in our settings: an interplay between internal values and external influences, empowerment of teachers’ roles by early socialisation, experiential workplace learning, and future prospects of their careers as teachers. Looking deeper, we identified several relatively unexplored factors influencing the PIF of our teachers: the importance of divine values and religious beliefs, influence of family, and how their roles are recognised by the society (Wahid et al, 2021).

The influence of religious beliefs and societal recognition on PIF seems to be predominant in Arabic and Islamic countries, something that may not be predominant in Western countries. The strong religious influence built a perception of teaching as an act of good deed and opportunity to enact one’s faith in God, cultivating the motivation to pursue a teaching career. From Hofstede’s framework viewpoint, familial influence plays a critical role in a collectivist society like ours, as proven in our study where the participants’ decision to be medical teachers was strongly influenced by also considering coexisting personal roles in the family (especially evident in female teachers). The existence of a family member acting as a role model and internal decision making in the family also supported the decision to pursue a teaching career (Wahid et al., 2021).

The communality in collectivistic society was also notable, since societal recognition was deemed as a reward to develop oneself professionally, showing a stronger emphasis on social relationship as opposed to the Western counterpart which might put more emphasis on individual values and self-fulfilment. The importance of socialisation was evident as many admitted that early in their teaching careers, they would often shadow their seniors, engage in faculty development programs, and nurture their identity by engaging with students and patients. Interacting with fellow teachers helped them to grow professionally and remind them of their roots, creating a valuable interplay between their internal motivation and external influences. This shows an important implication for faculty development (FD) programs: since FD plays an important societal role in supporting the teachers’ PIF, FD programs should be developed with an emphasis on workplace and social learning (Wahid et al., 2021).

Our study among medical students also emphasises the need to address cultural factors such as high power distance, uncertainty avoidance, and collectivism. Our findings suggest that the role of the learning environment is pertinent. In a hierarchical setting with large power distance like ours, we found that socialisation through the hidden curriculum might result in negative role-modelling, which might hinder students’ professional development. The hierarchical and collectivistic settings also influenced students’ responses to professional dilemmas, causing internal conflicts and confusion as to how they should act later on when misconducts are normalised by their hierarchical environment. Considering the study context, teachers have a great role on students’ PIF through good role modelling and facilitation for students in dealing with ethical and professional dilemmas during their learning process, especially in clinical practice. A practical implication is how our students preferred a more structured approach and clear guidance to develop reflective skills and feedback-seeking behaviour in this setting with high uncertainty avoidance compared with other settings (Findyartini et al., 2022).

Our findings suggest that PIF is indeed a fluid process and socialisation is essential. Many students admitted as they got involved further in their medical education journey and continuously reflected on their experience, they were able to understand the complexity of their PIF more. Many were aware about their psychological journey into becoming a professional and how they continuously internalise the traits expected of a professional. External influences like the hidden curriculum, the learning environment, and the behaviours of their peers seemed to intercalate with their initial motivations through continuous socialisation forms, showing a dynamic psychosocial transition (Findyartini et al., 2022).

III. RETHINKING CULTURE AND PIF: THE IMPLICATIONS

We propose two major ways by which culture influences PIF. First, it dynamically influences the societal expectation of professional traits. This should pose some questions, like what kind of professionals does the community need? How does the community currently, and probably in the near future, perceive what a professional is? By this first understanding of ours, it is then pertinent to continuously reflect and identify the needs of the community in defining the traits of a professional. Thus, simply adopting findings from Western literature might not be beneficial and results must be interpreted contextually, and this should call for further studies on professional identity formation in diverse socio-cultural contexts. We would also like to reiterate that professionalism is a temporal and contextual concept, and this will be continuously reinterpreted and redefined with influence from scientific breakthroughs, industrialisation, and globalisation. 

Second, we think of culture as a subtle yet powerful force saliently affecting the process to reach the intended outcome i.e professional identity, as elaborated before. Culture exerts substantial influence on the development process itself, and this is where culture operating on individual and institutional levels, we argue, plays a critical role. Take, for example, our findings on how our students preferred a more direct, structure-driven, and clear guidance in navigating their professional development, or how our teachers were greatly driven by religious beliefs and familial motivation. The communality informs how curriculum for students and FD programs for teachers could be developed. The concepts of intertwining roles of each unique individual student/teacher and the socialisation process involving the learning environment, role models and relevant experiences play a pivotal role in this matter. Curricula and FD program should be developed around the concept of the target as subjects with their own internal values and preferred ways of thinking and doing influenced by the communities of practice around them. We would like to also underscore that the PIF of students and teachers are very much interrelated and we expect that students’ PIF will be highly facilitated by the teachers whose PIF as educator is well internalised.

To summarise, we would like to reemphasise the role of culture and understanding of cultural diversity in the context of PIF. We urge students, teachers, and educators to look at and understand culture as a subtle force driving the aim and process to be professionals. Since socialisation is central in the identity development of both teachers and students, special attention should be given to first reflect and identify cultural values in different levels, most importantly the institution, to develop culturally-sensitive curriculum and faculty development programs.

Notes on Contributors

Ardi Findyartini (AF) currently serves as a Professor of Medical Education and the Head of Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AF led the study, developed the ideas, wrote, and critically revised the manuscript.

Azis Muhammad Putera (AMP) is a researcher at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AMP developed the ideas, wrote, and critically revised the manuscript.

Acknowledgement

The authors would like to thank all teaching and academic staffs of the Department of Medical Education, Faculty of Medicine, Universitas Indonesia, as well as the researchers, research assistants, research interns, and administrative staffs at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia for the great collaboration by which this paper can be produced.

Funding

The authors received no funding for this work.

Declaration of Interest

The authors declare no competing nor conflict of interests.

References

Al-Rumayyan, A., Van Mook, W. N. K. A., Magzoub, M. E., Al-Eraky, M. M., Ferwana, M., Khan, M. A., & Dolmans, D. (2017). Medical professionalism frameworks across non-Western cultures: A narrative overview. Medical Teacher, 39(sup1), S8–S14. https://doi.org/10.1080/0142159X.2016.1254740

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine: Journal of the Association of American Medical Colleges, 89(11), 1446–1451. https://doi.org/10.1097/ACM.0000000000000427

Findyartini, A., Greviana, N., Felaza, E., Faruqi, M., Zahratul, T. A., & Firdausy, M. A. (2022). Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Medical Education, 22(1), 443. https://doi.org/10.1186/s12909-022-03393-9

Hofstede, G. (2001). Culture’s consequence: Comparing values, behaviors, institutions, and organisations across nations. Sage Publications. https://doi.org/10.1016/S0005-7967(02)00184-5

Wahid, M. H., Findyartini, A., Soemantri, D., Mustika, R., Felaza, E., Steinert, Y., Samarasekera, D. D., Greviana, N., Hidayah, R. N., Khoiriyah, U., & Soeselo, D. A. (2021). Professional identity formation of medical teachers in a non-Western setting. Medical Teacher, 43(8), 868–873. https://doi.org/10.1080/0142159X.2021.1922657

*Ardi Findyartini
Faculty of Medicine,
University of Indonesia
Salemba 6 Central Jakarta 10430
+62 21 3901814
Email: ardi.findyartini@ui.ac.id

Submitted: 7 October 2023
Accepted: 19 June 2024
Published online: 1 October, TAPS 2024, 9(4), 65-67
https://doi.org/10.29060/TAPS.2024-9-4/PV3154

Justin Wen Hao Leong^*, Yu Bin Tan^* & Bochao Jiang

Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore

*Co-first authors

I. INTRODUCTION

“Teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction”- Hippocratic Oath

Since time memorial, the very act of teaching has been intertwined with that of being a physician. In so far that this tradition is found inscribed in the Hippocratic Corpus dating to the 5^th century BC. Beyond a calling and a duty, the sharing of experience and expertise is also a rewarding aspect of our roles of doctors. In a climate of ever-increasing demands of knowledge and clinical load, it is imperative we hold on to this aspect closely, and simultaneously look to and embrace new mediums to assist medical educators to meet the current challenges. In this article, we share our experience on how we can incorporate X, formerly known as Twitter, as an extra tool to facilitate teaching on the go during ward rounds and promote self-reflection after.

II. THE MEDIUM

X is a leading social medial platform with up to 541 million monthly users (Musk, 2023). Users can create posts, with each post limited to 280 characters with spaces. The term tweetorial, a neologism combining “tweet” and “tutorial”, is a consecutive series of posts that provide coverage of a given topic. One common format of a tweetorial involves the author creating a multi-post thread about a topic, providing a content outline followed by a brief discussion of the topic with links to various societal guidelines or papers. The user interface allows hashtags, images, and weblinks to be embedded into the posts.

Whilst some naysayers have decried the character limit by saying that it eschews complexity, conversely, it is precisely in the form of such brevity that makes it invaluable. For it is this very brevity that forces key information to be distilled in bite-sized teaching points (Breu, 2020).

Increasingly, physicians have been using the platform to disseminate research, share ideas and discuss topics. In the field of gastroenterology, popular hashtags include #Livertwitter or #GITwitter, with several physicians such as @drkeithsiau, @stevenbollipo, @AustinChiangMD from the United Kingdom, Australia and the United States respectively amassing followers of up to 118 thousand with each post on average being viewed thousands of times. The global scale and reach of X is undeniable; despite this, the posts remain personable and accessible, as readers are able to interact with the authors of these directly by liking, reposting, quoting, commenting or bookmarking them.

Whilst these have led to many discourses on the general use of social media in medical education, the ‘how-to’ of incorporating the use of X as a means of teaching on the run to residents and understanding its role in learning theory has not been expounded upon. In this reflection, we share how we can incorporate this medium in the immediacy of facilitating teaching on the run and the learning theories that underpin this.

III. SETTING THE STAGE

Teaching is a pre-planned learning activity, and even teaching on the run in a busy clinical setting can be planned. The crux as educators is firstly, to be keenly aware of the ever-evolving learning needs of our residents, and secondly, to amalgamate the two seemingly antithetical spheres of ‘running to do’ and ‘pausing to teach’ by having on hand an armamentarium of teaching posts that cover the gamut of core and common topics.

One way to be attuned to the learning needs of our residents is to refer to the programme-specific entrustable professional activities (EPAs). First introduced in the Netherlands in 2005, EPAs are discrete and professional core tasks that are speciality-specific. They are independently executable, observable in practice and measurable in output (Ten Cate, 2005). The EPAs clearly defines the need of the residents and across EPAs, span the breath of the content and desired outcomes after graduation from a specific residency programme.

For the educator, recognising the EPAs and imbibing the same shared mental model as our residents, coupled with pre-prepared content provides the chance to deliver a teaching point on a topic on-the-go whenever a given opportunity arises. The aim here is the immediacy of the educational intervention, to guide and stimulate learning in the here and now – to set the stage to seize the teaching moment.

IV. SEIZING THE MOMENT

Whilst covering the inpatient gastroenterology service, our team had a new admission – a young man with a history of chronic pancreatitis had just been admitted for complaints of abdominal pain. He appeared cachexic and was hunched up in bed in pain. After obtaining a history, performing a physical examination and ensuring that the appropriate investigations and medications were ordered, we came together for a short huddle. Just a few weeks prior, we had authored a tweetorial on chronic pancreatitis, covering the definition, pathophysiology, aetiology, diagnostic algorithm, imaging features and complications including pain, malnutrition, exocrine deficiency and cancer.

In the huddle, each member of the team came together, took out their smartphones and independently accessed the given thread on X. We then in a succinct fashion, embarked on a discussion of chronic pancreatitis with the tweetorial providing a scaffold for the discussion.

In cognitive learning theory, the locus of learning is the internal environment of the learner and his or her cognitive structures. The learner uses cognitive tools, including insight, information processing, perception and memory to lock-in the learning by assigning meaning to certain actions. One of the most important aspects of cognitive learning is the development of critical thinking through reflection. This process of reflection can either be a reflection ‘on’ action, where the learner reflects on a situation that has happened, or a reflection ‘in’ action where the learner reflects about the action in the moment, as they are performed. The core, here then, is in seizing the immediacy of such encounters, such that the reflection and synthesising of new knowledge will always be one of reflection ‘in’ action and allow the immediate synapse of what is gleaned to what is previously known.

Before we broke off our huddle to continue with our rounds, our residents could now articulate that more than a patient with a history of chronic pancreatitis presenting with abdominal pain, we had encountered a patient with hereditary pancreatitis with imaging features of pancreatic calcification, ductal lithiasis and intermittent Amman Type B pain who may benefit from a trial of neuromodulators. They then bookmarked the tweet for future reference, and within it, its attendant link to a clinical review paper on chronic pancreatitis for further reading.

V. REFLECTING AND PROPAGATING

Finally, our residents were encouraged to reflect on the topic towards the end of the day (reflection ‘on’ action) by reposting the thread on X and sharing their learning points with regard to the patient encounter and the topic. There were also encouraged to tag fellow residents in the team to further encourage discourse and craft their own new tweetorials on pertinent topics pertinent topics to maximise the use of X as a learning tool (Forgie, 2013).

The spirit of reflection the provides the transition from a cognitivist orientation to a humanist orientation of learning. Within this framework, learning is viewed as a personal act to achieve one’s own full potential with goal that is self-directed and autonomous. This has three main characteristics, firstly, personal involvement by the learner, secondly, learning that is self-initiated, and lastly, learning that is self-evaluated. Taken together, the combination of these three reflects the growth of an independent learner.

The creation of tweetorials by learners thus fosters the development of additional knowledge translation skills by training the learner to first dive deeper into the topic, synthesise knowledge, distil it and lastly, package it with brevity (Tsang, 2023). The learner-created tweetorial then takes on a life of its own online, allowing its own interactions and comments allowing the student to engage in critical thinking and constructive feedback online which in turn transitions into self-evaluation.

VI. CONCLUSION

The traditional Bloom’s taxonomy of remember, understand, apply, analyse, evaluate and create serves as a valuable framework for learning and X, if used appropriately, can be an excellent teaching tool to achieve these educational goals. Initially, the learner ‘consumes’ a tweet in a cognitivist framework, but by bringing the immediacy of the clinical encounter head-on into the screens of their smartphones, the use of X then fast tracks them into applying this new-found knowledge in the current clinical encounter. After the encounter, the learning then shifts into a humanist orientation with the vision of an independent, self-driven and self-critical learner that creates new work; and through this process, take their own steps toward becoming a teacher on the run with an X-tra tool.

Notes on Contributors

Justin Leong and Tan Yu Bin conceptualised the work, drafted the work, revised it and gave final approval of the version to be published. Jiang Bochao drafted the work, revised it and gave final approval of the version to be published.

Funding

There were no funding sources in this paper.

Declaration of Interest

No potential conflicts of interests relevant to this article was reported.

References

Breu, A. C. (2020). From tweetstorm to tweetorials: Threaded tweets as a tool for medical education and knowledge dissemination. Seminars in Nephrology, 40(3), 273-278. https://doi.org/10.1016/j.semnephrol.2020.04.005

Forgie, S. E., Duff, J. P., & Ross, S. (2013). Twelve tips for using Twitter as a learning tool in medical education. Medical Teacher, 35(1), 8-14. https://doi.org/10.3109/0142159X.2012.746448

Musk, E. [@elonmusk]. (2023, July 29). ? monthly users reach new high in 2023. [Image attached] [Post]. X. https://twitter.com/elonmusk/status/1684978651857596429

Ten Cate, O. (2005). Entrustability of professional activities and competency-based training. Medical Education, 39(12),1176-1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x  

Tsang, R., & Pinder, K.E. (2023). The #Tweetorial: An underutilised teaching tool in undergraduate medical education? Medical Science Educator, 33, 583–587. https://doi.org/10.1007/s40670-023-01764-5   

*Justin Wen Hao Leong
31 Third Hospital Ave,
Singapore 168753
Email: justinleongwenhao@gmail.com

Submitted: 3 January 2023
Accepted: 29 May 2024
Published online: 1 October, TAPS 2024, 9(4), 1-5
https://doi.org/10.29060/TAPS.2024-9-4/GP2940

Sengkhoun Lim¹, Steve Vilhem², Sambath Cheab¹, Laura Goldman³, Aklinn Nhem¹, Ponndara Ith¹ & Youttiroung Bounchan¹

¹University of Health Sciences, Cambodia; ²Institute of Humanities in Medicine CHUV, Switzerland; ³Boston University, United States of America

Abstract

Introduction: There is a global call for transforming medical education to meet evolving healthcare needs. However, navigating the challenges of educational change in resource-limited contexts requires key stakeholders, from leaders to educators and students, to adopt innovative approaches. This paper presents practical examples of such innovations from the University of Health Sciences (UHS) in Cambodia’s experiences, followed by discussions on enabled and hindered factors of their initiation, implementation, and sustainability. This paper also aims to inspire future medical education innovations.

Methods: This paper relied on internal document reviews, including strategic plans, project proposals & planning, course syllabi, and evaluation reports, and the collective working experiences of co-authors in initiating, implementing, and leading these innovations.

Results: Three innovative projects at UHS illustrated how creative ideas are put into practice, including (1) The elective International Programme (IP) with a dual objective of training local trainers while preparing students for international mobility, (2) The Master of Health Professions Education (MHPE), a cost-effective faculty development programme delivered in-person at UHS campus by faculty of a university partner, and (3) Peer-assisted Learning (PAL), a student-led initiative to promote learning skills.

Conclusion: Medical education innovations are needed in resource-limited contexts. The success of these initiatives resulted from multi-factors, notably long-term strategic planning, supportive leadership, active partnerships, policy commitment, local champions, resourcefulness, and student engagement. The late adoption of technology-enhanced learning, the necessity for robust faculty development programmes, and early investment in student leaders, coupled with post-graduate retention planning, represent challenges that present strategic opportunities.

Practice Highlights

• Medical education innovations are needed in a resource-limited country like Cambodia.
• Piloting before widespread implementation allows for tailoring to a specific local context.
• Long-term partnerships between external experts and internal faculty foster contextualisation, local capacity-building, and stakeholder buy-in.
• Continuous and supportive leadership with strategic planning is essential for driving and sustaining educational innovations.
• Identifying and nurturing local champions to carry out innovations is key to sustainability.

I. INTRODUCTION

The 1910 Flexner report inspired the transformation of medical education to a science and knowledge-based curriculum. A century later, an influential Lancet report called for transforming health professions education to meet changing population healthcare needs (Frenk et al., 2010). However, in resource-limited contexts, doctor training has not kept pace with public health challenges like an increase of chronic diseases. Moving away from the Flexnerian model presents significant challenges to the status quo because it involves leadership, technical, financial, and administrative commitments, specifically in Cambodia (Lim et al., 2024). To address these issues, key stakeholders, from leaders to educators and students, must adopt innovative approaches to medical education that are culturally and contextually appropriate.

This paper showcases three innovations that exemplify how creative ideas are put into practice at the university level: the elective programme, faculty development, and student-led initiative. Innovation, by definition, refers to the ability to introduce novel and useful ideas within a specific context. These examples are considered new and beneficial for stakeholders in the Cambodian context. The first two are practices adapted from other countries, while the last is an initiative of, by, and for students from within the university. The “Triple I” model of three phases of initiation, implementation, and institutionalisation, is used to discuss these innovations, especially the challenges to sustainability (Fullan, 2015). This paper also aims to inspire future innovations in medical education.

II. THREE INNOVATIONS IN MEDICAL EDUCATION

University of Health Sciences (UHS) is the oldest and largest state-owned university of health sciences in Cambodia. In late 2001, UHS became a public administrative institution entrusted by the Ministry of Health to be a leading university in medical education reforms. Below are three medical education innovations at UHS.

A. Elective Programme

Launched in 2013 by UHS-Faculty of Medicine (FoM) with financial and technical assistance from development partners, especially France, the International Programme (IP) is a tool for educational innovation and strengthening international relationships. This 3-year elective programme annually selects 60 outstanding students during their clinical phase (years 4-6). The IP has a dual objective: training of trainers (ToT) and student preparation for international mobility. To achieve these goals, UHS brings foreign professors from partner universities to role model a new generation of Cambodian trainers in modern teaching. Students actively engage in four main activities: academic training, language courses, research methodology, and socio-cultural activities. Visiting professors teach IP undergraduate students in the mornings and post-graduate residents in the afternoons to maximise their in-country time. Local trainers co-train with these professors in their respective disciplines to learn new teaching methods. French, English, and Khmer languages are mediums of instruction. 

The IP has functioned as a pilot initiative, introducing student-centered learning, simulation-based education, and standardized assessment to the medical curriculum. These approaches have been well-received by faculty and students. In 2017, case-based learning (CBL) and simulation were scaled up to all students at FoM. The IP is considered an achievement because of its contribution to UHS’s strategic goals: educational innovation, ToT, and strengthening international relations. Presently, UHS has a pool of at least 60 trainers in CBL and simulation at FoM. Furthermore, the IP model was replicated within UHS’s nursing and pharmacy programmes in 2015 and 2018, respectively.

B. Faculty Development Programme 

Faculty development (FD) is key to supporting educators in their multifaceted roles. UHS has invested in FD programmes to equip faculty with knowledge and skills, specifically responding to reforms in health professions education (HPE). A key initiative was a 2-year Master of Health Professions Education (MHPE) programme, offered in partnership with University of the Philippines (UP)-Manila from 2011 to 2016. Funded by the WHO and French Cooperation, the programme catered to two cohorts of 28 health professionals, including doctors, dentists, pharmacists, nurses, and medical laboratory technicians.

The programme’s hybrid delivery model was a historical first at UHS. It combined intensive 5-day on-site sessions led by visiting UP-Manila faculty, followed by distance learning modules. The MHPE programme is not only for individual professional development but also institutional development. While the programme faced challenges with language barriers, inter-professional learning, and technology limitations, it yielded positive outcomes in local human resource development in HPE. Eight students graduated with master’s degrees, while 12 received diplomas. Many graduates now contribute significantly to UHS, staffing the pedagogy unit and different faculties.

Building on local expertise, those MHPE graduates embarked on own FD programme development at UHS, beginning with a mandatory 4-day basic pedagogy course for all educators in 2015. The pedagogy unit has trained over 518 teachers in basic pedagogy. Currently, UHS’s FD programmes include short courses and workshops; strategically tailored to address national, institutional, and teacher needs. These programmes focus on competency-based course development, lesson planning, writing MCQs, and practical teaching skills (e.g., interactive lectures, small group, and simulation-based facilitation). For sustainability, UHS prioritises FD initiatives that are competency-based, cost-effective, and fit to the Cambodian context. Most FD programmes are now designed and delivered in Khmer by local trainers. UHS still collaborates with international partners to develop different FD programmes, especially for new HPE topics like interprofessional education (IPE).

C. Student-led Initiative

The value of students as active partners in education is well-established. Recognizing this notion, UHS actively promotes student engagement, particularly student roles in teaching. Through the Global Health through Education Training and Service (GHETS) grant (2016-2022), six cohorts of 56 students participated in the Essential Skills in Medical Education (ESME) online course. A group of student champions from the first cohort (including two authors: SL and SC) partnered with UHS-Medical Student Association (MSA) to launch the Peer-assisted Learning (PAL) club. PAL initially began as a 3-month extra-curricular course designed to integrate learning skills with basic science subjects. It has currently evolved into a hub for student-led initiatives, offering the Annual Medical Education Conference (AMEC), training courses, workshops, and socio-cultural events. Most activities were postponed during the pandemic, and some were restarted by UHS-MSA in 2023.

III. DISCUSSION

The “Triple I” model describes three phases of educational change over time (Fullan, 2015). The first phase is initiation, an attempt to embrace innovations. The second phase is implementation, the process of putting ideas into action. The third phase is institutionalisation when innovations become routine. The goal of change is institutionalisation; however, it does not occur without innovative adoptions being successfully initiated and implemented. This model is a conceptual framework used to discuss enabled and hindered factors in medical education innovations at UHS, Cambodia.

Active collaboration with development partners drives educational change at national and institutional levels in Cambodia (Lim et al., 2024). The IP and FD are examples of technical cooperation, directly contributing to the university’s long-term goals of educational innovation, human resource capacity-building, and international relations strengthening. Aligning innovations with organisational goals, shared beliefs, and core values is crucial for acceptability and implementation effectiveness (Century et al., 2012). Such partnerships hold particular significance in resource-limited contexts. Through external expertise and funding, medical schools can overcome barriers such as stakeholder buy-in, technical and resource constraints.  

Innovations utilizing existing or external resources are more likely to gain approval from university leaders. Student engagement can positively enhance the university’s reputation on the international and national stage. UHS continues supporting PAL student-led activities, which were initially cost-free and run by highly motivated student volunteers, despite not aligning directly with strategic priorities and may not be perceived as needed by stakeholders.

Innovation characteristics influence the process of putting ideas into action. Relevant stakeholders may struggle to perceive the necessity for change because needs are often unclear at the beginning of innovation. Educational change is inherently complex, demanding shifts in educational philosophy, teaching strategies, and even skillsets. While this complexity poses implementation challenges, it also results in greater change because more is being attempted (Fullan, 2015). The IP was initially co-led with international experts, and local stakeholders ensured contextual and cultural relevance through co-creation and co-teaching. The IP marked a radical departure from the status quo, transitioning from teacher-centered to student-centered instruction. This shift presented significant challenges to many UHS teachers whose teaching practices rely on didactic lectures. Considerable efforts are needed to increase faculty buy-in, commitment, and capacity-building. Placing teachers as co-trainers alongside visiting professors is one way to overcome these challenges and contribute to the success.

Piloting is another enabling factor in which innovations are tested before committing to their full adoption. The IP, FD, and PAL all started as small-scale, elective experimentations before scaling up to benefit all.

Sustainability remains a persistent challenge in resource-limited contexts. Innovative projects will likely cease after a few years of implementation due to a lack of financial, technical, or stakeholder commitment. At UHS, the IP, FD, and PAL are examples of sustainable innovations. Several factors contribute to sustainability. Changing university policies is key to ensuring medical schools engage in long-term transformation (Bland et al., 2000). These three initiatives were built into organisational and programme structures through policy change, budgeting, or academic calendar. For instance, UHS incorporated PAL student-led activities into its 5-year strategic plan (2019-2023) and allocated a small stipend for student peer-teaching. Additionally, students receive recognition through certificates and further opportunities. PAL is sustained through MSA, an established organisational structure at UHS.  

Strong leadership is paramount for driving and sustaining innovations (Bland et al., 2000). Beyond mere initiation, innovation implementation requires ongoing evaluation, revision, and expansion plans to sustain success. UHS strategic plans (2014-2018 and 2019-2023) made public commitment by setting clear indicators for innovative activities such as the IP and FD. These programmes had local leaders do hard work overtime. Empowering local champions to carry out innovations is key to sustainability. UHS exemplifies this through proactive approaches such as identifying and training faculty and student leaders, providing them opportunities to engage in impactful work. Notably, most FD programmes at UHS are now developed and conducted in Khmer by local trainers, underscoring institutional commitment to local capacity-building and sustainability.

Many challenges still exist. The university’s late adoption of technology-enhanced learning hindered its response to the COVID-19 pandemic, causing disruptions when moving to distance learning. Limited resources add another layer of complexity. To ensure effectiveness and sustainability, UHS must invest in technology-enhanced and robust FD programmes, especially in the context of transitioning toward competency-based medical education. Securing funding can be achieved through collaborative partnerships and increased budgets from UHS itself. Investing in student leaders early holds promise; however, results may not be immediately apparent. It takes a bird’s view to allocate resources to develop future leaders, and a transition plan is needed to retain these student champions at UHS after their graduation.

IV. CONCLUSION

Medical education innovations are needed in a resource-limited country like Cambodia. UHS strategically launched three small-scale programmes to meet institutional goals in medical education reforms. The sustainability of these programmes is due to several factors. Leveraging both internal and external resources, including development partners, local faculty and students, enabled knowledge transfer, and maximised resources. Long-term partnerships between international experts and local faculty resulted in contextualisation, capacity-building, and stakeholder buy-in at the home institution. Identifying and nurturing leaders and champions among faculty and students was a key feature alongside piloting innovations, allowing for local adaptations before scaling up. The challenges facing the university can be strategically turned into further opportunities.  

Notes on Contributors

Sengkhoun Lim conceptualized and designed the study, collected and analyzed data, and wrote the manuscript.

Steve Vilhem analyzed data and drafted the International Programme part.

Sambath Cheab provided input on the initial study design and participated in data collection and analysis.

Laura N. Goldman provided guidance on manuscript writing, contributed to the discussion section, and edited the whole manuscript into plain English.

Aklinn Nhem provided source documents, validated information, gave feedback, and proofread.

Ponndara Ith validated information, gave feedback, proofread, and edited the text.

Youttiroung Bounchan provided source documents, validated information, gave feedback, proofread, and edited the manuscript. All authors have read and approved the final manuscript.

Acknowledgement

The authors thank Professor Vonthanak Saphonn, Rector of the University of Health Sciences, for his continuous and supportive leadership in these medical education innovations and Professor Mam Bunsocheat for his contributions to the International Programme at the University of Health Sciences, Cambodia.

Funding

There is no funding involved for this paper.

Declaration of Interest

The authors report no conflict of interest.

References

Bland, C. J., Starnaman, S., Wersal, L., Moorehead-Rosenberg, L., Zonia, S., & Henry, R. (2000). Curricular change in medical schools: How to succeed. Academic medicine, 75(6), 575–594. https://doi.org/10.1097/00001888-200006000-00006

Century, J., Cassata, A., Rudnick, M., & Freeman, C. (2012). Measuring enactment of innovations and the factors that affect implementation and sustainability: Moving toward common language and shared conceptual understanding. The Journal of Behavioral Health Services & Research, 39(4), 343–361. https://doi.org/10.1007/s11414-012-9287-x

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., & Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923–1958. https://doi.org/10.1016/S0140-6736 (10) 61854-5

Fullan, M. (2015). The new meaning of educational change (5th ed.). Teachers College Press.

Lim, S., Cheab, S., Goldman, L. N., Ith, P., & Bounchan, Y. (2024). The past, present and future of medical education in Cambodia. Medical Teacher, 46(6), 842-848. https://doi.org/10.1080/014 2159X.2024.2327490

*Sengkhoun Lim
73 Preah Monivong Blvd (93),
Phnom Penh, Cambodia
+855 92 222 622
Email: sengkhounlim@ymail.com

Submitted: 17 January 2024
Accepted: 14 May 2024
Published online: 1 October, TAPS 2024, 9(4), 57-60
https://doi.org/10.29060/TAPS.2024-9-4/SC3234

Nicole Huiyi Ong¹, Boon Chong Kwok^2,3, Siti Munirah Aman⁴, Steven Michael Dans Macabasco⁵ & Wai Pong Wong²

¹Department of Physiotherapy, Singapore General Hospital, Singapore; ²Health and Social Sciences, Singapore Institute of Technology, Singapore; ³Rehabilitation, Clinical Pilates Family Physiotherapy, Singapore; ⁴Department of Rehabilitation, Outram Community Hospital, Singapore; ⁵Rehabilitation, NTUC Eldercare, Singapore

Abstract

Introduction: Clinical practice education is an important curriculum in developing physiotherapy students to professionals. This curriculum is largely dependent on clinical educators. Although traits of effective clinical educators had been studied in Western population, it was unclear if the Asian population would yield similar traits. Hence, we studied perspectives of students and academic educators to identify top five core traits of an effective clinical educator. The findings will then help guide policy development for clinical educator training and development.

Methods: A survey was circulated to physiotherapy students and academic educators through convenience sampling. We studied 16 traits – enthusiasm, availability, clarity, clinical competence / knowledge, feedback skills, organisational skills, professionalism, well prepared, scholarly activity, non-judgemental, respect students’ autonomy / independence, sincerity, listening skills, evidence-based practice, role model, and awareness of students’ learning needs.

Results: The top five traits identified by students and academic educators were similar in four traits – clinical competency / knowledge, clarity, feedback skills, and enthusiasm, and differed in the choice of “non-judgemental” by students and “awareness of students’ learning needs” by academic educators. Interestingly, when the top six traits were considered instead of five, students and academic educators identified the same traits but in different ranked orders.

Conclusion: The study found six common core traits of an effective clinical educator from the perspectives of students and academic educators. Continuing education development for clinical educators should focus on these six traits prior to other 10 sub-traits.

Keywords:           Training, Development, Education, Allied Health, Entrustable Professional Activities, Mentoring

I. INTRODUCTION

Clinical Practice Education (CPE) is a core component in undergraduate allied health studies, partnering clinicians with additional role as a Clinical Educator (CE) (Gibson et al., 2019). A study evaluating effective residency teaching for doctors identified 15 traits that a CE should possess, which are enthusiasm, competence-knowledge, clarity, availability, non-judgemental, independence, feedback skills, role model, professionalism, sincere, organised, well-prepared, evidence-based practice, scholarly activity and listening skills (Buchel & Edwards, 2005). A recent study found that being aware of the learning needs of students could be the 16^th trait a CE should possess (Francis et al., 2016). Considering recent shift towards the use of the Entrustable Professional Activity framework for work place competency review at student and professional levels (Kwok et al., 2023), it is important to consider which top five traits are considered core competence of a CE as defined by the pinnacle of entrustment at Level 5.

Perspectives of critical traits of an effective CE might differ between students, CEs and academic educators (AEs). Students in early years of undergraduate study and CEs identified similar top five traits of an ideal CE (Cross, 1995). In the study by Cross (1995), CEs should be approachable, possess good communication skills, be knowledgeable and demonstrate enthusiasm in teaching, including clinical competency (Cross, 1995). Competency of CEs was similarly desired among academic educators, alongside “being approachable” and “good communicator”, whereas two differences were noted as compared to CEs and students, which were “interested in learning process of the students” and “concerned about patient care” (Cross, 1995). It is possible that among the Asian population, competency of the CEs would be similarly desired. Recent studies might have considered different trait terms as compared to the classic study, for instance, “learning process” was likely subsumed under “learning needs” (Francis et al., 2016). It is unclear whether the Asian population will present with different trait ranking as compared to Western population.

Therefore, this study was undertaken to identify the top five essential traits of an effective CE. In view of notable differences between perspectives of students and AEs in past literature, this study explored similarities and differences of perspectives between students and AEs. In addition, we explored what gaps might exist in developing CEs. In this study, the AEs, all of whom used to be CEs, could provide useful and important inputs on the traits required of a CE. The findings would then provide directions for future policy development pertaining to clinical education and professional supervision.

II. METHODS

A. Study Design

A survey was conducted through convenience sampling. The study was conducted between March to December 2022. The study was approved by the Institutional Review Board of the Singapore Institute of Technology (SIT-IRB-2022031).

B. Participants

Students in the third year of undergraduate physiotherapy programme and AEs of the physiotherapy faculty (as of April 2022) were involved in the survey. Large variations in response rate exists in convenience sampling, so we projected at least 50% response rate for the students and also the AEs. Students who had withdrawn from the programme were excluded. Associate faculty educators were excluded because they were only involved in ad hoc teaching sessions. Informed consent was sought at the beginning of the survey and digitally recorded.

C. Procedures

The survey described the 16 traits that contribute to an effective CE, which provided participants with knowledge about each trait, which was externally validated by five physiotherapists from the public and private sectors with experience ranging from eight to 25 years. The demographic data included student identification numbers to ensure that each response was unique. Thereafter, the data was de-identified to ensure anonymity during data analysis. As the sample size for the AEs was small, no personal data was collected to ensure anonymity. A survey invitation including a standardised survey link was distributed via email to all eligible participants. Participants were then asked to rank the 16 traits from 1 to 16, with 1 being the most important trait and 16 being the least important. Survey items were not randomised. The online survey was hosted on the secured Qualtrics Survey System (Qualtrics XM, 333 W. River Park Drive, Provo, UT 84604 USA). Student participants were first notified via email, followed by four reminder notifications, two months apart, via the cohort group chat on WhatsApp. AEs were first notified via email, followed by two reminder notifications via WhatsApp three months apart.

D. Statistical Analysis

Data analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Continuous variables are presented with means (standard deviations) and categorical variables with counts (percentages). Friedman test was used to analyse the mean rank of each trait. Then Kendall’s coefficient of concordance (Kendall’s W) was used to test the level of agreement among students for the mean ranks of the traits, as well as among AEs. The level of agreement was interpreted based on common recommendation and should yield statistical significance at p < 0.05.

III. RESULTS

A total of 81 students completed the survey (response rate of 46.6%) and a total of five AEs completed the survey (response rate of 41.7%). The average age, mean (standard deviation), of the students is 24.5 (4.1) years, and 52 of them are female (64.2%). The traits were ranked and presented in Table 1. Among the top five traits, there were four similar traits found between students and AEs, which were clinical competency / knowledge, clarity, feedback skills, and enthusiasm. The students ranked “non-judgemental” within the top five traits, whereas the AEs identified “awareness of students’ learning needs”. If the top six traits were considered, both students and AEs yielded similar traits. In the traits ranking, the students showed fair level of agreement, approximating closely to moderate agreement, Kendall’s W = 0.38, p < 0.001, while AEs showed moderate level of agreement, Kendall’s W = 0.51, p = 0.001.

Submitted: 19 December 2023
Accepted: 26 April 2024
Published online: 1 October, TAPS 2024, 9(4), 50-56
https://doi.org/10.29060/TAPS.2024-9-4/SC3194

Craig S. Webster¹, Jack Forsythe², Antonia Verstappen¹, Phillippa Poole³, Tim Wilkinson⁴ & Marcus A. Henning¹

¹Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand; ²Auckland District Health Board, Te Whatu Ora, Auckland, New Zealand; ³School of Medicine, University of Auckland, Auckland, New Zealand; ⁴Education Unit, University of Otago, Christchurch, New Zealand

Abstract

Introduction: A valid, longitudinal approach is critical for service planning in healthcare and to understand career choice in medical graduates.

Methods: We quantitatively analysed self-reported influences underlying career choice in a national cohort of medical graduates over the first five years of their careers. Participants rated career influences on importance across 26 items using a 5-point Likert scale (1=not at all, 5=a great deal).

Results: We included 659 New Zealand medical graduates (mean 25.4 years old, 376 F, 283 M) from the University of Auckland and the University of Otago, graduating in 2012 and 2013 (85% response rate). Responses were linked longitudinally over their post-graduate years 1, 3 and 5, and underwent principal component analyses. At graduation the factor rated as the most important in career choice had a mean (SD) item score of 3.9 (0.7) and comprised: Medical School Experiences; Specialty Experience; Mentors; and Self-Appraisal – consistent with graduates securing initial employment. Factors which explained the most variance in career choice over the five years after graduation indicated that the costs of medical school and further training were consistently rated as the least important in career choices, while flexibility in working hours were consistently rated as the most important. Factors remained relatively stable over time, showing variation in scores of only a median of 0.5 Likert points, indicating further opportunities for career choice research.

Conclusion: Our results regarding costs of medical training are reassuring, and suggest that greater flexibility in working hours may attract graduates to underserved specialties.

Keywords:           Medical Education, Career Choice, Career Influences, Cost, Debt, Measurement, Medical Graduates, National Longitudinal Study, Working Hours, Work Culture

I. INTRODUCTION

A common strategic aim of medical schools throughout the world is to supply the range of graduates who will best meet the healthcare needs of their communities (Gorman, 2018). However, fulfilling this aim is far from straight-forward, with perhaps the most critical difficulty involving understanding the influences that underlie career choice in medical graduates and how these vary over time.

The financial burden of completing medical school and further training has been one of the most widely studied influences underlying career choice, with suggestions that rising costs may encourage graduates to pursue specialties perceived to be more highly paid, often in cities, thus undersupplying primary healthcare and rural locations. However, in New Zealand medical graduates are otherwise free to choose their preferred career path and choices may be influenced by many things other than training costs and debt, including personal interest, employment conditions, specialty availability and lifestyle preferences (Webster et al., 2020; Webster et al., 2017).

Therefore, in the following, we analyse the self-reported influences underlying career choice in a national cohort of medical school graduates during the first five years of their careers using quantitative data drawn from the existing longitudinal Medical Schools Outcomes Database (MSOD).

II. METHODS

The MSOD project is a bi-national longitudinal questionnaire study that aims to improve healthcare delivery in Australia and New Zealand (Poole et al., 2019). At graduation and in postgraduate years (PGY), graduates are asked to specify their preferred area(s) of medicine, and complete a schedule of influencing items, indicating the degree to which each was important in their choice, using a 5-point Likert scale with anchors of 1 (not at all) to 5 (a great deal) – see Supplementary Table 1 for full question set.

A. Data Analysis

We conducted a series of principal component analyses (SPSS v27, IBM Corporation, New York) of the responses to the 26 influencing item questions at each time point to identify factors within responses, and describe them over time.

III. RESULTS

Data from a national cohort of 659 New Zealand medical school graduates who had graduated from the University of Auckland and the University of Otago in 2012 and 2013 were included. The response rate for completed questionnaires in the Exit cohort was 85% – representing a sampling margin of error of only 1% at the 95% level of confidence. The mean (SD) age of participants in the cohort was 25.4 (2.7) years, with a higher proportion of female graduates (376 F vs 283 M). Over the next five years, this Exit cohort self-reported on the same set of influences underlying career choice at PGY1, PGY3 and PGY5 – maintaining a response rate between 53% and 56%, and a sampling margin of error of 3%.

We used conventional settings during analysis, comprising varimax rotation and suppression of loadings below 0.3. The Kaiser-Meyer-Olkin measure of sampling adequacy across time points demonstrated a median (range) of 0.77 (0.75 to 0.82), indicating distinct and reliable factors at each time point. In addition, Bartlett’s test of sphericity was highly significant at each time point, (2338<c²<3498, p<0.0001), demonstrating correlation with little redundancy in items (Kaiser, 1974).

Submitted: 12 December 2023
Accepted: 25 March 2024
Published online: 1 October, TAPS 2024, 9(4), 40-49
https://doi.org/10.29060/TAPS.2024-9-4/SC3254

Vivien Lee¹, Jeffrey Jiang¹, Anna Szücs¹, V Vien Lee¹, Low Si Hui², Faith Teo¹, Jose M Valderas¹ & Victor Loh¹

¹Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²National University Polyclinics, Singapore

Abstract

Introduction: Globally, persons with disabilities (PWD) face structural and social barriers to inclusive healthcare. Medical schools, as crucibles of medical professional identity formation, have the responsibility to foster person-centredness toward all patients, including PWD, among her graduates. We co-designed with PWD a “Communications with Persons with Disabilities” workshop and evaluated its impact.

Methods: The workshop enlisted PWD as patient educators, occurred within the third-year undergraduate Family Medicine posting, and was designed to positively impact communications skills and attitudes toward PWD. Students (n=135) were surveyed pre- and post- workshop following a mixed-methods approach (demographic data, Attitude Towards Disabled Persons (ATDP)-O scale, feedback questions, and post-workshop free reflections). Descriptive analysis was used for demographic and feedback questions, and thematic analysis for reflections. Paired t-test was used to evaluate change in ATDP-O scores.

Results: There were 69 survey respondents (51.11%). Most students agreed that communications training with PWD could be strengthened in medical school, and that the workshop was relevant to their future medical career (n=68, 98.55%). Attitudes towards PWD significantly improved after the workshop (ATDP-O change: +9.29 points (12.7%), p <0.001). Student reflections included attitudes, such as the importance of seeing the person beyond the disability, and a call for action towards inclusivity and accessibility of care for PWD.

Conclusion: Students’ attitudes were positively affected by involving PWD in the curriculum. Further research is needed for assessing the impact of how a longitudinal PWD curriculum could affect medical trainees and improve social inclusiveness in healthcare practice.

Keywords:           Medical Education, Communication, Persons with Disabilities, Disability, Social Inclusiveness, Student Attitudes, Person Centred Care, Active Learning

I. INTRODUCTION

Globally, persons with disabilities (PWD) face structural and social barriers to inclusive healthcare. In Singapore, few are comfortable with direct personal interaction with PWD (National Council of Social Service Singapore, 2019).

With respect to medical education, different disability curriculum from didactic lectures to longitudinal patient experiences have been described (Ali et al., 2023). Overall evidence suggests that more frequent and positive contact with PWD increased positive attitudes (Ali et al., 2023; National Council of Social Service Singapore, 2019).

Medical schools, as crucibles of medical professional identity formation, have the responsibility to foster person-centredness toward all patients, including PWD, among her graduates. In July 2022, the National University of Singapore’s Division of Family Medicine developed with PWD, piloted and assessed a four-hour experiential workshop for third-year medical students called “Communication with PWD” in July 2022.

The four-hour workshop was prefaced by pre-event reading materials. A plenary started on site learning, followed by fishbowl discussions where student volunteers took turns to perform a clinical consultation with PWD who enacted scripted role-plays. There was a ratio of one tutor and PWD to a group of ten to fifteen students. Each student would encounter three broad categories of disability (vision, hearing, mobility) during the fishbowl sessions. Students interacted with PWD after each role play. Reflections and debrief by tutors would close the workshop.

This study aimed to evaluate the workshop’s impact on students’ attitudes towards PWD for: (Q1) differences in pre-workshop attitudes towards PWD between male and female medical students; (Q2) within-person changes in students’ overall attitudes towards PWD pre-post workshop; (Q3) associations between pre-workshop attitudes towards PWD and personal experience with PWD; and (Q4) exploration of how the workshop has affected students’ attitudes towards caring for PWDs.

II. METHODS

A. Study Design

This study had a mixed methods design including a pre- and post-intervention survey (quantitative), and reflections (qualitative). Students attending the 3^rd and 4^th Family Medicine Rotation (January to March 2023) of Academic Year 2022/23 were invited to participate in the study. The questionnaire was administered in person. Students completed the questionnaires independently. A waiver of consent was applied for reflections. 

B. Survey

The pre-workshop questionnaire comprised demographic information and the 20-item Attitude Towards Disabled Persons (ATDP)-O scale (Yuker et al., 1960). The questions were scored on six-point Likert scale from “I disagree very much” (-3) to “I agree very much” (+3). The post-workshop questionnaire comprised the ATDP-O scale and feedback questions.

We used the original ATDP-O form as it had been used in other studies on medical students (Arabi et al., 2021) and was deemed reliable (reliability coefficient .80) and valid by prior psychometric analyses (Yuker et al., 1960).  Performance in local context was assessed through cognitive testing with five randomly selected medical students who were classmates of study participants and excluded from the study sample.

C. Reflections

Student reflection sheets included a single open-ended statement: “Please pen a question or a reflection you’d like to share from the session today”.  Reflections were transcribed verbatim and de-identified before analysis. All reflections were used to limit selection bias.

D. Data Analysis

Numeric data was analysed by R software (version 4.31). Internal consistency of the scale in our study sample was measured with Cronbach’s alpha. We used two samples independent unpaired t-test to evaluate Q1 (differences in baseline ATDP-O scores between males and females), two samples paired t-test to evaluate Q2 (change in pre-post workshop ATDP-O scores), and two samples independent unpaired t-tests, Welch’s t-tests and Spearman’s correlation tests to evaluate Q3 (difference in baseline ATDP-O scores across different types/levels of contact with PWD). In the evaluation of Q3, two samples independent unpaired t-test was used when two groups have similar sample sizes or similar variances while Welch’s t-test was used when there’s unequal variances or disparate sample sizes between two groups. Spearman’s correlation was used to analyse associations with ordinal variables.

Student reflections were analysed thematically. Four researchers (VLE, VVL, AS, FT) reviewed the data and generated initial codes independently. Multiple discussions were conducted to explore different perspectives and increasingly develop codes. Based on codes generated, potential themes and subthemes were developed over several iterations. Final themes and subthemes were reviewed in relation to the entire dataset.

III. RESULTS

Of 135 students invited, 69 students consented to the study and completed both the pre- and post-workshop questionnaire. The results are summarised (Table 1a and 1b).

Cognitive testing confirmed that students had no difficulties understanding questions nor suggested any edits for clarification. The internal consistency of the scale was α = 0.72 (pre-workshop) and α = 0.78 (post-workshop).

(Q1) Female gender had a significantly higher baseline ATDP-O scores (p = 0.028).

(Q2) There was a significant improvement of 9.29 points (12.7%) in the ATDP-O score post workshop (p <0.001).

(Q3) Previous experience of training to care for PWD (p<0.001) and previous experience caring for PWD (p = 0.033) had significantly lower baseline ATDP-O scores.

 

Results	Number (%)	ATDP-O baseline score Mean (SD)			Statistics
Overall	N=69	72.71 (10.46)
By age (Mean = 21.59, SD = 0.96)					Pearson’s r(67) = – 0.02, p = .857
By gender
Female	37 (53.62%)	75.32 (8.61)			t(67)  = 2.30, p = .025*
Male	32 (46.38%)	69.69 (11.69)
By ethnicity
Chinese	56 (81.16%)	73.18 (10.20)			F(2, 66) = 1.64, p = .201
Indian	12 (17.39%)	69.33 (11.18)
Others	1 (1.45%)	87.00 (.)
Self-reported disability
No	66 (95.65%)	72.74 (10.59)			t(2) = 0.14, p = .900
Yes	3 (4.35%)	72.00 (8.89)
Self-reported training to care for PWD
No	67 (97.10%)	73.06 (10.42)			t(7) = 7.45, p < .001*
Yes	3 (4.35%)	61.00 (1.41)
Self-reported frequency of care for PWD (ranked variable ranging from never = 1 to often = 4)
Never	34 (49.28%)	75.7 (9.5)			Spearman’s rho(67) = – 0.26, p = .033*
Rarely	22 (31.88%)	69.8 (11.8)
Sometimes	12 (17.39%)	69.5 (9)
Often	1 (1.45%)	75 (.)
Self-reported knowledge of PWD who is important to them
No	53 (76.81%)	73.57 (10.95)			t(67) = 1.24, p = .219
Yes	16 (23.19%)	69.88 (8.34)
Self-rated likelihood of pursuing career in Family Medicine (ranked variable ranging from very unlikely = 1 to very likely = 5)
Very likely	9 (13.04%)	72.1 (10)			Spearman’s rho(67) = 0.03 , p = .803
Likely	18 (26.09%)	73.2 (11.5)
Undecided	37 (53.62%)	73.5 (10.3)
Unlikely	4 (5.80%)	63.5 (8.9)
Very unlikely	1 (1.45%)	78 (.)
Do you feel your education about persons with disabilities in medical school has been adequate so far?
Agree	1 (1.45%)		–		–
Neither disagree nor agree	19 (27.54%)		–		–
Disagree	42 (60.87%)		–		–
Strongly disagree	7 (10.14%)		–		–
Would you find it important to include education and training on persons with disabilities?
Strongly agree	23 (33.33%)			–	–
Agree	39 (56.52%)			–	–
Neither disagree nor agree	5 (7.25%)			–	–
Disagree	1 (1.45%)			–	–
Strongly disagree	1 (1.45%)			–	–
Do you feel that the education provided during the Communications with Persons with Disabilities workshop was relevant to your future career as doctors?
Strongly agree	45 (65.22%)			–	–
Agree	23 (33.33%)			–	–

Table 1a. Baseline ATDP-O scores and curriculum feedback

 

Results	ATDP-O score Mean (SD)	Pre-Post workshop comparison statistics
Descriptive statistics
Pre-workshop ATDP-O score	72.71 (10.46)	t(68)  = 8.69, p < .001*
Post-workshop ATDP-O score	82.00 (11.46)
Difference in ATDP-O scores
Overall sample	9.29 (8.88)	t(68)  = 8.69, p < .001
By age (Mean = 21.59, SD = 0.96)		Pearson’s r(67) = – 0.06, p = .643
By gender
Female	8.62 (9.33)	t(67) = – 0.67, p = .505
Male	10.06 (8.41)
By ethnicity
Chinese	9.02 (9.45)	F(2, 66) = 0.15, p = .859
Indian	10.33 (6.21)
Others	12.00 (.)
Self-reported disability
No	9.50 (8.06)	t(2) = 0.36, p = .752
Yes	4.67 (23.12)
Self-reported training to care for PWD
No	9.09 (8.92)	t(1) = – 2.17, p = .230
Yes	16.00 (4.24)
Self-reported frequency of care for PWD (ranked variable ranging from never = 1 to often = 4)
Never	8.8 (6.1)	Spearman’s rho(67) = 0.05, p = .678
Rarely	11.5 (9.1)
Sometimes	9.4 (10.8)
Often	-22 (.)
Self-reported knowledge of PWD who is important to them
No	10.72 (7.61)	t(67) = 2.52, p = .014*
Yes	4.56 (11.20)
Self-rated likelihood of pursuing career in Family Medicine (ranked variable ranging from very unlikely = 1 to very likely = 5)
Very likely	10.4 (9.2)	Spearman’s rho(67) = 0.07, p = .547
Likely	10.9 (7.8)
Undecided	7.9 (9.5)
Unlikely	11.5 (9.3)
Very unlikely	11 (.)

Table 1b. Difference in ATDP-O scores post workshop

Most students found the workshop a positive experience and reported feelings of thankfulness and inspiration towards patient educators. Four themes emerged from the students’ post-workshop reflections, of which we highlight those related to attitudes – Humanizing mindsets towards PWD (Theme 1) and Call for action towards inclusivity and accessibility (Theme 2). The other themes were Knowledge and Skills, as students included knowledge and communication skills they acquired during the workshop (Appendix 1 and 2).

A. Theme 1 – Humanising Mindset towards Persons with Disabilities

Students expressed attitudes of empathy, sensitivity, and humanising care through viewing PWD as individuals beyond their disabilities. A student reflected

“Being able to speak to members of these respective communities helped me to understand how empowered PWD can be… It is essential that [PWD] are treated as exactly that, [and] not characterised by their disabilities.”

On providing care for PWD, students noted the distinction between empathy and sympathy, and highlighted the importance of empathy instead of pity. As summed up by a student,

“Not to sympathise but to empathise. Not to see them and pity them”

B. Theme 2 – Call for Action towards Inclusivity and Accessibility

Concurrent with attitudes expressed in the reflections, students discussed the need to improve inclusivity and accessibility from an individual and societal perspective. One student wrote,

“As doctors, we need to try our best to alleviate their disease burden, and at the same time, make their journey to accessing healthcare more seamless with less barriers.”

Beyond self-improvement, students were aware of the need to shift their own perspectives of disability from a medical to a social model. Students also reflected the need for greater national efforts towards societal inclusivity for PWD. A student reflected,

“I think policymakers and organisations should periodically involve PWD to [better] take their needs into consideration as they have the right to integrate into our society just as much as everyone else.”

IV. DISCUSSION

Our study showed positive change in attitudes towards PWD among medical students after a workshop with improvement of 9.29 points in the ATDP-O score (Table 1b), reinforced by their post-workshop reflections. To our knowledge, this is the first study in Asia evaluating an educational intervention focusing on communications skills training with PWD. Based on student reflections, the communications workshop was effective in developing knowledge and communication skills, prompting the key attitudes of humanizing care, and a call for action towards societal inclusivity and accessibility towards PWD.

We intentionally had PWD co-designing the workshop and playing key roles as patient educators. Student reflections support these curriculum design decisions. Our work coheres with literature that a contact-based approach with PWD would be impactful: reducing anxiety and improving empathy levels, rather than more theoretical approaches to promote attitudes towards PWD (Arabi et al., 2021).

Our study corroborates the widely reported result that female gender positively influenced baseline attitudes towards PWD in medical students (Satchidanand et al., 2012). A possible explanation is females having a propensity to exhibit more empathetic feelings toward others. There is a greater change in attitudes in males than females after the workshop, but this change is not significant.

In contrast to prior research that consistently associated increased contact with PWD with more positive attitudes (Satchidanand et al., 2012), we found that having previous experience with PWD influenced baseline ATDP-O scores negatively (Table 1a). Moreover, there was a significantly smaller change in ATDP-O scores if they knew a PWD who is important to them (Table 1b). A possible explanation is “caregiver fatigue” due to unavailability of support to allow adequate care for PWD (Arabi et al., 2021). The type of previous experience may thus be key factors in shaping current attitudes towards PWDs.

This study has several limitations. We cannot determine if positive change in attitudes post-workshop would translate into changes in clinical practice in the future. The survey was not compulsory for students, potentially leading to selection bias. We tried to overcome the selection bias by including all student reflections.

V. CONCLUSION

There was significant improvement in students’ attitudes towards PWD post-workshop, as shown through the ADTP-O score and reflection analysis. Medical students benefit particularly from the fishbowl discussions which allows students to interact with persons with disability, growing our future generations of healthcare professionals who humanise care.

Notes on Contributors

Author VLE conceptualised the study, developed the methodology, conducted the investigation, did the formal analysis and visualization of data, wrote the original draft, reviewed and edited the manuscript. Author JJ conceptualized the study, developed the methodology and original draft, reviewed and edited the manuscript. Author AS developed the methodology, did the formal analysis of data, reviewed and edited the manuscript. Author VVL did the formal analysis of data, wrote the original draft, reviewed and edited the manuscript. Author LSH did the formal analysis and visualization of data. Author FT did the formal analysis, reviewed and edited the manuscript. Author JMV supervised the conceptualization and methodology of the study, reviewed and edited the manuscript. VLO supervised the conceptualization of the study, developed the methodology, reviewed and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

Ethical Approval

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of the National University of Singapore on 11 November 2022 (NUS-IRB-2022-608).

Data Availability

Quantitative data repository can be freely accessed at: https://doi.org/10.6084/m9.figshare.24013134  

Qualitative data repository can be freely accessed at: https://doi.org/10.6084/m9.figshare.24051195  

Funding

There was no funding for this research study.

Declaration of Interest

Authors VLE, JJ and VLO are tutors in the “Communications with Persons with Disabilities” workshop. There are otherwise no other conflicts of interest.

References

Ali, A., Nguyen, J., Dennett, L., Goez, H., & Rashid, M. (2023). A scoping review for designing a disability curriculum and its impact for medical students. Canadian Medical Education Journal, 14(3), 75–86. https://doi.org/10.36834/cmej.74411

Arabi, H., Adarmouch, L., & Ahmed Eladip, G. (2021). The assessment of student doctors’ attitude towards disabled people after teaching them a module. Acta Bio-Medica: Atenei Parmensis, 92(2), e2021059. https://doi.org/10.23750/abm.v92i2.9547

National Council of Social Service Singapore. (2019). Public Attitudes Towards Persons with Disabilities 2019. https://www.ncss.gov.sg/docs/default-source/ncss-publications-doc/pdfdocument/public-attitudes-towards-persons-with-disabilities-2019-infographics.pdf

Satchidanand, N., Gunukula, S. K., Lam, W. Y., McGuigan, D., New, I., Symons, A. B., Withiam-Leitch, M., & Akl, E. A. (2012). Attitudes of healthcare students and professionals toward patients with physical disability: A systematic review. American Journal of Physical Medicine & Rehabilitation, 91(6), 533–545. https://doi.org/10.1097/PHM.0b013e3182555ea4 

Yuker, H. E., Block, J. R., & Campbell, W. J. (1960). A scale to measure attitudes toward disabled persons. In Human Resources Study Number 5. Human Resources Foundation.

*Vivien Lee
1E Kent Ridge Rd,
Singapore 119228
Email: vivienl@nus.edu.sg

Submitted: 3 April 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 33-39
https://doi.org/10.29060/TAPS.2024-9-4/OA3282

Meltem Saygılı¹, Aysun Kandemir Türe¹ & Şirin Özkan²

¹Department of Health Management, Kırıkkale University, Kırıkkale, Türkiye; ²Department of Medical Services and Techniques, Vocational School of Health Services, Uludag University, Türkiye

Abstract

Introduction: Many societal changes threaten the sustainability of health systems. Entrepreneurs play a significant role in creating sustainable innovations necessary for development and structural change. This study aimed to evaluate how university students studying health sciences perceive individual entrepreneurship during the COVID-19 pandemic and to explore the impact of COVID-19-related hopelessness on their perception of entrepreneurship.

Methods: Six hundred eighty-one undergraduate students from the faculty of health sciences in Türkiye, participated in the study. The Individual Entrepreneurship Perception Scale and Beck Hopelessness Scale were used to collect data.

Results: The results revealed that the students’ perception of individual entrepreneurship was high, while their hopelessness levels were moderate. In addition, a moderate negative relationship was found between the students’ hopelessness levels and their perception of individual entrepreneurship. The regression analysis showed that the students’ hopelessness levels and sub-dimensions (hope, loss of motivation, and future expectation) accounted for 26.3% of the total variance in individual entrepreneurship perception. Increased hopelessness regarding the sub-dimensions of hope, loss of motivation, and expectations for the future decreased their individual entrepreneurship perceptions.

Conclusions: These findings suggest that individual entrepreneurship perception among health sciences students could be negatively impacted during extraordinary periods related to health crises like pandemics. Developing hope, motivation, and expectations for the future is crucial to enhancing individual entrepreneurship perception among health sciences students.

Keywords: Individual Entrepreneurship Perception, Hopelessness, Health Sciences, University Students, COVID-19 Pandemic

Practice Highlights

• University education plays a critical role in developing students’ perceptions of entrepreneurship.
• Students’ perceptions of entrepreneurship are affected by changing environmental conditions.
• The COVID-19 pandemic has led to a significant increase in awareness of Healthcare Entrepreneurship.
• The COVID-19 pandemic has negatively affected students’ expectations and hopes for the future.
• Health sciences students experienced the psychological effects of the pandemic more intensely.

I. INTRODUCTION

Entrepreneurs are described as individuals who “implement bold new ideas from the outset, taking on the risks of the business or venture that enables innovation to happen” (Suryavanshi et al., 2020). Entrepreneurship education seeks to provide students with in-depth knowledge, motivation, and skills to increase entrepreneurial intentions’ success in various settings (Sampene et al., 2023). In developing economies such as Türkiye, government efforts to improve unemployment conditions are directed towards developing students’ positive attitudes towards entrepreneurship and increasing their interest in self-employment.

Universities are crucial in developing students’ entrepreneurial intentions (Bagheri, 2018). It is critical to examine and develop the entrepreneurial potential of university students trained to fulfill important roles in the field of health services in the future. This is because students and newly graduated healthcare professionals with entrepreneurial skills are now needed to develop innovative healthcare delivery models that can improve the quality of healthcare services, improve treatment outcomes, and reduce the cost of care (Fashami et al., 2021; Mohamed et al., 2023). It is stated that healthcare is one of the main industrial areas where user entrepreneurship takes place worldwide (Schiavone et al., 2020) and the pandemic environment brings unique opportunities for entrepreneurs, especially in healthcare. However, research shows that fear and worry due to the COVID-19 pandemic are making the future workforce anxious and hopeless about their professional futures (Duplaga & Grysztar, 2021; Tao et al., 2023). In such an environment, it is predicted that university students, especially those who are trained to work in health service delivery, may act in different ways in their decisions about their professional future.

Because an individual’s perception of current conditions can significantly, positively, or negatively affect the formation of entrepreneurial intentions and the likelihood of starting an enterprise (Krichen & Chaabouni, 2022). Considering the increasing entrepreneurship opportunities in healthcare and the negative effects of the COVID-19 pandemic on healthcare services, it has become important to address the entrepreneurship perceptions of students who will serve in this field in the future and to evaluate the hopelessness experienced. When the literature was examined, no other research addressing entrepreneurship in the context of hopelessness was found. Therefore, we believe that our research findings will make a valuable contribution to filling this gap in the literature.

A. Universities, Health Sciences Education and Entrepreneurship

Recent years have focused on the role of universities in industrial competitiveness and their impact on social change (Hart & Rodgers, 2023), and universities in teaching and initiating entrepreneurship have emerged as leading actors. Recent research examining students’ attitudes toward entrepreneurship reveals that universities have a critical role in developing entrepreneurial spirit and perceptions of entrepreneurship in students (Krichen & Chaabouni, 2022; Liao et al., 2022; Sampene et al., 2023). Moreover, university students now value real experience more and prefer universities that offer entrepreneurship opportunities and experiences (Taneja et al., 2024).

Universities providing education in healthcare have traditionally emphasised vocational training and unfortunately, there are very few university programs with curricula that focus on innovation and entrepreneurship in healthcare (Suryavanshi et al., 2020). Consequently, most newly graduated physicians and other healthcare professionals start their careers without the knowledge, experience, and courage to integrate their medical knowledge with the healthcare business world, and thus are unable to commercialise new healthcare delivery methods (Boore & Porter, 2011).

B. Hopelessness Experienced by Students Due to the COVID-19 Pandemic and Perception of Individual Entrepreneurship

Students are one of the groups that experience the psychological effects of the pandemic most intensely (Marahwa et al., 2022). Studies conducted with students during the pandemic period showed that students experienced higher levels of anxiety and depressive symptoms due to uncertainties about the future and the negative effects of the pandemic on their educational lives (Alnıaçık et al., 2021; Hajinasab et al., 2022; Kaplan Serin & Doğan, 2023; Zhang et al., 2021). Moreover, it was also determined that students’ hopelessness levels were higher in the first wave of the pandemic and during the quarantine period and decreased with normalisation (Tao et al., 2023). In addition, it has been found that students who are educated in the field of health and have clinical experience are more anxious and hopeless than undergraduate students who are educated outside the field of health (Pretorius, 2021). Although entrepreneurship is a future-oriented orientation and is perceived as the ability to turn negative situations into opportunities, it is estimated that the psychological effects of COVID-19 may negatively affect entrepreneurial intention in students. Therefore, this study aims to examine the effect of hopelessness experienced by health sciences faculty students during the COVID-19 pandemic on their perception of individual entrepreneurship.

II. METHODS

A. Sampling and Participants and Data Collection

The study was conducted with university students studying at the Faculty of Health Sciences in Türkiye. The faculty consists of six departments, namely Physiotherapy and Rehabilitation, Health Management, Social Work, Nutrition and Dietetics, Child Development and Nursing, and has 2335 students. The sample size required for the study was calculated using the formula (n=[z²xp(1-p)/d²]/1+[z²xp(1-p)/d²N]) and it was determined that a minimum of 337 participants would be sufficient with a 5% error level and 95% confidence level. Participants were selected using a simple random sampling technique and volunteerism was taken as a basis in obtaining the data. The study was conducted between April and May 2022 and 681 valid questionnaires were returned from the participating students.

Data were collected using the socio-demographic information form, Individual Entrepreneurship Perception Scale, and Beck Hopelessness Scale. The Individual Entrepreneurship Perception Scale is a 5-point Likert scale consisting of 31 items and six sub-dimensions: planning, locus of control, self-confidence, communication, motivation, and self-discipline. This scale was developed by Incik and Uzun in 2017 to assess university students’ perceptions of entrepreneurship. The reliability coefficients (Cronbach’s Alpha) of the sub-dimensions of the Individual Entrepreneurship Perception Scale and the total scale were found to be 0.80, 0.84, 0.75, 0.75, 0.75, 0.72, 0.75, 0.60 and 0.92, respectively (Incik & Uzun, 2017). For this study, it was determined that the Cronbach Alpha values of the Individual Entrepreneurship Perception Scale ranged between 0.69 and 0.93 (Table 2).

The Hopelessness Scale was initially developed by Beck et al. in 1974 and subsequently adapted into Turkish by Durak and Palabıyıkoğlu in 1994. This scale comprises 20 items divided into three sub-dimensions: expectations for the future, loss of motivation, and hope. Each question in the scale requires a ‘yes’ or ‘no’ response, and the maximum achievable score is 20. An increase in the overall score denotes a higher level of hopelessness. The reliability coefficients for the sub-dimensions of the scale were calculated to be 0.78, 0.72, and 0.72, respectively (Durak & Palabıyıkoğlu, 1994). Table 2 presents the Cronbach’s alpha coefficients for the sub-dimensions and the scale, which were found to be 0.75, 0.77, 0.74, and 0.88, respectively.

B. Statistical Analysis

The statistical analyses used were performed in SPSS v23.0. Descriptive analyses such as percentage, mean, standard deviation, reliability analysis (Cronbach’s Alpha), and normality tests were performed to obtain the results. To test the normal distribution, kurtosis, and skewness values were calculated for each scale’s sub-dimensions and total scores. It was determined that the values obtained were in the range of -1.5 to +1.5 and the data showed a normal distribution (Tabachnick & Fidell, 2013). The results of the analysis are presented in Table 2. In addition, multiple linear regression analysis was used to investigate the relationship between hopelessness and students’ perception of individual entrepreneurship.

III. RESULTS

The study involved students with an average age of 21.3 years, ranging from 18 to 44 years old. 86% of the participants were female students, and the majority (52.3%) reported a grade point average of 3 or above (with a scale of 0 to 4). 68.3% of the students lived in the city center with their families. Among the students’ mothers, 37.7% had a primary school graduate degree, and 81.4% were not working. On the other hand, 32.2% of the students’ fathers had a high school graduate degree, and 78.4% were actively working. Most of the students (68.3%) stayed in dormitories. Regarding career plans after graduation, most students expressed their interest in working in a health institution (public or private). At the same time, only 15.6% said they wanted to start their own business. 15% of the students were still undecided about their work plans (Table 1).

Submitted: 21 February 2024
Accepted: 16 July 2024
Published online: 1 October, TAPS 2024, 9(4), 26-32
https://doi.org/10.29060/TAPS.2024-9-4/OA3255

Aletheia Chia¹, Menghao Duan¹ & Sashikumar Ganapathy^2,3

¹Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore; ²Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore; ³Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore

Abstract

Introduction: Mentoring is an essential component of post-graduate medical training programs worldwide, with potential benefits for both mentors and mentees. While factors associated with mentorship success have been described, studies have focused on intrapersonal characteristics and are largely based in Western academic programs. Mentorship occurs in a broader environmental milieu, and in an Asian context, cultural factors such as respect for authority, hierarchy and collectivism are likely to affect mentoring relationships. We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify challenges and develop best practices for effective mentoring.

Methods: 14 faculty mentors from a post-graduate paediatric residency program were interviewed between October 2021 to September 2022. Data was collected through semi-structured one-on-one interviews, with participants chosen via purposeful sampling. Qualitative analysis was done via a systematic process for phenomenological inquiry, with interviews thematically coded separately by 2 independent reviewers and checked for consistency.

Results: 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “harmony and avoidance of open conflict” and the “importance of trust and establishing a familial relationship”. Mentors also highlighted the value of structure in Asian mentoring relationships.

Conclusion: Cultural factors, which are deeply rooted in social norms and values, play an important role in shaping mentoring relationships in an Asian context. Mentoring programs should be tailored to leverage on the unique cultural norms and values of the region in order to promote career growth and personal development of trainees and mentors.

Keywords:           Medical Education, Graduate Medical Education, Professional Development

Practice Highlights

• Cultural factors are key in shaping Asian mentoring relationships.
• This includes being ‘professional, but also personal’, ‘respect and hierarchy’, ‘harmony and avoidance of open conflict’ and the “importance of trust and establishing a familial relationship’.
• Mentoring programs should be tailored to leverage on the unique local cultural norms and values.

I. INTRODUCTION

Mentoring is an essential component of post-graduate medical training programs worldwide. Mentorship is a reciprocal, interdependent relationship between a mentor (often a faculty member who is senior and experienced) and a mentee (beginner or protégé in the field) (Sambunjak et al., 2006). Benefits for mentees include aiding career preparation, development of clinical and communication skills, independence, and preventing burnout (Flint et al., 2009; Ramanan et al., 2006; Spickard et al., 2002). Mentors derive satisfaction from aiding the next generation, motivation for ongoing learning and institutional recognition (Burgess et al., 2018).

Variables associated with mentoring success have been described. Key components identified by mentors and mentees are communication and accessibility, caring personal relationship, mutual respect and trust, exchange of knowledge, independence and collaboration, and role modelling (Eller et al., 2014). Personality differences, lack of commitment, conflict of interests and mentor’s lack of experience can contribute to unsuccessful mentoring relationships (Straus et al., 2013).

However, mentorship occurs in a broader environmental milieu. Sambunjak (2015) described an ecological model of mentoring in academic medicine, with a first societal level of cultural, economic and political factors; a second institutional level of system- and organisation-related factors, and a third level of intrapersonal and interpersonal characteristics. Studies on mentorship have mainly focused on the latter and are situated in Western academic programs. In an Asian context, cultural factors such as respect for authority, hierarchy and collectivism may affect mentoring relationships (Chin & Kameoka, 2019). Trainees may show more deference to their mentors, and mentors may be more directive than collaborative. An Asian study surveying Doha’s postgraduate paediatric program found 75% mentees unsatisfied in their mentoring relationship (Khair et al., 2015).

We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify the challenges faced by trainees and mentors and develop best practices for effective mentoring.

II. METHODS

A. Study Design

This qualitative study is based on an interpretive phenomenological approach of participants’ lived experiences in their mentoring relationships. Through close examination of individual experiences, phenomenological analysis seeks to capture the meaning and common features, or essences, of an experience (Starks & Trinidad, 2007).

Semi-structured interviews were conducted. The interview guide was designed to follow a pre-determined structure whilst allowing for flexibility in probing. It was based on insights from literature on key socio-cultural determinants of successful mentoring relationships. Data was collected until saturation, with no new themes emerging.

B. Setting

We studied a paediatric residency program of a tertiary academic centre in Singapore, with 47 residents and 180 faculty members.

A formal mentorship program (Figure 1) has been in place since 2010. Residents indicate preferred faculty mentors at the start of residency, and are advised to consider specialty of interest, characteristics, and gender. Matches are subject to availability, review by the residency program, and mentor acceptance. Residents have one formal mentor throughout the 6 years unless the mentorship is terminated by mutual agreement between mentor and mentee.

Figure 1. Mentorship program structure, with suggested meeting timings and requisite forms. Meetings are required minimally 6-monthly and are scheduled on an ad-hoc basis by the mentor and mentee.

C. Participants

Purposive sampling to identify mentors in the residency program who would provide comprehensive and relevant insights. Considerations included age, gender, race, and years of mentorship and faculty experience. Study members and their mentors were excluded.

Study information sheets were provided to participants with assurance of confidentiality, and written informed consent obtained from each participant. The study was approved by the SingHealth Institution Review Board.

D. Analysis

Qualitative analysis was done via a systematic process for phenomenological inquiry (Creswell & Creswell, 2022), whereby statements were analysed and categorised into clusters of meaning that represent phenomenon of interest. Transcripts were interpreted independently by 2 reviewers (AC, MD) and reviewed by a 3rd study member (SG). Iterative data analysis and collection was performed, with coding done after each interview to identify new themes and inform further interviews.

III. RESULTS

We interviewed 14 mentors from October 2021 to September 2022. 8 were male and 6 were female. 12 were Chinese, 1 Indian, and 1 of other ethnicity. This was representative of faculty demographics. Mentors had two to eleven years of mentorship experience within the program, and one to five existing and prior mentees.

Mentors described their lived experiences in their mentoring journey, providing insights into key values and their relationships’ evolution. 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “avoidance of open conflict” and the “importance of trust”. Mentors also highlighted the value of structure in Asian mentoring relationships.

A. Professional, but also Personal

All mentors agreed that the relationship was predominantly professional, with their key role being that of professional and career guidance. They described their roles as:

“Guidance through difficult decisions or challenges” (#1), “leaning the real world of medicine” (#2), “driving professional development” (#12) and providing “timely and wise advice to support the journey” (#13)

Relationships “predominantly focused on professional or educational aspects… as that’s what it was meant to be” (#10), and were “mainly limited to career-related matters (#11)”.

However, many also identified personal connection as key. While the focus was primarily professional, awareness of personal or emotional aspects aided in understanding their mentors to further professional development and psycho-emotional growth. This included sharing of family lives, and emotional difficulties faced at work.

As the journey progresses it becomes a lot more about the psycho-emotional aspect, and about their mental health and personal well-being. (#1)

A lot of time is spent discussing family issues. If we knew more about the personal life of our mentee it’s so much easier to tailor the advice based on the individual’s unique circumstances. (#3)

A minority of mentors kept their relationship strictly professional and preferred not to talk about aspects outside of work, as it was ‘easier’ (#10) and shared concerns of ‘overstepping certain norms’ (#11).

B. Respect and Hierarchy

Respect was a key factor brought up when exploring the socio-cultural aspects of mentoring in our Asian community. Mentors varied in their opinion as to the extent that this resulted in a hierarchical relationship, and if this had a negative or positive impact on the relationship.

All agreed that respect is a key value in mentoring relationships:

Culturally there’s a large part to play as we’re taught to respect our elders. (#1)

Respecting elders – definitely it’s more prominent in our Asian culture. (#2)

Many mentors highlighted that this resulted in a hierarchical relationship. This manifested in the way senior doctors were addressed strictly by title, polite communication, and consideration of what would be ‘proper’ to discuss or ask a mentor to do.

The hierarchical kind of mindset is still very strong, and is something that is not necessarily healthy. (#4)

You would always see your mentor as someone higher than you. It’s similar to the way in our Asian context we see our parents. a certain sense of distance (#11).

The way medicine is a 师傅徒弟 kind of thing (‘master and disciple’) (#13)

Many shared that this could be a barrier to open communication with juniors wanting to “respect and agree” with their mentors (#14), slowing the growth of some relationships.

No matter how much honesty and trust there is. If they want to say something that their mentor is not happy to hear, or strikes them as being a bit rude or disrespectful – they won’t say it. (#1)

Our culture does say to respect your senior, don’t argue and don’t disagree with your senior. Sometimes they’re not very vocal, ‘ok sir ok sir’. And then later you find out they have certain issues. (#9)

One mentor felt that hierarchy did not play a large part in his mentoring relationships. This was possibly personality related, describing himself as naturally “quite informal”.

Mentors also highlighted factors that mitigated the hierarchical nature of their relationship. This included time, and setting clear boundaries and goals of the relationship.

When we give… a clear boundary and aim with no go zones, then culture may not necessarily be that important anymore (#10)

A minority of mentors felt that hierarchy and respect was not a limiting factor in their relationships:

If the primary aim is having someone to offer you guidance and a different point of view, even if the mentee sees you as someone who is not equal, you can still have that effectiveness. (#11)

C. Harmony, Avoiding Open Conflict and Confrontation

Another socio-cultural concept highlighted was the avoidance of confrontation. While some of this was linked to avoiding disagreements given the hierarchical nature of the relationship, avoiding open conflict and striving for harmony was also a key factor.

Rather than openly bringing up something, to avoid being confrontational we have evolved other means of trying to work our way through that conflict. There is a conscious and deliberate effort to avoid open and confrontational conflict. (#3)

When I was in the UK, they really questioned their mentors quite a lot – almost like a quarrel. That kind of questioning style may not be that well received in our own culture. (#2)

When mentees had differing opinions from their mentors “they would rather not talk about the topic again, or just ask someone else” in order to preserve the relationship (#1).

Within our program, this resulted in difficulties in exiting the relationship to avoid “offending” the mentor:

When the mentor-mentee relationship is breaking down, culturally it can be more difficult for mentees to request to swap. That’s very detrimental to both the mentor and the mentee in the long run. (#1)

This also manifested in avoiding overly ‘emotional’ discussions, with discussion often being more “superficial”, “reserved” (#7) and “factual” (#5) in nature.

Conversely, one mentee shared that younger mentees being of a “younger generation” were more open to speaking their mind, and that this would continue to evolve.

D. Importance of Trust and Establishing a Familial Relationship

In exploring key values for successful mentoring relationships, many highlighted the importance of trust and building up an established relationship.

Chemistry and compatibility when starting out was key. Mentors often felt more comfortable if there was a pre-existing relationship they had their mentors and had “shared commonalities and chemistry”. Honesty and trust were key in enabling the relationship to progress. This included respecting each other’s confidentiality. Relationships without trust was difficult as mentors “had to keep guessing what they want”, and “whatever you plan may not be the real goals of what they actually want” (#2). Over time, establishing the relationship made it easier to confide in each other, overcoming boundaries brought on by hierarchy.

It’s about forming relationships before you can start reflecting with the person. Over time we get to know each other, and seeing that what is shared is truly kept private and confidential. Once we have trust among each other it (reservations) doesn’t become a barrier. (#7)

There must be a certain comfort and trust level before one readily does share vulnerabilities. (#2)

This can be enabled by being approachable, and creating safe environments where mentors can share their difficulties without consequence. However, this could be compromised if mentors have to take up a supervisory role or be involved in remediation processes.

Mentors who developed close and trusting relationships with their mentees described it as familial in nature. This could be as a big brother or sister who would give advice to their younger siblings in non-threatening and neutral ways. It was also described by one mentor as parental in nature.

One interviewer highlighted that whilst Asian cultural factors may limit mentoring, there were also potential benefits:

We must find the best of both worlds. The independence that the Western systems have is good, but Asians tend to be better at teamwork and team spirit. (#13)

E. Value of Structure in an Asian Mentorship Relationship

Many mentors highlighted the value of having a framework for their mentoring relationship. Formalisation of the relationship and having a structure provided a foundation for discussions and enabled them to set boundaries. This prevented it from becoming awkward or “random and situation-based” (#15), and also helped faculty who were “still learning the whole journey of mentoring” (#7).

When we don’t know what to talk about it becomes quite awkward and uncomfortable. But if in the Asian context the mentor brings to it some structure, and they respect that structure, that structure is helpful. (#10)

A minority of mentors felt having a framework was too rigid or unnecessary.

The structure must be there to guide the mentors, but the mentors chosen must also be of a certain maturity so they can find their own way. We must not be too prescriptive or rigid. (#13)

IV. DISCUSSION

In this study, we explored the lived experiences of mentors within an Asian paediatric postgraduate training program. Existing studies have explored characteristics of effective and ineffective mentor relationships, but less is known about the impact of sociocultural factors. Key thematic concepts identified such as “respect and hierarchy” and “avoidance of open conflict” highlighted the importance of cultural factors in shaping mentoring relationships in an Asian context. These are deeply rooted in social norms and values of the region.

Hierarchy is a fundamental aspect of many Asian cultures, where individuals are expected to show respect and deference to their ‘elders’ or those in positions of authority. This was also observed in other Asian communities. A study in postgraduate medicine in Japan found that mentees had an inner desire to “respect the mentor’s ideas”, with both mentees and mentors embracing “paternalistic mentoring” (Obara et al., 2021). In our interviews, this was most apparent in the way mentees addressed their mentors: by title and respectfully. On a deeper level, this was a barrier to open communication. Open sharing was identified as crucial for a constructive mentoring relationship (Burgess et al., 2018), with the lack of it a cause of failed mentoring relationships (Straus et al., 2013).  The willingness to share personal experiences by both mentors and mentees is key for effective mentoring and career growth. Additionally, this is not conducive to fostering creativity and innovation, which are increasingly important in the medical profession.

Communication was also affected by avoidance of open conflict and confrontation. Asian cultures have been described as collectivist, where the needs of the group take precedence over that of the individual, and intragroup harmony is paramount (Chin & Kameoka, 2019). In mentoring relationships, this translates to prioritising a successful and harmonious relationship over personal goals. Indirect communication styles are also more common in many Asian cultures. This has been described as high-context communication, whereby “most of the information is either in the physical context or internalised in the person, while very little is in the coded, explicit, transmitted part of the message” (Hall, 1976). Relying on indirect language nonverbal cues rather than explicitly stating one’s thoughts and feelings can hinder open communication.

Hierarchy and a lack of open communication may result in mentors taking on the role of advisors or coaches rather than true mentors. While there is no universal definition of mentorship, key features are that of a long-term dyadic relationship that encompasses educational, training and professional aspects that is personal and reciprocal (Sambunjak & Marusic, 2009). This is in contrast to tutors or coaches that primarily exhibit educational functions, or counsellors that exhibit personal functions. If the mentor-mentee relationship if influenced by hierarchical norms, mentors may be seen as figures of authority rather than partners in development. Cultural respect for authority figures and an emphasis on conformity may also discourage mentees from questioning or having open conversations with their mentors, limiting mutual learning.

Challenges with hierarchy and communication can be overcome with the aid of a structured program, and eventually establishment of trust and ‘familial’ relationships.  A structured program can guide mentors and mentees in having open communication. In an Asian context, mentors may initially play a more authoritative role in guiding and directing their mentees with the aid of a structured guide, from which more two-way communication may open up as the relationship becomes more established. Whilst desirable mentors have characteristically been described as not “bossy” or authoritative (Sambunjak & Marusic, 2009), a study of Japanese physician-scientist mentor-mentees viewed more paternalistic mentoring as favourable (Obara et al., 2021).  However, this will need to be individualised, as a highly directive mentoring style may not be well-suited to those who prefer a more collaborative and participatory mentoring relationship. Communication and learning styles may also continue to evolve with as incoming trainee physicians belong increasingly to Generation Z (1997-2012) instead of Generation Y/Millennials (1981-1996). A study of the mentorship experiences of Gen Z women medical students by Li et al (2024) described how current society had afforded them more opportunities for empowerment and expression, and emphasised the importance of tailored mentorship that considered the mentee’s identify and intersectionality.

Having mutual respect and trust were also key. The mentee and mentor having a pre-existing relationship and familiarity helped, and was more common in our context given that mentees could indicate their mentor of interest. Mutual respect and having a personal connection were also identified as key components in effective mentoring relationships by Eller (2014) and Straus (2013).

Whilst we had initially hypothesised that Asian sociocultural concepts would limit mentorship relationships to be largely professional, mentors shared that mutual respect, trust, and time enabled the relationship to also extend to sharing of personal matters and psychosocial wellbeing. Successful relationships were even described as ‘familial’, with a sense of fulfilment from both parties. A family-like relationship and a sense of loyalty to the mentor and organisation was also described in Japanese mentoring relationships (Obara et al., 2021). Such relationships may be more common in more collectivist cultures. These can be furthered by fostering a sense of community amongst mentees and mentors, such as through group activities, peer support, and shared learning experiences.

A. Limitations

This study was conducted in one of the two paediatric training centres in Singapore. Future studies should expand to other postgraduate programs to improve applicability of the results.

The investigators were participants in the program as mentees or mentors, with potential for bias in analysis. To minimise this, transcripts were analysed independently by two investigators followed by review by the third investigator. While our study focused on the lived experience of mentors, examining the perspective of mentees would be able to provide a more balanced and comprehensive understanding of mentoring relationships and highlight gaps where they can be better supported, and should be considered in future studies.

Our study did not delve into gender dynamics. Female medical trainees may face unique challenges, and male mentors may be stereotypically less nurturing and more process-oriented. Existing studies are varied: a survey of American cardiologists found sex concordance to be beneficial (Abudayyeh et al., 2020), whereas Jackson (2003) did not find same-gender matching to be important in an US academic program. In our initial interviews, gender did not come up as a significant factor and was hence not a focus subsequently. The role of gender in our program may have been minimised by a balanced gender ratio, with 59% of faculty female.

B. Future Research and Practical Implications

Given the significant influence of sociocultural factors on mentoring relationships, mentoring programs should be tailored to reflect the unique cultural norms and values of the region. In Asian cultures, this would include methods to reduce hierarchy, ensuring accessibility to mentors, and having a structured program. Training on mentorship for mentors and mentees would be beneficial to promote characteristics of effective mentoring relationships, and should include a focus on culturally sensitive mentoring with a recognition of how culturally-shaped beliefs can affect mentorship. This is particularly important in multicultural societies where cross-cultural mentorship is more common.

V. CONCLUSION

Cultural factors play an important role in shaping mentoring relationships in an Asian context. Whilst such these may be limiting to a degree, these can be also be leveraged on to further effective mentoring programs. Mentoring programs should be tailored to reflect the unique cultural norms and values of the region to promote career growth and personal development of trainees and mentors.

Notes on Contributors

AC, MD and SG contributed to study conception and design. Participant interviews were conducted by AC. Analysis and thematic interpretation were done by AC, MD with review by SG. All authors were involved in drafting the manuscript and reviewing it critically, and all read and approved the final manuscript.

Ethical Approval

The study was approved by the SingHealth Institution Review Board (IRB number 2021/2542).

Data Availability

The data of this qualitative study are not publicly available due to confidentiality agreements with the participants. 

Funding

No funding was received for conducting this study. 

Declaration of Interest

The authors declare that they have no competing interests.  

References

Abudayyeh, I., Tandon, A., Wittekind, S. G., Rzeszut, A. K., Sivaram, C. A., Freeman, A. M., & Madhur, M. S. (2020). Landscape of mentorship and its effects on success in cardiology. JACC: Basic to Translational Science, 5(12), 1181-1186. https://doi.org/10.1016/j.jacbts.2020.09.014

Burgess, A., van Diggele, C., & Mellis, C. (2018). Mentorship in the health professions: A review. The Clinical Teacher, 15(3), 197-202. https://doi.org/10.1111/tct.12756

Chin, D., & Kameoka, V. A. (2019). Mentoring Asian American scholars: Stereotypes and cultural values. American Journal of Orthopsychiatry, 89(3), 337-342. https://doi.org/10.1037/ort0000 411

Creswell, J. W., & Creswell, J. D. (2022). Research design: Qualitative, quantitative, and mixed methods approaches. SAGE Publications.

Eller, L. S., Lev, E. L., & Feurer, A. (2014). Key components of an effective mentoring relationship: A qualitative study. Nurse Education Today, 34(5), 815-820. https://doi.org/10.1016/j.nedt. 2013.07.020

Flint, J. H., Jahangir, A. A., Browner, B. D., & Mehta, S. (2009). The value of mentorship in orthopaedic surgery resident education: The residents’ perspective. The Journal of Bone and Joint Surgery, 91(4), 1017-1022. https://doi.org/10.2106/JBJS.H.00934

Hall, E. T. (1976). Beyond culture. Anchor Press/Double Day.

Jackson, V. A., Palepu, A., Szalacha, L., Caswell, C., Carr, P. L., & Inui, T. (2003). “Having the right chemistry”: A qualitative study of mentoring in academic medicine. Academic Medicine, 78(3), 328-334. https://doi.org/10.1097/00001888-200303000-00020

Khair, A. M., Abdulrahman, H. M., & Hammadi, A. A. (2015). Mentorship in pediatric Arab board postgraduate residency training program: Qatar experience. Innovations in Global Health Professions Education. https://doi.org/10.20421/ighpe2015.6

Li, C., Veinot, P., Mylopoulos, M., Leung, F. H., & Law, M. (2024). The new mentee: Exploring Gen Z women medical students’ mentorship needs and experiences. The Clinical Teacher, 21(3), e13697. https://doi.org/10.1111/tct.13697

Obara, H., Saiki, T., Imafuku, R., Fujisaki, K., & Suzuki, Y. (2021). Influence of national culture on mentoring relationship: A qualitative study of Japanese physician-scientists. BMC Medical Education, 21(1), 300. https://doi.org/10.1186/s12909-021-02744-2

Ramanan, R. A., Taylor, W. C., Davis, R. B., & Phillips, R. S. (2006). Mentoring matters: Mentoring and career preparation in internal medicine residency training. Journal of General Intermal Medicine, 21(4), 340-345. https://doi.org/10.1111/j.1525-1497.20 06.00346.x

Sambunjak, D. (2015). Understanding wider environmental influences on mentoring: Towards an ecological model of mentoring in academic medicine. Acta Medica Academica, 44(1), 47-57. https://doi.org/10.5644/ama2006-124.126

Sambunjak, D., & Marusic, A. (2009). Mentoring: What’s in a name? JAMA, 302(23), 2591-2592. https://doi.org/10.1001/jama. 2009.1858

Sambunjak, D., Straus, S. E., & Marusic, A. (2006). Mentoring in academic medicine: A systematic review. JAMA, 296(9), 1103-1115. https://doi.org/10.1001/jama.296.9.1103

Spickard, A., Gabbe, S. G., & Christensen, J. F. (2002). Mid-career burnout in generalist and specialist physicians. JAMA, 288(12), 1447-1450. https://doi.org/10.1001/jama.288.12.1447

Starks, H., & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17(10), 1372-1380. https://doi.org/10.1177/1049732307307031

Straus, S. E., Johnson, M. O., Marquez, C., & Feldman, M. D. (2013). Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Academic Medicine, 88(1), 82-89. https://doi.org/10.1097/ACM.0b013e31827647a0

*Dr Aletheia Chia
Department of Paediat,
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Email: aletheia.chia@mohh.com.sg

Submitted: 8 January 2024
Accepted: 2 July 2024
Published online: 1 October, TAPS 2024, 9(4), 14-25
https://doi.org/10.29060/TAPS.2024-9-4/OA3212

Hema Suryavanshi¹, Santosh R Patil², Kaladhar Reddy Aileni³ & Mohmed Isaqali Karobari⁴

¹Department of Oral Pathology and Microbiology, Chhattisgarh Dental College & Research Institute, India; ²Department of Oral Medicine and Radiology, Chhattisgarh Dental College & Research Institute, India; ³Department of Preventive Dentistry, College of Dentistry, Jouf University, Kingdom of Saudi Arabia; ⁴Dental Research Unit, Centre for Global Health Research, Saveetha Institute of Medical and Technical Sciences, India

Abstract

Introduction: Oral health education is essential for adolescents, yet traditional methods face challenges in engaging this demographic. This study evaluates the effectiveness of a multimedia-based dental education program among high school students. This study was carried out to assess the impact of a comprehensive multimedia-based dental education program on oral health knowledge and practices among high school students.

Methods: A total of 228 students were recruited and randomly assigned to experimental (n=114) and control (n=114) groups. The experimental group received a four-week multimedia program, while the control group followed the standard curriculum. Outcome measures included oral health knowledge scores, brushing frequency, flossing habits, dietary choices, and observational assessments. Statistical analysis employed descriptive statistics, paired t-tests, and analysis of covariance (ANCOVA).

Results: The multimedia-based program led to a significant increase in oral health knowledge scores in the experimental group compared to the control group (Mean Change: 14.6, p < 0.001). Moreover, the experimental group demonstrated higher brushing frequency (p < 0.001), increased flossing habits (p < 0.001), and improved dietary choices (p < 0.05). Observational assessments showed higher adherence to oral hygiene practices in the experimental group (p < 0.001).

Conclusion: The multimedia-based dental education program effectively improved oral health knowledge and practices among high school students. This approach holds promise for scalable and engaging oral health education strategies.

Keywords:           Multimedia-based Education, Oral Health, Adolescents, Dental Education, Health Promotion, Preventive Dentistry

Practice Highlights

• Integrated multimedia elements enhanced participant engagement, utilising videos, e-learning modules, and pamphlets.
• Positive shifts in oral health practices observed, with increased brushing and flossing frequencies in the experimental group.

I. INTRODUCTION

Oral health education serves as a cornerstone in empowering adolescents with the knowledge and skills necessary to maintain optimal oral hygiene. By educating young individuals about the importance of regular brushing, flossing, and dental check-ups, as well as the impact of dietary choices on oral health, preventive practices can be instilled early on. This not only helps in preventing common dental problems like cavities and gum disease but also promotes overall health and quality of life (Nakre & Harikiran, 2013).

Furthermore, addressing oral health education during adolescence is strategic as it provides an opportunity to intervene during a critical developmental stage. By targeting adolescents with effective educational interventions, it becomes possible to shape behavior and instill healthy habits that can last a lifetime. This proactive approach not only benefits the individual’s oral health but also reduces the burden on healthcare systems by minimising the need for costly and invasive dental treatments later in life (Tadin et al., 2022).

The increasing prevalence of dental problems presents a significant public health challenge, as untreated oral diseases can lead to pain, discomfort, and even serious complications such as tooth loss, systemic infections, and impaired overall health (Texas Dental Association, 2008). Moreover, dental problems impose a substantial economic burden on healthcare systems, with costs associated with treatment, emergency care, and lost productivity. In light of these challenges, effective educational interventions are crucial for curbing the burden of oral diseases (Ghoneim et al., 2022). Oral health education programs aim to raise awareness about the importance of oral hygiene, preventive measures, and regular dental check-ups. By providing individuals with the knowledge and skills necessary to maintain good oral health practices, these interventions can empower them to take proactive steps to prevent dental problems and minimise their impact (Kassebaum et al., 2017). This study addresses this need by investigating the impact of a multimedia-based dental education program on the oral health knowledge and practices of high school students.

Adolescence represents a critical period for establishing lifelong health behaviors, and oral health is no exception (National Institutes of Health, 2021). Unfortunately, global studies indicate a concerning prevalence of dental issues among adolescents, including dental caries, gingivitis, and poor oral hygiene practices (Agbelusi & Jeboda., 2006, Zhang et al., 2021). Such issues not only impact immediate health but can also lead to long-term consequences, emphasising the urgency of effective oral health education.

Traditional oral health education methods often face challenges in engaging and effectively conveying information to adolescents. Conventional classroom lectures and textbook-based approaches may struggle to capture the attention of this demographic, potentially limiting the efficacy of such interventions. However, there is evidence to suggest that traditional oral health education has been effective in improving oral health knowledge (Angelopoulou et al., 2015), reducing plaque accumulation, and promoting oral health in adolescents (Gousalya et al., 2022). On the other hand, it is important to note that traditional models of oral health education have been criticised for their didactic delivery and failure to acknowledge the individual context and motivations of the recipients (Ford & Farah., 2012).

As technology becomes increasingly integrated into daily life, leveraging multimedia platforms for health education emerges as a promising strategy to enhance engagement and knowledge retention (George et al., 2014).

The primary objective of this study was to assess the effectiveness of a comprehensive multimedia-based dental education program in improving oral health knowledge and promoting positive oral hygiene practices among high school students. By employing a well-structured intervention and rigorous evaluation, this research aims to contribute valuable insights that can inform the design and implementation of future oral health education initiatives.

The significance of this study lies in its potential to inform evidence-based oral health education strategies for adolescents, especially in regions facing resource constraints. If successful, the multimedia-based approach could serve as a scalable and cost-effective model for widespread implementation in school settings. Ultimately, the outcomes may contribute not only to the improvement of oral health outcomes among adolescents in the study setting but also to the development of best practices with broader implications for global oral health promotion.

II. METHODS

A. Intervention

A comprehensive multimedia-based dental education program was developed by a team of experienced dental educators, multimedia designers, and content developers. The program included visually engaging educational videos covering various aspects of oral health, interactive e-learning modules to reinforce key concepts, and informative pamphlets providing supplementary written material.

Throughout the intervention period, the research team closely monitored the attendance and participation of students in both the experimental and control groups. Attendance records, completion rates of e-learning modules, and participation levels in interactive sessions were meticulously documented to assess the program’s adherence.

1) Program feedback and modification: Continuous feedback sessions were held with both students and educators to evaluate the effectiveness of the multimedia-based dental education program. Adjustments and modifications were made in real-time based on feedback received, ensuring the program remained dynamic and responsive to the specific needs and preferences of the participants.

2) Quality assurance: To maintain consistency and quality across program delivery, educators underwent training sessions, and periodic evaluations were conducted to assess their adherence to the prescribed curriculum and teaching methodologies.

B. Study Design

A randomised controlled trial was conducted involving 228 high school students, aged 14 to 18, recruited from four local high schools in Burhanpur, India, after obtaining permission from the school authorities. Institutional Review Board (IRB) approval with approval number GGSCDS&RC/2022/IEC/168 was obtained prior to the start of this study. Students and their parents/guardians were provided with detailed information about the study, and informed consent was obtained from all participants. The study was conducted between January 2022 and December 2023.

A sample size calculation was conducted prior to the initiation of the study to ensure adequate statistical power. Based on previous literature and anticipated effect sizes, the calculation indicated that a sample size of 228 participants would provide sufficient power to detect significant differences in oral health knowledge and practices between the experimental and control groups. Factors such as an alpha level of 0.05, a power of 0.80, and an effect size estimate derived from similar interventions were taken into consideration during the calculation. This approach ensured that the study was adequately powered to detect meaningful differences in the outcomes of interest.

Random assignment of participants to the experimental and control groups was performed using a computer-generated randomisation sequence. The sequence was generated by an independent researcher not directly involved in the implementation of the study. Participants were assigned to the experimental or control group based on their identification numbers, ensuring an equal chance of allocation to either group. This randomisation process helped minimise selection bias and ensure that any differences observed between the groups could be attributed to the intervention rather than systematic differences in participant characteristics.

Given that participants were recruited from multiple local high schools in Burhanpur, India, cluster randomisation was employed to minimise contamination between groups. High schools were considered as clusters, and randomisation was carried out at the school level to prevent potential contamination of intervention effects between students within the same school. This approach helped maintain the integrity of the study design and reduce the risk of cross-group contamination, thereby enhancing the internal validity of the findings.

To address potential biases related to academic performance, we collected demographic information from all participants, including indicators of academic achievement. This information allowed us to assess any confounding variables during data analysis. Additionally, randomisation was employed to ensure that participants with varying academic backgrounds were equally distributed between the experimental and control groups, minimising the impact of academic performance on study outcomes.

1) Experimental group (n=114): Prior to the intervention, informed consent was obtained from both students and their parents/guardians. The multimedia-based dental education program was delivered to the experimental group during regular school hours. The intervention spanned four weeks, with carefully structured sessions designed to cover topics such as oral anatomy, proper brushing and flossing techniques, the impact of diet on oral health, and the importance of regular dental check-ups. Each week, students participated in interactive discussions, watched educational videos, completed e-learning modules, and received informational pamphlets to reinforce the acquired knowledge. To ensure engagement and understanding, the program incorporated quizzes, group activities, and open discussions facilitated by trained dental educators.

2) Control group (n=114): The control group received the standard oral health education provided as part of the existing school curriculum. The standard curriculum included traditional classroom lectures, textbook readings, and basic demonstrations of oral hygiene practices. No additional multimedia resources were introduced to the control group to maintain a clear distinction from the experimental group.

C. Development of Survey Instrument

The survey instrument utilised for baseline assessment underwent a rigorous validation process to ensure its reliability and validity in measuring participants’ oral health knowledge. The validation process included several key steps aimed at enhancing the quality and accuracy of the survey instrument.

The survey items were delved based on an extensive review of existing literature on oral health knowledge among adolescents. Content experts in the fields of dentistry, public health, and education were consulted to ensure that the survey items adequately covered essential concepts related to oral health.

Prior to the commencement of the main study, a pilot test of the survey instrument was conducted with a small group of high school students similar to the study population. Feedback from the pilot test participants was carefully analysed, and adjustments were made to the wording and clarity of the survey items based on their input.

The survey instrument underwent thorough review by a panel of experts comprising professionals from diverse backgrounds, including dentistry, education, and survey design. The expert panel assessed the relevance, comprehensibility, and appropriateness of the survey items for the target population, providing valuable feedback for further refinement.

D. Outcome Measurements and Analysis

In this study, a comprehensive set of outcome measures was employed to assess the impact of the intervention on participants’ oral health knowledge and practices. The study commenced with a baseline assessment, during which demographic data, oral health history, and participants’ knowledge of oral health practices were collected. Throughout the four-week intervention period, participants’ oral health practices were evaluated weekly through self-reports and observations, ensuring continuous monitoring of their adherence and engagement with the program. Following the intervention, a post-intervention assessment was conducted, and participants’ oral health practices were monitored for an additional two weeks to assess the sustainability of behavior changes beyond the intervention period.

1) Pre-intervention assessment: Before the initiation of the intervention, a thorough baseline assessment of participants’ oral health knowledge was conducted using validated surveys (Appendix A). These surveys covered a wide spectrum of oral health concepts, including the anatomy of teeth and gums, the significance of fluoride, and common dental diseases. Individual knowledge scores were calculated, establishing a baseline measure for each participant, with the maximum score for the knowledge assessment set at 100 (Appendix B).

2) Post-intervention assessment: Following the four-week intervention period, participants from both the experimental and control groups underwent a post-intervention survey (Appendix C). This survey mirrored the pre-intervention assessment and allowed for a direct comparison of changes in knowledge. Individual knowledge scores were recalculated, and the difference between pre- and post-intervention scores was used to quantify the impact of the educational program.

3) Brushing frequency: Participants’ brushing habits were assessed through a combination of self-reporting and observation. Each participant maintained a detailed log, recording the frequency and duration of their toothbrushing activities. Trained researchers also conducted periodic observations to validate self-reported data, enhancing the reliability of the findings.

4) Flossing habits: Similar to brushing, participants self-reported their flossing habits, detailing the frequency and thoroughness of their flossing routine. Periodic checks were conducted to corroborate self-reported data, ensuring the accuracy of the information gathered.

5) Dietary choices: The study assessed participants’ dietary habits related to oral health, including the consumption of sugary snacks and beverages. Dietary logs and self-reporting were used, and nutritional assessments were conducted to evaluate participants’ awareness of the relationship between diet and oral health.

Trained researchers conducted periodic observations to assess participants’ oral health practices in a naturalistic setting. This included direct observations of toothbrushing and flossing routines, as well as an assessment of participants’ adherence to recommended oral hygiene practices.

Throughout the study, continuous monitoring and quality checks were implemented to ensure the accuracy and reliability of the outcome measures. Any deviations or unexpected trends in the data were promptly investigated, and corrective actions were taken as needed. This approach ensured the robustness of the study’s outcome assessments.

Descriptive statistics were employed for demographic data. Paired t-tests were used to compare pre- and post-intervention knowledge scores. Analysis of covariance (ANCOVA) was conducted to assess the impact of the intervention on oral health practices, controlling for baseline differences. IBM SPSS Statistics software (version 22.0) was utilised for data analysis, with a predetermined significance level set at p < 0.05.

III. RESULTS

The demographic characteristics table illustrates a well-balanced study population, with both the experimental and control groups having similar age distributions (16.2 ± 1.0 vs. 16.1 ± 0.9) and gender representation (Male/Female: 56/58 vs. 55/59). Baseline knowledge scores align closely, with mean scores of 45.2 (experimental) and 44.8 (control) and standard deviations of 8.3 and 8.1, respectively (Table 1).