Development of an educational program to improve skills for preventing, diagnosing, and treating non-communicable chronic diseases for final-year medical students in rural and urban communities

doi:10.21203/rs.3.rs-2621956/v1

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Development of an educational program to improve skills for preventing, diagnosing, and treating non-communicable chronic diseases for final-year medical students in rural and urban communities

https://doi.org/10.21203/rs.3.rs-2621956/v1

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Background: The e-Learning with flipped classroom approach educational program is an alternative to online learning (e-Learning) and face-to-face learning for addressing the challenges related to long-distance skill training.

Methods: Consisting of weekly live-time virtual sessions with expert physicians, available resources including updated guidelines, review articles, and blog interactions between colleagues for discussing the clinical cases to improve learning techniques. The availability of all the content (recorded lectures and bibliography) at any time for review is an important aspect for easy learning. This multimodal approach was directed to medical students working in rural communities to get the necessary skills for preventing, diagnosing, treating, and improving the quality of care in non-communicable chronic diseases (NCCD). In addition, this model includes a pre and post-course evaluation, a quality of care test, and a dropout and satisfaction survey. The students who obtain the approving grade at the end of the course get a certificate with medical endorsement.

educational program

non-communicable diseases

undergraduate

e-learning

The medical students who serve in rural communities need skills to manage non-communicable diseases (NCCD). The necessary skills are often insufficient because their academic program needs to enforce the development of the required clinical competencies. As a result, they must be fully trained to solve it properly and promptly when facing a real clinical scenario. Due to the high prevalence of NCCD in our country, these diseases represent the main reason for seeking healthcare in both rural and urban medical centers [1]. If the diagnosis and treatment of these conditions are delayed or inadequate, short- and long-term complications will follow and increase morbidity and mortality [2]. Since this problem represents a great expense for our National Health System, improving the training of undergraduates who attend rural areas should be a priority [3]. Even when a nationwide medicine program includes many hours of teaching about NCCD, this training is knowledge-based with little evaluation of clinical skills. There needs to be higher access to medical training on NCCD for medical students during their social service.

Different types of medical training: Massive Open Online Courses (MOOCs).

A new global higher education service in places with limited access has been offered online at the world's best universities [4]. Despite a high number of students registered (more than 5–12 million), only 6–25% finished their course. An explanation for this phenomenon is that if an educational institution cannot guarantee a benefit with labor market value, they will drop out of the course [5].

E-learning With Flipped Classroom Approach

Effective teaching delivery models that combine in-person teaching (physical/virtual classroom) with online pre-reading material are needed globally to maintain the continuity of medical education. Flipped classroom modality is a new educational format that improves e-Learning. This format makes the student the protagonist of the training, participating actively in constructing the knowledge. In-person sessions (physical or virtual classroom) consolidate the information obtained during the review of the web educational material [6]. Teaching students self-directed learning skills can increase knowledge retention even without face-to-face education. During the COVID-19 pandemic, transferring medical education to e-Learning platforms solved the hybrid education model [7]. Existing studies suggest that clinical skills obtained in an e-Learning with a flipped classroom or e-Learning approach are as effective as traditional education [8, 9]. Nevertheless, there needs to be more evidence of studies with implications for the future direction of medical e-Learning with a flipped classroom approach and the development of the following years of the hybrid educational model in NCCD. On the other hand, it supports university teaching (face-to-face) with the Service-Learning approach, and the online program allows students to enrich their learning. Studying online, while offering a social service allows one to engage in reflective activities to deepen the understanding of what is being taught.

The Challenges Of Online Learning And Teaching

The usage of digital platforms and evaluation methods in education is increasing rapidly. Although the future of medical education is unpredictable and volatile, MOOCs are proving to be a great way to educate faculty and students without relying on instructors. Students' encounters with technology have the potential to alter their motivation to progress through the course. Because MOOCs cater to a wide range of demographics, a welcoming environment is essential for students of all ages and digital abilities [4]. The flipped classroom model emerged in 2007 in Colorado. Professors Jonathan Bergman and Aaron Adams began using software to make video lectures or PowerPoint presentations and later posted the results online so that students who had failed class could access the insights [10].

Academic professionals expressed concerns about the impact of technical challenges on teaching and assessment. Academic staff saw distance learning as an opportunity to improve their teaching skills, whereas students get an opportunity to strengthen their independent learning skills [11, 12].

Interaction is a term that refers to any communication that occurs between two or more individuals or objects. The literature recognizes three types of interactions in particular: (i) student-content, (ii) student-student, and (iii) student-teacher [13].

This project aims to implement an easy-to-use, structured e-Learning with flipped classroom approach for acquiring the basic skills for preventing, diagnosing, and treating the most frequent NCCD, considering the three types of learning interactions mentioned above (Fig. 1). The program focuses on diabetes, hypertension, dyslipidemia, and obesity while improving the medical students' clinical competency and academic performance during their final year.

e-Learning with a flipped classroom approach Educational Program

We designed a one-year educational program with four modules addressing dyslipidemia, hypertension, diabetes, and obesity. Each module had an average duration of 3 months, including material designed and produced by several consultants with broad and relevant clinical experience. The complete program will have a duration of 4 years. Each year, new medical students can enroll in the program.

The program included different kinds of educational material, such as:

- Pre-recorded video Lectures: Lectures about the general concepts of each topic. Students were allowed to download the videos at any time. This material was the preamble of later synchronous live-time virtual sessions.

-Bibliographic collection: This was a repertoire of relevant articles for each topic. The articles' collection included an annual update on national and international guidelines for the management of each NCCD. The bibliography was obtained through the retrieval services of the "José Luis Bobadilla Fernández" Library of the School of Public Health of Mexico through the services of ScienceDirect, Ebsco.

- Live-time virtual sessions. These took place once a week. A specialist led the discussion of real clinical cases and answered all questions from the attending students, questions derived from the social service experience.

-Blog Questions to the Expert. In this area, medical students could ask questions not addressed during live sessions, supporting service learning. Experts replied within 72 hours.

- Social Interaction: This is where the students can interact and comment regarding clinical cases and medical information and discuss newly published articles. Medical students work collaboratively with their colleagues (classmates) and share what they have learned.

- Homework: The participants sent the registry of clinical indicators guaranteeing the anonymity of the attended patients. They also sent solutions for clinical cases published online as an exercise for the live session.

- User’s Guide: This section includes general information about the course, evaluation methods, and a calendar of the activities.

- Didactic Planning. Each module contains information and the calendar of the sessions.

- Advertisement: New announcements regarding each module, class, or update.

- Technical support: Help regarding internet connection, availability of materials, and access to sessions.

-Professors: Professors were specialists from NCCDs Clinics in the INCMNSZ, such as Diabetes Clinic, Lipid Clinic, UIEM, Cardiology and Hypertension Department, Obesity Clinic, and CAIPaDi (Centro de Atención Integral al Paciente con Diabetes).

Beneficiary Population. Mexico's Ministry of Health (SSA) invited all students who participated in the program.

Online platform. For implementing this program, the SSA provided a list of rural health centers with free internet access. Later, the call was opened to all states considering that students did not necessarily have to connect from the center health but could connect from their residence or in an internet cafe.

A portal web was developed to report the participants' and user managers' academic profiles and other socio-demographic data. The MOODLE Learning Management System (LMS) was a technological tool supporting free and open-source software. The National Institute of Public Health oversaw the development and adaptations of the web application for the implementation of the program. Through this technological tool, the activities of the students were supervised. The access to content was conditioned through carrying out the diagnostic evaluation. Recorded live sessions, readings, educational videos, surveys, and evaluations were published in LMS - MOODLE.

Evaluation. Our program seeks to ensure that the social service intern has the necessary skills for clinical practice. The evaluation is accomplished in four ways:

1. Assess the quality of care in the attention of NCCD

2. Assess clinical performance and discussion of the real cases in the platform and discuss with the expert within live-time virtual sessions.

3. Assess that the students do the right things and apply the principles of the course to their patients, sending their records in an anonymous format to save the patient's identity.

4. Assess the knowledge of NCCD through pre and post-test.

First, a questionnaire was applied regarding the activities carried out on each patient, such as whether the albumin/creatinine ratio was requested or whether the feet were checked in patients with diabetes. This first questionnaire was applied before starting the course. This evaluation was based on different parameters of quality of care.

In diabetes, the evaluation was based on parameters of the National Committee of Quality Assurance [14], which evaluates if patients had an ophthalmological and renal evaluation, a foot examination, and counseling for smoking cessation. The evaluation of the hypertension module was based on the ICAHi (hypertension care quality index).[15, 16] In the module evaluation, we assessed screening, the indication of self-monitoring, ambulatory blood pressure monitoring, evaluation of complications, the establishment of individualized goals, prescription of lifestyle changes, and registry of most common drugs used. In this case, we also evaluated the correct management of secondary hypertension.

The obesity evaluation was based on the 5A Module[17]. Pre-module questions included information on measurement of weight, height, abdominal circumference, and use of the EOSS scale, patient education on diagnosis and impact on health, treatment options, individualized goal setting, lifestyle changes, drug risk not approved for weight loss, and if follow-up is given for weight change and comorbidities.

Dyslipidemia was evaluated based on the ESC/EAS Guidelines for the Management of Dyslipidemias 2019 [18]. The questionnaire included information about the individualized goal of LDL-c, evaluation of cardiovascular risk in patients with hypertriglyceridemia, and treatment with and without lipid-lowering drugs.

The second way to evaluate is in live-time virtual sessions. In these sessions, the duration is one hour, and real-life clinical cases are presented. The objective is to make an interactive session where the trainees solve the clinical case with the help of the expert. Likewise, doubts on the theme are resolved to consolidate knowledge by putting it into practice in the case discussed. Additionally, practical questions can be resolved on the blog throughout the week. The expert is in charge of answering these questions twice a week.

The third method of evaluation consists of requesting the sending of the patient records to evaluate that the quality evaluation scores are obtained in the attention of each area. ***For diabetes, we evaluated the percentage of patients in control of glycosylated hemoglobin, blood pressure, and LDL cholesterol; we also evaluated the percentage of patients who have had an ophthalmological and renal evaluation, a foot examination, and counseling for smoking cessation. In the post-module evaluation for hypertension, we assessed the percentage of patients achieving blood pressure control, the results of the studies evaluating complications, the criteria for studying a patient with secondary hypertension, and the need for reference to a second-level clinic. In the evaluation post-module for obesity, we also included the change in weight, body mass index, and waist circumference at basal, three, and six months. For the dyslipidemia module, we evaluated indications for screening, tests solicited, and management according to results, time for follow-up, and management of severe hypertriglyceridemia.

A knowledge assessment was also carried out before and after each module. The objective was to have a basal parameter and later to know if the minimum knowledge of each subject was obtained. They could claim a certificate for that module if they obtained a minimum grade of 8/10. Then, if the students finished all four modules with a minimum grade of 8/10, they could obtain a certificate issued by the Mexican Society of Nutrition and Endocrinology (SMNE).

Satisfaction surveys. We assessed the rating of satisfaction with the program at the end of each video conference and the end of each module. The items assessed were:

learning content and teaching materials
learning environment (technological support)
expert performance opinion

Abandonment surveys. We assessed the number of users who finished the training program each year. We evaluated:

Time dedicated to the program.
A place where they connected for the session.
Interaction with experts.
Course expectations.
Reasons for abandoning the course.

Due to the challenges and the need to improve traditional MOOC e-Learning, we designed an educational program with a flipped classroom approach considering the limitations and opportunities in other scenarios. The flipped classroom represents a new methodological perspective in the teaching-learning process. The student actively participates in the construction of knowledge. In this e-learning approach, the knowledge is acquired outside the physical or virtual classroom since the participant studies online with all the available material.

Our program includes synchronous and asynchronous virtual sessions to improve communication with the professor and engage the student's participation. This program guarantees feedback between lecturers and students by having specific blogs (virtual feedback) during live sessions (synchronous feedback) and student-student interactions through specific social blogs for discussing clinical cases and other activities during the flipped classroom. This strategy helps students to check the approach of the other medical students. It also increases their motivation and improves learning engagement, satisfaction, and interaction [9].

The possibility of reaching medicine students through digital processes could increase efficiency, teaching, and acquiring competencies in any geographical location. It helps incorporate opportunities for distance learning for rural and remote physicians. Also, expanding the number of students with a reduced need for staff or spaces increases educational institutions' capacities and the possibilities of distributing education uniformly. The advantages of e-Learning with a flipped classroom approach are that students can review the learning materials at their own pace and as often as possible [10, 16]. Another advantage is the online self-assessment. The forms capability of the web enables learners to complete online self-assessment tests, which can be programmed to provide immediate grade reports and feedback to learners while they are online [17]. The flipped classroom approach of our program implies that teachers are flexible with students regarding the studying time and making of the exam. Class time consolidates more complex cognitive processes (review of the clinical case approach, concepts, group exercises, correction of mistakes). Following the teacher's guidelines, the student uses all the network resources to understand some context better. The YouTube tutorials and video lectures cover all kinds of educational content.

The challenges of web medical education could be the implementation and updating of technological equipment, the preference for a face-to-face modality by some students, and the time spent in front of the computer. Teaching and training via the internet require special attitudes, competencies, educators' skills, and effective materials development [17, 18]. A qualitative survey about e-Learning satisfaction in 1328 students from health science in eleven countries showed that e-Learning was satisfactory in acquiring knowledge [19]. However, 41% reported interference due to network problems, 60% considered that clinical and practical skills are best learned in clinics and laboratories, and 34% of the students did not feel confident enough to take exams after e-Learning sessions [19]. The evidence found in a systematic review is that e-Learning for teaching clinical skills is as effective as traditional methods [7].

On the other hand, a Turkish study showed that students struggle with meeting affective and psychomotor targets while they successfully reach cognitive objectives. During the COVID-19 emergency, teachers working in distance education modality preferred not to design their materials and relied on ready-to-use products [20, 21, 22]. They only employed homework, end-of-unit quizzes, and online course participation as measurement and evaluation tools. They agree that they cannot deliver accurate and effective evaluation tools [4]. This dissatisfaction stems from the requirement to modify their teaching format quickly while maintaining the quality of medical education. Teachers also disliked the high degree of effort required to combine classroom and clinical work [5, 6]. Instructors should take steps to retain communication, collaboration, and personal engagement with their students after implementing an online learning scheme [7]. Also, teachers lament students' failure to attend online courses, apathy, lack of immediate feedback, limited communication with students, and short course lengths. Because of those concerns, e-Learning with flipped classroom approach constituted a better educational alternative.

Students' experiences during e-Learning depend on having reliable internet access. Some academics voiced concern about the digital gap and how some nations with a low level of digital readiness may face additional technology-related issues [3]. The availability and use of information technologies and infrastructures in a country are called digital readiness [3].

In our country, technological facilities are available in big cities. Nevertheless, in rural areas, it is still a challenge to be addressed. Our work seeks to make decision-makers aware of these difficulties to facilitate support for social service doctors located in the most remote parts of the country.

Technical challenges with gadgets may also impact students' online learning experiences. Another important component in successfully adapting to e-Learning is having access to proper technological instruments. Even in higher education, roughly 76% of students had incompatible devices for online study, 15% used a laptop, and 85% used a smartphone [3]. Baczek et al. reported that 54% of medical students had technical issues with information technology [23]. Half of the medical students report less interaction with lecturers, and just 4% believe online learning classes are interactive. Over half of the students said they prefer in-class over online collaboration. They appreciate the direct assistance and proximity to lecturers and classmates, which is better in an in-class modality [3, 8]. This problem is solved with flipped classroom modality where the students highly participate in small group discussion-based activities and live-time sessions. These sessions help increase their motivation to learn and enhance their engagement and interest in the subject matter [9].

The "eyestrain induced by long time spent looking at screens" was the most common stumbling complaint for 73% of students who claimed it could have an ergonomic impact. This detrimental effect could be linked to the widespread use of smartphones and the small screen sizes available on these devices [3].

E-Learning needs to address the main issues for better adherence to acquiring knowledge and competencies. An e-Learning with flipped classroom approach educational program could improve data acquisition, easy access to bibliographic resources (including clinical guidelines and review articles), pre-class web material, and achieve closeness with teachers and other students to facilitate learning. The support of the technology team is essential to facilitate communication (sending emails, reminders, grades, and tasks) between students and teachers to achieve these objectives.

NCCD: non-communicable chronic disease, MOOCs: Massive Open Online Courses, LMS: Learning Management System, ICAHi: hypertension care quality index.

Review Board Statement

This protocol complied with the 1964 Declaration of Helsinki and further revisions up to 2013 (7^th revision). The Institutional Review Board of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, approved this study (protocol Nº 2233-17/20-1) as an expedited review.

Ethics approval and consent to participate

Expedited review refers to projects and investigation that, due to their nature, do not imply a greater risk than the one a person is exposed to in their daily activities or lives, nor do they compromise the physical or mental health of participants, therefore, informed consent is not required and the student´s anonymity is preserved.

Consent for publication

All authors reviewed the manuscript and consented for submission and publication.

Availability of data and materials

The datasets used during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This project received an unrestricted grant from Fundación Gonzalo Rio Arronte I.A.P. Project # S.637.

Authors' contributions

ICB and PAV conceived the study. NHG and ICB participated in the design of the study. LJA helps with the online platform logistics. ICB, ACGU, PAV, and EAChM wrote the first draft of the manuscript. All authors participated in the thematic analysis, created the content of the modules, and approved the final manuscript.

Acknowledgments

We want to acknowledge the Mexican Ministry of Health's participation in inviting medical students. This paper thanks the program supported by the Fundación Gonzalo Rio Arronte (FGRA). We thank School of Public Health of Mexico: Luis Javier Aguilar López,Jacinto De Jesús Altamirano; Fernando Montealban; Paola Navarrete Guadarrama; Osvaldo Huerta Muratalla, Teresa Paola Olmos Gonzalez, Liliana Correa Barragan, Nenetzen Saavedra Lara. We thank Secretaria de salud (SSA): Rosa Elena Villareal, Maria de Jesus Santiago Martinez.

Enhancing performance

Through the educational program with technological tools for specialized consultation, they will be able to enhance their care in the prevention, timely diagnosis, and adequate treatment of the most relevant NCCD patients in our country: diabetes, obesity, dyslipidemias, and arterial hypertension.

Simultaneous virtual sessions

Through distance and synchronous virtual sessions, participants can participate in interactive courses with distinguished specialists without leaving their residences.

Shared purposes

Improve academic performance and competency development for the prevention, diagnosis, and treatment of NCCD, which will positively impact the achievement of their professional clinical goals.

Academic Advising

With the program, participants will have access through electronic media to workshops, videos, presentations, and a selected updated bibliographic collection.

Patient-centered

Improve NCCD care parameters according to treatment guidelines through validated scores and scales to reduce morbidity and mortality associated with these diseases in the long term.

Continued support

With the creation of a virtual space for the presentation and resolution of doubts and specific problems that cannot be solved with previous resources, communication with professionals from specialized centers will be established in real-time.

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No competing interests reported.

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Development of an educational program to improve skills for preventing, diagnosing, and treating non-communicable chronic diseases for final-year medical students in rural and urban communities

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Version 1

Abstract

Figures

Background

E-learning With Flipped Classroom Approach

The Challenges Of Online Learning And Teaching

Methods

Discussion

Abbreviations

Declarations

References

Additional Declarations

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