The overall mean (SD) rating of 3.26 (0.48) on the five-point scale for post-self-assessment of the bloc coursesin Table 2points to the high quality of the bloc courses and the students’satisfaction. Specifically, the teaching’s major effecton the students’perspective on the public health system in Malawi was rated highly. The topics of the bloc coursemodules, the teaching quality, and the impact of the bloc courses on theclinical practice were also very highly rated by the students.
The overall mean (SD) rating of 9.10 (0.91) on the 10-point scale of the RSES in Table 3shows the development of students’research self-efficacy that allowed them to conduct a small research project on their own. Studentsfelt enabled to identify and formulate research problems and questions,to perform a literature search, and to write aliterature review. They also gained the confidence to research a team, to plan, to collect data, and to present their findings.
The project also changed the students’ research-related attitudes, intentions and actions in a positive way, as indicated by the respective overall mean (SD) ratings of 3.99 (0.08), 3.85 (0.32) and 2.78 (0.85) in Table 4. They strongly agreed that learning and understanding research and incorporating it into their clinical practice is important and that they plan toincorporate research and make use of the findings in their clinical practice. For the “action” statement of the SOC model,the perceived change is smaller compared to the attitudinal and intentional statements. Being involved in another than the current research project appears to be rare.
The findings are presented according to emerging themes from the open-ended post-self-assessment survey questionnaires, the IDIs and FGDs.The IDI and FGD numbers, the location of the interview and the date of the interview are given in brackets after the quotes.
Clinical knowledge, skill, and self-confidence
All interviewed students referred the bloc courses and supervised ward rounds as being helpful and relevant to their daily clinical practice. It helped themto improve their clinical knowledge and skills by addressing their gaps in theory and practice. It also improved their clinical reasoning and problem-solving capacity. The bloc courses also widened their knowledge in the differential diagnoses, making them more confident in patient management.
“We [supervisor and students] can discuss [case-based learning] … come up with the diagnosis and then management…if I see the same case second time in the same condition…I will have enough knowledge to manage that” (IDI1/MJ/04042019).
“You [students] are the first one to crack [deal with] the patients…the first thing you learn from there [in wards] is that one has confidence” (FGD1/LG/02042019).
The combination of bloc courses and supervised ward rounds helped the students to assess and manage the patients, and to make the decision for a referral.
“It is very important to be equipped with the proper knowledge to make the proper diagnosis and to make the proper first management, treatment and to make the proper decision of referring on time” (FGD3/BT/08042019).
Evidence-based clinical practice and quality of care
Students stated that having research skillsisvery important as a health care professional. It helped them to deliver evidence-based care in patient management.
“Research skills are important because it has helped me to understand both scientific and ethical way how to address a relevant topic in medical profession” (RSES-SOC-6).
Studentsalso valued the importance of doing their own research to use evidence in their clinical work, linked to their own context and needs. This practice is not very common in the African context, they felt. They also believed that it would contribute to improved quality of care.
“In developing countries like Malawi, there are few clinical research projects. Most studies that influence our clinical practice is either adopted from research done outside Africa or in a few African countries. These findings might be irrelevant to our setting. Hence, it is important to enhance local research to strengthen our health system……Research-based clinical practice will enable our system to improve care [quality] and reduce the morbidity and mortality” (RSES-SOC-9).
Though studentswere interested and valued the importance of being involved in further research, they were concerned about thelack of funding and resources to continue it at the district level.
A holistic approach to disease management
Studentsmentioned having gained a more holistic approach todisease management during the training program. They learned to consider patients´ andtheir families´socio-economic and psychological situation, acute and chronic disease, and to identify the root causes of the diseases. Students believed that their approach would help to reduce the disease burden and hospital admissions.Communication with the patients’ families and counseling them are also part of the disease management mentioned by the students.
“We should not look only on the disease, but also on the other aspects…to know a patient holistically… that a child can be treated holistically in all aspects” (FGD3/BT/08042019).
“Itry to dig more and try to find the reason and to address that… to avoid that the child will not come back again with malnutrition[example of a malnourished case]” (FGD2/SL/03042019).
Communication and networking capacity
Students mentioned that the bloc course module on “Communication” together with the practices during the supervised ward rounds improved their communication skills within and outside the team and health facility. As a result, teams work more effectively, which is important in clinical practice, according to the students.
“Teamwork is the most important thing in medicine[clinical practice]. You gain a lotof clinical knowledge, but if you don't develop or grow the knowledge of teamwork, then that is nothing… we have learned here to build an effective team” (FGD3/BT/08042019).
Students valued good communication with the patients and their families for keeping them informed and involved in decisionmaking about disease management and referral. Moreover, the personal network of the students with physicians from different hospitals made them feel connected which was seen as useful for referrals. Students also connected frequently with their supervisors and other students by using technology, such as WhatsApp. Technology became a platform for the students to discuss clinical cases and helped them to diagnose, treat and refer the patients on time.
Leadership was one of the non-clinical skills the project had focused on. Students mentioned that the process of learning made them feel confident, prepared them to play a leadership role, or act as a role model at their facility and community.
“We have learned a lot about leadership…different attitude…how we can approach certain problems, how we can solve certain problems, even the conflicts within the workers” (FGD3/BT/08042019).
“I need to be the first one with a different approach and to make a difference to the people” (IDI1/MJ/04042019).
The global context of teaching and learning
Students valued the involvement of international teachersand supervisors as it put their knowledge and work into a global contextand widened their horizons.
“It is not only one country that it becomes the whole world coming together…It is like teaching us and making us fit for everything as far as the globe is concerned” (FGD1/LG/02042019).
Students appreciated reading the latest scientific articles during the bloc courses which put their knowledge in an international context. As a result, they became familiar with global standards and guidelines of health care. This exposure helped them to better understand how global decisions influence local practice and how different countries put different emphasis on health topics.
Obtaining new knowledge, serving the children with this knowledge, improving the overall health situation of the country, and advancing their career motivated the students.
“… a lot of children are suffering and dying there [at district]because of mistreatment and mismanagement … when I go back home [at district], I should treat the patients even with the least management that is there [available at district level]. But, I have to give the best management”(FGD1/LG/02042019).
Through the new knowledge and skills acquired in research, students became more autonomous and motivated to improve the quality of care at their facilities.
“I will be the pediatric team lead in the district, it is paramount for me to do research by myself to improve the quality of care in the pediatric department” (RSES-SOC-7).
Students concerns beyond the learning modalities
Studentsexpressed their concern ifthe new cadre (specialist pediatric CO) will be acknowledged in the government system bya salary raise. Otherwise,they saw the risk of this cadre leaving the public sector.
“If they [COs] are not promoted [with a new title and pay scale], they will go out [of the government system] and the gap will remain the same” (FGD3/BT/08042019).
Students were worried abouttheir further professional developmentand about having the opportunity to do a Master’s degree in the relevant field. A Master's degree was seen as a motivation for them as well as for the upcoming COs.They suggested continuing the supervisionsupport after their graduation and recommended to continue thetraining program with more students. They felt this to be a requirement to deal with the shortage of health care workers at the district level and to improve the quality of care.Thekey informants agreed with the students’ views, but mentioned the shortage of supervising and teaching staff as an additional barrier.Several logistical issues, for example, lack of financial support, high tuition fees, and lack of an accommodation facility during their study were mentioned.