AN INVESTIGATION ON THE EFFECTIVENESS OF DISTANCE EDUCATION FOR POST BASIC TRAINING OF ASSISTANT MEDICAL PRACTITIONERS (AMPs) IN SRI LANKA

M. T. M. JIFFRY

K. C. DALPATADU

G. H. FERNANDO

Abstract

The study examines the use of distance teaching methods to provide post-basic training for Assistant Medical Practitioners (AMPs) in Sri Lanka and was based on four learning modules on priority topics in Medicine, Surgery, Paediatrics and Gynaecology & Obstetrics which had been prepared in a format suitable for distance learning.

Of the 22 districts in Sri Lanka, three districts were chosen as the study areas. Ten AMPs from each of the three districts were randomly selected for this pilot study. One group was provided with learning modules only, the other two groups were given the learning modules, together with clinical training at a teaching hospital (TH) for one group and at a non-teaching hospital (NTH) for the other. This sample population was evaluated by means of a pre-test and a post-test during the study.

The study revealed that (a) the base level of knowledge of the AMPs was lower than expected, (b) the control group which was provided with only the learning modules showed significant improvement, (c) disciplines like Gynaecology & Obstetrics needed some degree of clinical input, highlighting the importance of at least a short exposure of clinical teaching in some disciplines, and (d) the teaching hospital group performed better than the non-teaching hospital group emphasising the importance of the infrastructure available in a teaching hospital setting for clinical teaching.

INTRODUCTION

Assistant Medical Practitioners (AMPs) are middle level health professionals who are directly involved in the provision of primary health care in Sri Lanka. At present there are about 1250 AMPs working at various government hospitals, especially in rural areas. The AMP training programme began at the Faculty of Medicine, Colombo in 1976. Additional centres have subsequently been established in Peradeniya, Jaffna and Kalutara. After completion of the 2 1/2 years basic training, the AMPs do not have any opportunity to enrol on a continuing education programme. A survey carried out on AMPs revealed that the lack of such a programme and the lack of a career structure had led to frustration and inefficiency in the delivery of health care; 96% were dissatisfied because of the lack of opportunity for future professional achievements and 84% were dissatisfied because of the unavailability of any continuing education programme even on the basis of self education (Weerakoon and Jiffry, 1989). The major obstacle to the conventional form of a post basic training programme was the requirement to affiliate the AMPs to a training institute away from their present working station and home towns. Therefore, a decision was made to implement a pilot study to evaluate the practicality of using the distance education format for the continuing education of AMPs.

Distance education is an educational process where teacher-learner interaction mainly occurs through instructional media and the learner is necessarily distanced from the teacher by space and time. One of the tremendous advantages of this system of education over the conventional form is that the learners can be stationed at their own places of work. Furthermore, they can study at their own pace and also chose the topics according to their own priority and liking. However, distance education had not been tried out for clinically oriented disciplines anywhere in the world except for the training of nurses in Canada (Kerr, 1988). The distance educational format usually has several possible components including face to face teaching, printed materials and electronic media. As the production of clinically oriented educational material in the form of electronic media proved to be too costly only face to face teaching sessions and printed media have been utilised in this investigation. It was envisaged that the best form of face to face component relevant to this study would be the clinical demonstration of patients. However, it was not certain whether a Teaching Hospital (with teaching facilities and service functions) or a Base Hospital (only service functions) should be used to carry out the clinical teaching to yield the maximum benefits. Furthermore, it was also intended to test the extent to which the face to face component would help in the learning process of the AMPs at this level. Therefore, one group of AMPs was chosen as the control group and provided only with the learning modules. The other groups were exposed to the modules as well as clinical teaching.

The aims of this study were to evaluate;

1. the usefulness of distance learning as a mode of continuing education for AMPs.

2. the extent to which face to face teaching in the form of clinical demonstration of patients could complement and supplement distance learning.

3. which type of hospital (base or teaching) was more suitable for face to face teaching.

MATERIALS AND METHODS

Four learning modules for the distance teaching format had been prepared according to distance education principles by a course team consisting of authors (Medical Officers teaching the AMPs), subject specialists (Consultants) and academics, over a period of 10 months. The topics were selected according to the findings of a previous survey (Weerakoon and Jiffry, 1986) carried out on the AMPs to ascertain their deficiencies and learning requirements. These topics included Diabetes Mellitus (Medicine), Acute Abdomen (Surgery), Neonatal Emergencies (Paediatrics) and Post Partum Haemorrhage (Gynaecology & Obstetrics).

The Puttalam, Kalutara and Gampaha districts (geographically demarcated administrative areas in Sri Lanka) were chosen as being the most feasible study areas, due to their close proximity to the study centre as well as the availability of sufficient numbernumbers of AMPs in service. Ten AMPs from each district were selected on a random basis. The AMPs of Gampaha district were provided with the study modules only and this group was considered as the control group (CG). The Kalutara and Puttalam groups were assigned to follow weekly clinical sessions at the Panadura Base Hospital (a teaching hospital for AMPs, abbreviated as TH) and at the Chilaw Base Hospital (Non-Teaching Hospital – NTH) respectively, in addition to being provided with learning modules.

All three groups were evaluated at a pre-test before the commencement of the course. Thereafter, they were given the study modules, self assessment forms and other instructions regarding the rules of the project. They were expected to learn the modules while working at their stations and to attend the clinical demonstrations at the hospitals assigned (Kalutara & Puttalam groups); the Gampaha group (control group – CG) was asked to confine themselves only to the modules and any other material they came across. They were clearly instructed not to attend any organised clinical teaching during this period. All three groups were given about 10 months to complete the four modules. During this period they were requested not to discuss the contents of the modules with other participants if they met. The investigators paid two monitoring visits to the hospitals where the clinical teaching was being conducted to ascertain the progress of the project. In addition a co-ordinator was also appointed to each district to attend to the immediate needs of the learners.

The training programme was free of charge to the trainees. The entire study was funded by World Health Organisation. At the end of approximately ten months the post-test was conducted in Colombo for all three groups together. The pre and post test marks were compared statistically using paired t test.

RESULTS

Of the 30 trainees who had been selected to take part in this project, only 29 reported for the orientation programme and thereafter for the pre-test. Thus the sample for the study consisted of 29 trainees, the missing trainee being from the Puttalam district. However, at the end of the project only 25 trainees were able to take part in the post test. From the Puttalam district (NTH) all 9 trainees sat for both pre and post tests, whereas from Kalutara (TH) and Gampaha (CG) districts, of the original 10 participants only 7 and 9 participants respectively sat for the pre-test and participated in the post-test. In the analysis of results, only the marks of those who sat for the post-test were used.

Marking of MCQs

The MCQs were marked in the following manner. For each correct response a +1 score and for each wrong response a -1 score was allocated. A zero score was allocated to responses that had not been attempted.

A data base programme was developed to analyse the responses on dBase III+. From this data base programme it was possible to group the marks of the trainees of each district and classify them according to the subjects. Thereafter, for each question the total number of +1 marks and -1 marks obtained was calculated separately.

For further analysis of the MCQ marks, especially in view of the fact that some authorities do not favour carrying forward of the negative marks (Ward, 1981), two methods were adopted. These are described below.

Method A

In this method of analysis, all the positive and negative marks were added together, as in the case of a conventional marking of an MCQ paper.

Method B

For each MCQ there are five responses. If a student gets all the five responses correct, he/she could score a maximum of 5 marks. If there are 10 students in a group the total marks would be 50. The actual correct responses (+1) obtained for each MCQ by each group has been calculated and expressed as a percentage of the maximum possible score. For example, if for Question1 the total number of correct responses obtained by 10 trainees was 30 marks, since there could be a maximum of 50 marks, the percentage would be 60%. In this method of analysis the negative marks were not taken into account.

In both methods the MCQ marks were presented separately according to the groups and disciplines.

MCQ Marks

The marks of the MCQs of all trainees who sat for the pre and post tests calculated according to method A are summarised in Table I.

In Table II, the MCQ marks of all the trainees who presented themselves for the post-tests are compared with their performance at the pre-test (The marks of all those who could not sit for the post-test have been excluded from this comparison).

The MCQ marks of all the groups for all the subjects at the pre-test were found to be below 40% (Table II). There was an overall improvement in the performance at the post-test. However, a score of more than 50% was achieved by all three groups only in Medicine. The Kalutara group (TH) also achieved more than 50% in Paediatrics.

In the case of MEQ, all the groups scored less than 45% in all disciplines at the pre-test. The Gampaha group (CG) scored especially low with a mean of 6.57% in Paediatrics. However, all the groups except the Gampaha group (CG) improved remarkably at the post-test, in Gynaecology & Obstetrics. In Medicine all three groups scored more than 50% at the post-test.

Generally, in all four subjects there has been an improvement in the performance of the MEQ.

DISCUSSION

Selection of topics
The topics representing the four clinical disciplines were chosen from a list of priority topics that had been identified at a previous workshop. For each of the four topics chosen from each discipline, the degree of clinical input needed was found to be variable. For example, in the case of the topic in Surgery "Acute Abdomen", supplementary clinical teaching was essential. The clinical skills expected from the trainees was the ability to recognise this condition and transfer the case to a hospital/ward with necessary facilities for urgent treatment at the appropriate time. On the other hand, topics like "Diabetes Mellitus" are common clinical entities that the AMPs would have noted almost daily in their routine clinical work. In addition because of such frequent exposure an AMP would have gained some experience to manage such cases. It was therefore expected that the trainees would be able to diagnose diabetes and manage this condition satisfactorily.
Face to face teaching by consultants

The consultants belonging to the Teaching (Panadura Hospital in Kalutara district) and Non-Teaching (Chilaw Hospital in Puttalam district) Hospitals played a significant role in this project.
