|ORIGINAL RESEARCH PAPER
|Year : 2008 | Volume
| Issue : 2 | Page : 126
Student Evaluation of an Integrated, Spiral Model of Epidemiology Education at the Ege University
ZA Ocek, S Taner Gursoy, M Ciceklioglu, F Aksu, M Turk Soyer
Ege University, Faculty of Medicine, Department of Public Health, Bornova, Izmir, Turkey
|Date of Submission||11-Oct-2007|
|Date of Acceptance||11-Feb-2008|
|Date of Web Publication||09-Sep-2008|
Z A Ocek
Ege University, Faculty of Medicine, Department of Public Health, 35100 Bornova, Izmir
Source of Support: None, Conflict of Interest: None
Objectives: The Ege University Faculty of Medicine (EUMF) introduced a community-oriented undergraduate curriculum in 2001. In developing the epidemiology portion of the new curriculum, learning objectives were written for their relevance to different learner stages within the general curriculum and to Turkey's public health problems. Key learning objectives were that students should be able to comprehend the moral values of scientific research, principles of study design and evidence appraisal, and the role of epidemiology in clinical practice. The curriculum included didactic lectures and group activities. The aim of the present study was to explore third-year students' perceptions of the epidemiology curriculum.
Methods: The program was evaluated at the end of our students' third year through written evaluations using quantitative and qualitative methods. Two hundred fifty-five students (92.7%) of all third-year medical students participated in the evaluation. Quantitative methods were based on student ratings, whereas qualitative method assessments involved content analysis of the students' open-ended statements.
Findings: Based on responses to fixed response items, more than seven out of every 10 students appreciated the value of epidemiology to the work of physicians. More than six out of 10 students evaluated the curriculum favorably, but only a third indicated that they became more interested in epidemiology with time, and one-quarter found epidemiology challenging. In students' open-ended responses, the most frequent positive statements referred to students' heightened interest in research and appreciation of the curriculum's interactive teaching. Some students criticized the content as difficult and felt that there were too many didactic lectures.
Conclusion: Based on their evaluations, students found our new epidemiology curriculum acceptable, and regarded it as relevant and valuable to their future practice.
Keywords: Epidemiology education, medical students, public health curriculum, critical appraisal, scientific research
|How to cite this article:|
Ocek Z A, Gursoy S T, Ciceklioglu M, Aksu F, Soyer M T. Student Evaluation of an Integrated, Spiral Model of Epidemiology Education at the Ege University. Educ Health 2008;21:126
There is increasing recognition of the importance of learning epidemiology for future physicians (Marantz et al., 2003). Widely regarded as the “basic science” of public health (Stone, 1998; Marantz et al., 2003), epidemiology also provides a foundation for such important competencies as critical thinking, clinical judgment and the practice of evidence-based medicine (Waters, 1984; Stone, 1998; Marantz et al., 2003; Khan et al., 2006). However, since medical students do not always perceive the need to study epidemiology (Novick et al., 1985), teaching epidemiology to them can be a challenging task (Waters, 1984; Novick et al., 1985; Dannenberg et al., 2002; Marantz et al., 2003).
Many innovative methods, such as analysis of current community health problems (Novick et al., 1985), case discussions (Marantz et al., 2003), and critical appraisal of the literature (Astin et al., 2002) have been used to make epidemiology more attractive to medical students. The introduction of clinical epidemiology ward rounds in a pediatrics rotation is one successful example of how to teach the relevance of epidemiology in clinical practice (Stone, 1998); however this strategy is not appropriate for early students still completing basic science courses. The experience of Aberdeen University showed that epidemiology could be integrated with primary care training by general practice-based tutors (Moffat et al., 2004). Another approach puts epidemiological concepts into a public health context and integrates epidemiology and public health with other subjects within the first years of medical education. The British Committee of the General Medical Council also emphasized interdisciplinary integration in public health teaching and noted that the assessment of population needs and the influence of environmental and social factors are relevant to many parts of the curriculum (General Medical Council, 1993).
The aim of the present study was to examine students’ perceptions of the epidemiology teaching they receive in the first three years of the undergraduate curriculum at Turkey’s Ege University.
Description of Epidemiology Education in Ege University Medical Faculty
Ege University, with its half-century history, is the focus of educational and cultural life of Izmir, the third largest city in Turkey. There are two medical faculties in Izmir; the Ege University Medical Faculty (EUMF) is the older.
EUMF introduced a new community-oriented curriculum in 2001. The content and overall structure of the new curriculum were based on the spiral curriculum concept. According to this concept, students revisit topics, themes and subjects at several stages of the curriculum in order to help reinforce and deepen knowledge as it fits with other topics being learned at each stage (Harden & Stamper, 1999; Moffat, 2004). The new curriculum was organized into four stages within the first three years. Stage one is an introduction to medical sciences, and stage two covers normal human structure, function and behavior. Stage two includes four blocks: respiratory/circulatory, excretory/lymphatic systems, digestive system/metabolism, and musculoskeletal/nervous systems and human life stage. Stage three is an introduction to the pathological sciences, and stage four addresses pathology of each of the four system blocks of stage two (Figure 1).
Within this curricular framework, subjects that could not be horizontally integrated into other topics were covered under three domains. The educational committee called these domains “vertical corridors”; they included Community Health and Field Implementations (CHFI), Interpersonal and Clinical Skills, and Medical Ethics and Medico-legal Responsibilities. The Public Health Department, an academic unit within the EUMF, is responsible for the CHFI, which spans the first three years of the curriculum. CHFI aims to improve students’ awareness of its topics and develop positive attitudes towards the social dimensions of medicine. It covers a broad range of public health topics, including epidemiology.
Figure 1: Spiral Curriculum of Ege University Faculty of Medicine
In developing the education processes of the epidemiology curriculum, we decided the learning objectives should be relevant to other aspects of the general curriculum and related to the public health problems of Turkey. According to our learning objectives, students should be able to comprehend the moral values of scientific research and the responsibilities of scientists, the principles of defining disease distribution, research terminology used in medicine, the importance of setting and testing a hypothesis, the principles of study design, the structure of a scientific article, the principles of appraising evidence, practical approaches to data collection and presentation, and the usefulness of epidemiology in clinical practice.
The epidemiology curriculum has two components: lectures (19 hours) and group activities (14 hours per student) (Table 1). For group activities that are implemented as group discussions or problem solving sessions, the class of 300 students is divided into eight sections of 34-35 students each; each group activity lasts 90 minutes. An instructor moderates the students’ group discussions regarding cases. For the problem-solving session, instructors divide the 35 students into smaller groups of up to five students. Each smaller group completes a task and then presents its conclusions to the larger group. While attendance at lectures is voluntary, advance preparation and attendance are required for group activities. Students are informed that five points would be deducted from their score for each absence without a valid excuse and two points deducted if they were judged unprepared. We have made only minor modifications in the epidemiology curriculum during its four years. Its group activities are summarized below.
Table 1: Epidemiology lectures and group activities in CHFI Domain in Ege University
Discussion about the life of scientists
The first topic is the philosophy of science. Preparation for the activity consists of reading a booklet about the life of a scientist (Albert Einstein, Marie Curie, Isaac Newton or George Mendel). The instructor asks students to identify key characteristics of scientists and their work. The social responsibilities of scientists and the independence and neutrality of science are discussed.
Activities addressing causation start with a discussion on the relationships between nutritional, psychological and social factors in people’s health, referencing a hypothetical case of lead poisoning. Then students create a causal web and list causal factors for this case.
Normal distribution, mean, measurement error
Activities for this activity consist of demonstrating how to identify priority nutrition problems through screening and assessment by using body mass index, Z score and Gaussian distribution.
Health Indices of a Population
Groups with three students each make home visits with their midwife preceptors within the health center district. After the visits, each group calculates health indices for the district, which are composed of approximately 3000 persons. Typical indices are crude birth rate, infant mortality rate, and fertility rate. Students then explain the health problems facing mothers and children of their district to the larger student group.
Critical Appraisal I
This activity consists of critically appraising an article using a questionnaire guide. Rather than using original articles, we prepared a mock article appropriate to the students’ level of understanding and included illustrative examples of biased data sources. We designed and use a “critical appraisal of an article form” appropriate to the level of the students’ knowledge and our learning objectives [see appendix].
This activity was designed to demonstrate the key principles of questionnaire design. Students were reminded of the aims and variables of the article in “Critical Appraisal 1”. They were asked to list the variables and prepare a questionnaire as if they were to plan another study with the same objectives as the mock article but they did not use the questionnaires to actually collect data. At the end of the activity the instructor provided feedback on the students’ questionnaires and explained the concept and techniques used to assess the validity of questionnaires.
Critical Appraisal II
For this activity we prepared six article abstracts that present studies of varied study designs including case-control, cohort and experimental types. Each abstract addresses an important Turkish public health problem facing individuals at each stage of life: smoking during pregnancy, child abuse, cervical cancer, immunization, computer game addiction among children, and Alzheimer disease. We ask students to find sources of potential bias and to calculate and interpret the risk indices for each article.
Following the completion of the last activity of the epidemiology curriculum, we asked third-year students to provide feedback via anonymous forms; 255 (92.7 %) of the 275 students completed the form.
The feedback form had two main parts. The first part consisted of responses on a Likert scale (strongly agree = 1; agree = 2; neither agree, nor disagree = 3; disagree = 4; strongly disagree = 5) to 15 statements based on the perceived value of the curriculum on epidemiology and scientific methods and other perceptions of the curriculum. In order to create an initial set of candidate statements, we reviewed the literature evaluating epidemiology education and listed all educational objectives of CHFI related to the methods of science and epidemiology. A panel of faculty further refined this initial set. Two of the 15 items were negatively worded statements. Finally, we asked 10 fourth-year students to comment on the relevance and comprehensibility of the statements. Cronbach's alpha was used to assess the internal consistency (reliability) of the 15 evaluation statements.
In the second, qualitative part of the form, students provided feedback by answering open-ended questions on their perceptions of the three best and three worst aspects of epidemiology education.
The feedback forms included two additional questions. Students were asked about their personal experiences conducting research and asked whether they wanted to continue their careers in the field of medical research. Students who replied “yes” to this second question were also asked to indicate their interests within various areas of research, such as research in clinical issues, public health, ethics, history of medicine, and medical education.
We calculated the mean of each item within the Likert scale. To obtain percentage distributions, we grouped responses of “strongly agree” and “agree”, and “strongly disagree” and “disagree”.
We analyzed students’ statements on the best and worst aspects of the curriculum using qualitative content analysis. All authors initially read the statements to gain a global understanding of the content. Then two of the authors (ZÖ, MÇ) organized the statements into codes and further into main themes encompassing the initial codes. To ensure reliability, this thematic analysis was done through an iterative, consensus-building process after the text was initially coded independently. We resolved disagreements about coding in face-to-face meetings and used tabulations to determine the frequencies of various themes.
This study provided quantitative and qualitative results. The Cronbach's alpha of the scale used for quantitative evaluation was 0.77, indicating good internal consistency. The quantitative results based on a series of statements are shown in Table 2. Students indicated that they appreciated the value of epidemiology to their careers but their assessments of the curriculum were more negative. The statement with which students most often agreed was "I will continue to improve myself and update my knowledge after graduation”. Approximately three out of four students thought epidemiology training was essential to understanding the scientific literature and felt that they could begin to criticize the factors affecting the findings of published research and acquire knowledge about how to write an article. However, the percentages of the students who became more interested in reading scientific articles and epidemiology were 46.8% and 35.1%, respectively. Half of the students thought epidemiology education should be part of the curriculum in each educational year.
Eighty percent of the students indicated that they might incorporate some research into their careers. Students expressed the greatest interest in pursuing clinical research (Table 3). Only 11% of the students had ever actually participated in a research project.
Table 2: Students’ perceptions of the value of education on epidemiology and scientific method and responses on educational objectives and aspects of the learning experiences
Table 3: Interest in pursuing medical research, by type of research
A total of 184 students (72.2%) wrote at least one open-ended statement on their questionnaires. Of the 381 statements, 243 were positive, while 138 were negative. Table 4 presents a framework of the content analysis with the main themes and then the codes that support their validity.
Table 4: Framework of content analysis of students’ statements on best and worst aspects of the epidemiology education
The most positive characteristic of the program most often cited by the students was the development of professional behaviors and attitudes. They stated that they observed that the epidemiology curriculum helped them to be able to read the scientific research literature. Many of the students’ statements reflected that they felt they had attained the fundamental knowledge and attitudes that were the goals of the CHFI curriculum. The curriculum’s practice-based and interactive teaching methods and group discussions were especially appreciated. Students appreciated that instructors were student-centered in their teaching approaches. Some students stated they perceived the relevance of epidemiology; the importance of learning epidemiology became more fully appreciated as their training progressed.
Some students criticized the tasks of the group activities as too time consuming and tiring. A few students indicated that the curriculum used much more time than required to learn epidemiology and felt the program began too early in their training. Three students commented that they would have preferred a more compact epidemiology course of only one block. Some students criticized epidemiology education as boring and the content difficult, with far too many lectures. Some students suggested increasing the proportion of group activities over lectures.
This paper describes the experience of an integrated approach to the teaching of epidemiology in a Turkish medical school. We evaluated our curriculum through student feedback using a combination of quantitative and qualitative methods.
As in earlier reports (Houlden et al., 2004; Hren et al., 2004; Burazeri et al., 2005; Khan et al., 2006), our study found that third-year students at EUMF had positive attitudes towards scientific research. However, like studies of medical students at other institutions (Novick et al., 1985; Moffat et al., 2004), our students did not always perceive their immediate need for information about epidemiology. Moffat reported that medical students understand the importance of epidemiology more fully as undergraduate training progresses (Moffat et al., 2004). Half of our students agreed that they became more interested in epidemiology after two years of previous study, and 14 students explained in open-ended statements that their interest improved as the training progressed.
Previous studies have described a number of innovative methods for teaching epidemiology. The ratings given by our students about how well they achieved the learning objectives were just above the mean scores in most of these studies (Novick et al., 1985; Stone, 1998; Magill et al., 2001; Marantz et al., 2003; Dyke et al., 2004; Dehaven & Chen 2005). Furthermore, it has been previously reported that students often do not enjoy their epidemiology courses (Marantz et al., 2003) and regard the topic as boring (Moffat et al., 2004). Our EUMF students gave similar scores for level of achievement of learning objectives and some reported feeling bored by the curriculum. On the positive side, most of our students provided enthusiastic statements and commented that they had gained skills in critical appraisal and had a high regard for scientific research.
In order to allow students to see the importance and interestingness of epidemiology, it is appropriate to principally use interactive teaching approaches (Marantz et al., 2003); therefore, we devoted half of our program to group activities. Some students, nevertheless, felt that the relatively few lectures could be decreased still further. The fact that the medical students in Aberdeen University provided similar feedback supports the importance of practical teaching in epidemiology (Moffat et al., 2004). Although reporting that the group activities were more effective, some students found the tasks given in the activities difficult and tiring. Considering that our students’ previous experiences as learners rarely included student-centered, interactive teaching strategies, it is not unexpected that they would have difficulties with problem-solving activities.
The spiral model of learning was one of the main principles of our curriculum. In this model, reiteration and repetition of curricular subjects occur in a spiral of learning at a slightly higher level each time they are presented, which allows students to progress up the learning spiral (Moffat et al., 2004). In spite of these advantages, our students had difficulty comprehending the integration of the subjects related to epidemiology. This may be due to the fragmented structure of our school’s training. The involvement of all faculty is crucial for the curriculum’s integration and, in our case, too few faculty related to the epidemiology curriculum, which hindered creating a strong connection between epidemiology, critical appraisal and the content of their lectures. Harden and Stamper (1999) reported that departmental course offerings to medical students are less holistic and called the boundaries between courses and departments the main obstacles to a spiral curriculum. If epidemiology training had a part in our faculty development program, it would help eliminate these boundaries between the departments in EUMF.
The most important challenge we encountered during implementation of our epidemiology program was the large number of students. In order to accommodate the numbers, we divided 300 students into eight smaller groups and repeated each group activity eight times. This approach required more faculty time for epidemiology education than the old curriculum. For that reason, some faculty members started to see epidemiology education as a threat to the time allocated for their subjects and reflected their feelings to students. We know from other studies that student attitudes towards educational reform may be ambivalent in the early stages and innovation may be resisted particularly if different learning cultures exist within the same curriculum (Rosenthal & Ogden, 1998; Preston-Whyte & Fraser, 1997). On the other hand, the commitment of the faculty administration and curriculum development committee to continuing the CHFI was critical to the program’s sustainability.
This study addressed only the third-year students of one medical faculty and assessed an educational program with relatively few lectures and activities thereby limiting the generalizability of its findings. The information from students about their attitudes and skills was self-reported and may not reflect how students will incorporate epidemiology and research into their future practices. The qualitative data of this study is based on open text provided by students, where they likely felt more comfortable being open and honest than they would have in interviews. On the other hand this approach typically does not provide as rich material as obtained through interviews and focus group discussions. Biased interpretations of data are a particular challenge when analyzing qualitative data (Mays & Pope, 1996). The principal step we took to protect against biased analyses was to undertake coding independently by two investigators. However, the fact that both investigators were members of the university’s public health department could have diminished the effectiveness of this approach in reducing bias. Finally, this study only looked at students’ acceptance of the curriculum. An evaluation that examines longer-term outcomes, such as students’ abilities and acceptance of epidemiology when they graduate or later in practice, would be a more important test of the effectiveness of the curriculum; this evaluation is currently underway.
We present these findings with the hope that faculty at other schools who teach epidemiology will find useful ideas they can incorporate into their curricula. Although experience at EUMF showed that students with traditional educational backgrounds have difficulties when introduced to participatory learning activities, students generally found that our epidemiology curriculum was acceptable, relevant, and of value to their future practice of medicine. However, teaching medical students the principles of scientific research is a long-term effort, the effects of which will only become clear in the future (Marusic & Marusic, 2003). Much will be gained from future studies of our graduates’ professional behaviors and attitudes towards science and their skills in critical appraisal.
The authors would like to thank the students who participated in this study.
Ethical approval: The necessary permission was given by the educational committee of the School of Medicine. Since this study is part of the innovative medical education curriculum, no other explicit ethical approval was sought.
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Appendix 1: Question form of “Critical Appraisal 1”