Context: Most caregivers of people living with HIV/AIDS (PLWHA) in rural Kenya are women. In resource-limited situations, this can be a challenging and risky responsibility. Objective: Assess the risk factors to which home-based caregivers are exposed. Setting: Study of Home-based Health Care (HBHC) activities done in the Busia and Teso Districts of Western Kenya, with 824 patients under HBHC, from April 2004-April 2005. The Ministry of Health HBHC Policy in 2000 reduced bed-occupancy in Government Health facilities. Consequently, many AIDS-Related-Infections (ARI) patients, upon discharge, were nursed by relatives. Methods: Relevant information reviewed and data collected using: questionnaires; personal and key informant interviews (KII); and observation of caregivers' working conditions and protective measures. Results: The majority of home caregivers were women. Most caregivers (85%) were unaware of risks involved in PLWHA caregiving. Fifty-two percent had chest pains and coughs, 55% skin infections and 24% tuberculosis. Over 8% were found to be HIV+ upon testing at the Voluntary Counselling and Testing (VCT) clinic. Conclusions: Women, and sometimes young children, assume the caregiving burden. Ignorance of risks and non-use of protection may predispose these caregivers to infections. Results point to the need for advocacy to improve the working conditions of home-based caregivers by primary health care policy makers. Finally, because the caregivers were sexually inactive, the caregivers that were HIV+ attributed their infections to nursing PLWHA.

Context: During the last decade a major curriculum reform was carried out at the Pontificia Universidad Católica de Chile Medical School. The process included changes in curriculum development, staff development and in the infrastructure. However, it is not known how students perceived the climate of their education within the new model. Objectives: To measure students' perceptions of the educational environment of the new curriculum and to evaluate the internal consistency of the 50-item Dundee Ready Education Environment Measure (DREEM) Spanish version questionnaire. Methods: The DREEM Spanish version questionnaire was administered to undergraduate medical students in training years 3, 4 and 5. Internal consistency of the instrument and its subscales were measured with the method described by Cronbach, and the results were expressed with alpha coefficient ranging from 0 to 1. Findings: Responses were received from 297 out of 328 students (90.5%). The 50-item DREEM Spanish version was found highly reliable with an alpha coefficient of 0.91. The subscale with the highest mean score was "Academic Self-Perceptions", which indicates students' perceptions of their academic achievements. Mean score of this subscale was 22.3 ± 4.1 corresponding to 69.7% of the maximum score. The lowest mean score was for the Students' Perceptions of their Social Environment: 15.9 ± 4.0 (56.8%). The overall mean score for the 50 items was 127.5 ± 20.9 (63.8% of maximum). Scores observed in students in year 5 were significantly lower for several subscales, including Students' Perceptions of Learning, Students' Perceptions of Teachers, Students' Perceptions of the Learning Atmosphere and Students' Perceptions of the Social Environment, and also lower for the overall mean score (119.3 ± 20.2) compared to scores in years 3 and 4 (128.8 ± 21 and 132.5 ± 19.7, respectively; p<0.001). Conclusions: The school's educational climate was generally perceived positively by students, although they viewed the school's social environment less favorably. Specific areas identified by students as needing improvement included an overloaded curriculum and inadequate student supports. The DREEM Spanish version proved generally reliable, by internal consistency scores based on ratings by Chilean undergraduate medical students; it should be a useful tool for assessing students' perceptions of the educational environments of other Latin American medical schools.

Objective: To undertake process documentation (PD) of two health education interventions for tribal school children (6-14 years) and adolescent girls (12-19 years) in rural central India. Methods: The present participatory process documentation exercise was undertaken at Kasturba Rural Health Training Center, (KRHTC), Anji, which is a field practice area of the Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. The various steps identified for process documentation were decided after reviewing the monthly and annual reports of KRHTC, training reports, published research papers, flipbooks and daily diaries of health educators. In order to get the health educators' perceptions, a free listing and pile sort exercise on the domain of 'perceived advantages of the present approach' was undertaken, followed by a semi-structured Focus Group Discussion (FGD) with the educators. A two-dimensional scaling and hierarchical cluster analysis was completed with the pile sort data to get the collective picture of perceived advantages. Results: The health education interventions were need-based, focusing on a target audience. The approach was community-based and has the potential to stimulate an action-experience-learning cycle of health educators and community members by stimulating their creative potential. The health educators found locally-developed handmade flipbooks with relevant messages and culturally sensitive pictures to be facilitating factors. Conclusions: The present study provided process documentation of two health education interventions which could be useful to both governmental and non-governmental organizations working in resource poor rural settings of developing countries.

Objective: To demonstrate that evidence-based medicine (EBM) training can be imparted in developing countries using minimal resources. Design: Development of a minimal cost workshop with validation of gain in EBM skills using the Berlin questionnaire. Setting: Teaching hospital in Pakistan. Participants: Multidisciplinary faculty from The Shifa College of Medicine and Nursing, Pakistan. Intervention: A 14-hour locally-tailored McMaster-style workshop, using a problem-based, learner-focused small group format, with pre- and post-workshop evaluation of EBM skills. Results: Analysis of the pre- and post-Berlin questionnaires of the participants revealed that the pre-workshop Berlin questionnaire score for the group was 4.7±2.3, with a post-workshop Berlin score of 7.6±1.0 (p<0.001). Conclusion: EBM workshops can be locally-tailored in developing countries, where access to such workshops is generally not available. Workshops can serve to promote EBM skills in faculty, who can then help to disseminate and model concepts. The process increases awareness and interest in EBM, which in this case resulted in formation of a national platform for EBM.

Introduction: The assessment of professional development and behaviour is an important issue in the training of medical students and physicians. Several methods have been developed for doing so. What is still needed is a method that combines assessment of actual behaviour in the workplace with timely feedback to learners. Goal: We describe the development, piloting and evaluation of a method for assessing professional behaviour using digital audio recordings of clinical supervisors' brief feedback. We evaluate the inter-rater reliability, acceptability and feasibility of this approach. Methods: Six medical students in Year 5 and three GP registrars (residents) took part in this pilot project. Each had a personal digital assistant (PDA) and approached their clinical supervisors to give approximately one minute of verbal feedback on professionalism-related behaviours they had observed in the registrar's clinical encounters. The comments, both in transcribed text format and audio, were scored by five evaluators for competence (the learner's performance) and confidence (how confident the evaluator was that the comment clearly described an observed behaviour or attribute that was relevant). Students and evaluators were surveyed for feedback on the process. Results: Study evaluators rated 29 comments from supervisors in text and audio format. There was good inter-rater reliability (Cronbach α around 0.8) on competence scores. There was good agreement (paired t-test) between scores across supervisors for assessments of comments in both written and audio formats. Students found the method helpful in providing feedback on professionalism. Evaluators liked having a relatively objective approach for judging behaviours and attributes but found scoring audio comments to be time-consuming. Discussion: This method of assessing learners' professional behaviour shows potential for providing both formative and summative assessment in a way that is feasible and acceptable to students and evaluators. Initial data shows good reliability but to be valid, training of clinical supervisors is necessary to help them provide useful comments based on defined behaviours and attributes of students. In addition, the validity of the scoring method remains to be confirmed.

Introduction: The objective structured clinical examination (OSCE) has not been used extensively in undergraduate medical education in resource-constrained locations, including Pakistan. The Shifa College of Medicine (SCM) in Islamabad modified an end-of-clerkship OSCE assessment in internal medicine for final year medical students from a previous static, pattern-recognition format to an interactive, clinical reasoning and skill-based format. Methods: We modified the OSCE to be more dynamic and effective by creating a customized clinical skills laboratory, using standardized patients, developing competency checklists for OSCE stations, and stimulating more active participation from faculty members. Students were surveyed at the end of their medicine clerkship about the OSCE's organization, content, perceived utility and validity and its stressfulness. Faculty involved in the modified format also reported their perceptions in an open-ended survey. Results: The modified format was generally received positively by students and faculty. Twenty-eight percent of students found the OSCE to be stressful, which is a lower proportion than reported in the literature in other settings. Students suggested that OSCEs should be given more frequently and come with clearer instructions, and they indicated a need for better training in counseling skills. Responses from faculty were generally positive even though the modified format was regarded as more labor-intensive and time-consuming. Conclusion: The OSCE, in its true sense, can be created and successfully implemented to assess the clinical skills of medical students in a resource-limited setting in the developing world.

Context: Residents' perceived needs in communication skills training are important to identify before designing context-specific training programmes, since learrners' perceived needs can influence the effectiveness of training. Objectives: To explore residents' perceptions of their training needs and training experiences around communication skills, and whether these differ between residents training in inpatient and outpatient clinical settings. Methods: Four focus groups (FG) and a self-administered questionnaire were conducted with residents working in in- and outpatient medical service settings at a Swiss University Hospital. Focus groups explored residents' perceptions of their communication needs, their past training experiences and suggestions for future training programmes in communication skills. Transcripts were analysed in a thematic way using qualitative analytic approaches. All residents from both settings were asked to complete a questionnaire that queried their sociodemographics and amount of prior training in communication skills. Findings: In focus groups, outpatient residents felt that communication skills were especially useful in addressing chronic diseases and social issues. In contrast, inpatient residents emphasized the importance of good communication skills for dealing with family conflicts and end-of-life issues. Felt needs reflected residents' differing service priorities: outpatient residents saw the need for skills to structure the consultation and explore patients' perspectives in order to build therapeutic alliances, whereas inpatient residents wanted techniques to help them break bad news, provide information and increase their own well-being. The survey's overall response rate was 56%. Its data showed that outpatient residents received more training in communication skills and more of them than inpatient residents considered communication skills training to be useful (100% vs 74%). Discussion: Outpatient residents' perceived needs in communication skills were more patient-centered than the needs perceived by inpatient residents. Residents' perceived needs for communication skills may differ not only because of their differing service priorities but also because of differences in their previous experiences with communication skills training. These factors should be taken into account when designing a training programme in communication skills.

Introduction: Effective facilitation of PBL tutorials requires tutors to develop observation skills, cognitive strategies and motor skills. The initial tutor training workshops at Aga Khan University were geared towards providing an understanding of the theory of the PBL process but not hands-on experience in facilitation. Objectives: To use structured, small group experiential learning (SSGEL) to enhance skills in PBL tutorial facilitation, with opportunities to practice and provide individual feedback. Methods: The workshop was structured using Gagne's principles of instruction as a framework, making the learning more experiential and systematic. Cue cards were used with trigger statements related to disruptive behaviors and inappropriate feedback statements from students that commonly occur during PBL sessions, to give tutors an opportunity to handle these simulated situations. Outcomes: Analysis of the post workshop evaluation forms provided generally positive feedback from participants on the structure and content of the revised workshop. Participants highlighted the session on PBL experience as highly interactive and rated it as a good learning experience, with an average rating of 4.54 out of 5. Conclusion: The structured small group experiential learning exercise provided faculty with an opportunity to practice facilitation skills focusing on developing a standard approach in dealing with common, difficult situations in maintaining group dynamics during a PBL session. The structure of the program was designed to enable participants to better understand the rationale and philosophy of PBL and the curricular change in our school, and to prepare them to serve more effectively as PBL tutors.

Challenge: Healthcare students and practitioners need to be able to critically assess themselves and their actions in order to learn from their experiences and improve their care of patients. Students' behaviours can be directly observed and faculty can provide direct feedback on it, when necessary. But 'reflection', a mechanism for assessing one's self, is less visible and often remains an abstract notion that is difficult to understand, use, and assess. Educational model: We designed an educational model to help healthcare educators and learners visualize reflection. We posit that it can provide a greater understanding of what reflection is, how it works and how to facilitate its development and use by individuals. As a metaphor we used the angler's (fisherman's) float, which to function properly must stand balanced and steady in the water. Likewise, healthcare practitioners try to maintain an upright balance to be able to learn and work effectively. The visible component of the float, the portion above the water, is the 'behaviour'. The hidden, "mental" components of the float are under water: expert thinking (a combination of 'clinical reasoning' and 'scientific thinking'), 'personal reflection', and 'unconscious thoughts'. Each of these mental components plays a role in maintaining balance in learning and working, varying with the circumstances and context. And of course, without water a float has no meaning. In the float model, the water symbolizes the organisational and cultural context in which each practitioner must learn to function. Applications: We propose that the float model can be used to reveal the interplay among clinicians' mental processes, which occur unseen "underneath the water" but subtly influence the appropriateness of the behaviour witnessed at the surface. We believe the model can help prevent errors in understanding practitioners' behaviours and their causes, such as when they blur scientific thinking and personal reflection, take reflection as a goal in and of itself, and deny the value of the intuitive and unconscious aspects influencing their behaviours.