Context: Nurses provide the bulk of primary care services in South Africa. Post-apartheid health legislation envisions the provision of comprehensive primary services at all public clinics, which implies the need for a cadre of primary care nurses able to render such services. Objectives: To identify core competencies of clinic nurses and develop an evaluation tool for primary care nursing in South Africa. Methods: The descriptive and exploratory techniques used included two meetings of a reference group of South African primary care professionals, followed by a consensusbuilding exercise. Using the Delphi technique expert opinion was solicited from South Africa, Canada and the USA. Findings: The reference group meetings yielded a list of nine core competencies. Infrastructure issues, such as the supermarket (one-stop shopping) approach to service delivery, communication and transport systems, and the quality of supervision still cause concern. These issues underscore that competence cannot be measured in a vacuum. Input from Delphi participants affirmed the nine core competencies and the need to assess the impact of core competency training. One possible way to measure the nine core competencies would be to use proxy indicators. Discussion/Conclusions: Identifying core competencies is a complex process. There is a need to process a wide range of views and ideas. Also, balancing academic concerns with service delivery needs and constraints is an ongoing challenge. A potential limitation of the Delphi technique is participant selection bias and fatigue. Accessing a diverse international panel and making numerous follow up attempts via phone, mail and email were used to attempt to ameliorate these inherent limitations. Although the process is cumbersome, providing ''experts'' with a venue to wrestle with these ideas can be fruitful. Future studies would help to assess the reliability of the findings.

Introduction: This study investigates beginning Jordanian nursing students' level of awareness and attitudes toward the nursing profession, their expected future practices and their anticipated reactions when faced with challenging hypothetical situations, together with any correlation between these variables and the students' sex, age and social status. Methods: The cross-sectional, descriptive methodology was applied to a population of 330 male and female students enrolled at the first year level of associate nursing at two Ministry of Health (MOH) training institutions in November 2003. Findings: A student's personal desire to become a nurse accounted for only 31.0% of the total, while 69.0% began a nursing career because of other reasons, such as family or economic pressures. There was no correlation between the student's gender, high-school public certificate average, or socio-economic condition and the decision to become a nurse. Upon graduation, 30.0% of students would prefer to work at hospitals, 19.0% at emergency rooms, 21.0% at an ambulatory health center and 26.0% in administrative positions. Females favoured working at health centres over males (24.8% vs. 12.1%, respectively), while more males favoured working in administrative positions than females (30.8% and 23.5%, respectively). Analysis of students' expected reactions to various challenging encounters with a patient showed that approximately 50% would react in a less than professional manner. Recommendations: Curricular emphasis should be placed on expanding and raising nursing students' awareness of their responsibilities toward patients, especially in challenging or difficult situations, and on improving their concept of nursing as a profession.

Context & Objective: Evidence-based general practice requires skilled researchers in the field. This study explores the issues faced by professionals from the Australian general practice sector who were considering higher degree training in research. Method: Sixteen participants were interviewed by telephone during October 2002. All were purposively selected across general practice-related professions and had expressed an interest in research. Interviews were audio-taped, transcribed and analysed independently by two researchers. Results: Three main themes emerged: (1) ''The Specialist Gap''-a perceived lack of training options providing research skills that were relevant to general practice, particularly mixing quantitative and qualitative methods. (2) ''Career Changes''-the ability to expand career opportunities through research was highly desirable, particularly the potential to combine clinical skills with population health roles. (3) ''Career impediments''-perceptions of current degree options implied that their currency was limited by lack of career advancement. Course selection was often by affiliation and personal recommendation rather than career pathways yet students face large financial costs for little career gain. Conclusion: Training for clinical researchers in the Australian general practice sector may be limited by lack of career opportunities for graduates. If a stronger culture of research is to develop, career development strategies need to be further explored.

Introduction: This paper outlines a collaborative, cross-national educational initiative, commenced in 2001, in which an Australian university provided clinical and research education assistance to a Filipino University. The aim was to establish the first Filipino Master of Science in Physical Therapy program that would train physiotherapists in their home country using best available content and teaching expertise. Process: Principles of quality transnational education underpinned the program design and contractual agreements. Australian educational input was tailored to local constraints to ensure efficient and effective delivery of high quality, relevant material. Approximately 60% of the inaugural program was delivered by Australian educators in one-week intensive courses on-shore in the Philippines, using local facilities and case-scenarios. Follow-up support and evaluation were provided by video, email, written workbooks and assignments once these educators returned to Australia. Filipino graduates, who were competent with course content, taught the remaining subjects. In line with an aim of empowering Filipino graduates to assume responsibility for teaching all aspects of the program by 2006, the Australian educators are now teaching less than 25% of the course content to subsequent student cohorts. After 2006, they will provide mentorship only to the program. Results: In 2003, 12 students in the first cohort graduated with Master of Science in Physical Therapy from the University of Santo Tomas (UST). Twenty-four students subsequently enrolled in the second cohort (commenced 2003) and 21 students into the third cohort (commenced 2004). Six of the inaugural graduate cohort are currently acting as tutors for the Australian educators and will assume full teaching roles in 2006. Comparison of feedback from student evaluations at UST indicates significant improvements in teaching quality for the graduates from the inaugural program. Research activity and publications have also increased as a result of completion of the program. Discussion: Such a cross-institutional, cross-national program has not been described previously for physiotherapy, and no other similar health program (for nursing) evaluated the educational processes in the manner used in this program. The program met its aims and has produced sustainable educational outcomes and outputs. Conclusion: Future scholarly activities between the two institutions include extension of postgraduate training to other health disciplines, cross-institutional PhD student enrolments and collaborative research.

Context: Recurrent drought is a major disaster affecting many countries. As a result of poor rain fall a major drought was forecast for Ethiopia in 2003. The country appealed for support to avert drought-related health problems. University of Gondar decided to respond to the appeal by sending students and staff to selected drought-affected areas. Objectives: To illustrate how an institution has turned the response to a natural disaster into a service-learning educational opportunity while maintaining equilibrium between the two. Methods: The drought relief response of the institute was twined with the regular teamtraining programme and academic schedule of senior health science students and 190 of them were transferred to deployment sites. Findings: Students provided support for the national effort of reducing drought-related morbidity and mortality by participating in multifaceted public health and relief activities, and fulfilled their regular learning objectives at the same time. Discussion: This project demonstrated the use of a natural disaster as a learning method to expose students to a more realistic array of health problems and human conditions. It also demonstrated the feasibility of addressing social responsibility, while fulfilling academic responsibility through community-based approach. Conclusion: Service-learning is a valuable learning method. Balancing the service and teaching objectives and maintaining the quality of both can be attained through careful twining of the objectives of both components.

Context: A growing number of health professions schools have implemented programmes for community-based education (CBE) for their students. There are indications, however, that particularly in developing countries, CBE programmes are not always optimally implemented or sustained. Objective: To test the suitability of an established method for curriculum evaluation, combined with a set of generic objectives for CBE programmes, for evaluation of CBE programmes. Methods: As a case study, Coles and Grant's model for curriculum evaluation was applied to the CBE programme of the Medical Faculty of Diponegoro University (MFDU) in Semarang, Indonesia. Document analysis yielded information on the programme on paper; participatory observation and staff interviews on the programme in action. In addition, MFDU's CBE programme was evaluated against a set of generic objectives for CBE programmes recently designed by us. Results: MFDU has created great opportunities for its CBE programme in which, however, also significant weaknesses were revealed. (1) In the community, much time was spent on formal teaching; (2) Students' work in the community was not jointly identified with community members regarding the community's felt health needs; (3) There was rarely continuity, and evaluation or follow-up of the students' work in the community; and (4) No systematic programme evaluations are carried out. Discussion: This evaluation study showed shortcomings in the implementation of MFDU's CBE programme. The major weaknesses identified point at an underutilization of the opportunities and potential jeopardization of the facilities in the community. On the other hand, more time is needed in the CBE programme to establish the health needs to be addressed jointly with the community and to assess the impact of activities undertaken. A thorough review of the CBE programme, perhaps taking the outcomes of this study into account, could turn MFDU's CBE programme into a fine example for other medical schools in Indonesia and beyond. Conclusion: Coles and Grant's method for curriculum evaluation proved suitable for evaluation of a CBE programme in a developing country. After additional comparison with a reference list of objectives for CBE programmes, reasoned suggestions for programme can be made.

Objective: ''Facts for Life'' is an essential tool for saving the lives of children. In this study we wanted to evaluate the knowledge of ''Facts for Life'' among Turkish women. Design: This is a cross-sectional field study. We used 25 indicator questions to evaluate the knowledge of women in the following main subjects: safe motherhood, childhood immunization, childhood diarrhoea, children's acute respiratory diseases, and household hygiene. We filled out printed questionnaires during face-to-face interviews. For each correct answer we gave 4 points, and the sum of the points was accepted as the knowledge score. Setting: Bursa metropolitan area in Turkey. Subjects: Married women between 15-44 years of age. We selected 1000 of them from the household cards of the health centers that were located at the Bursa metropolitan area by using a random selection method. Results: Mean knowledge score was 72.0±0.3. About 3/5 had moderate, 1/5 good + very good, and 1/5 bad knowledge scores. Childhood diarrhoea was better known than acute respiratory diseases. The very well known ''Facts for Life'' were those concerning food and household hygiene. Conclusion: Women's knowledge about ''Facts for Life'' was at a moderate level. The knowledge level of older women was better than the younger. Some false beliefs still existed. Knowledge about ARI and diarrhoeal disesases in childhood were the least known facts.

Background: The gap between what is known and what is done about public health (the evidence-practice gap) needs addressing. One solution may be through mixed and participatory training in accessing and appraising research. Approach: Residential workshops trained policy-makers, practitioners and researchers from seven southern-African countries in evidence-based decision-making for HIV prevention. They included training in accessing, critiquing and summarizing research, whilst remaining responsive to the priorities of the participants. Reflections: Drawing on the participants' feedback and our observations, we reflected on how these workshops may have addressed the evidence-practice gap. We identified three areas: access to research, understanding of research and the relevance of research. The workshops enabled a small group of people to access relevant research in a timely manner. However, more needs to be done to disseminate research findings appropriately as any long-term impact will be affected by the political and economic context in which participants work. We are confident that the participants went away with increased understanding of the purposes and processes of research, but for research to make a difference, the research community needs to emphasise more the publication of research findings written for potential users. The workshops were most successful in influencing researchers to consider bridging the evidence-practice gap by producing more relevant research, applicable to policy-makers and practitioners. Conclusion: This intensive intervention has the potential to reduce the evidence-practice gap for HIV prevention in southern Africa by training non-researchers to engage with research, whilst providing an opportunity for researchers to engage with policy-makers and practitioners.

Context: Removal of underlying pathologies through the application of science and technology alone will not restore a patient's health; that will require connecting with the person behind the disease. Being ill changes physical and social functioning, emotional well-being, and last but not least, it affects one's self-concept. It invariably leads to questions of the meaning and understanding of being ill, hence Pauli et al. (2000) termed the notion of a somato-psycho-socio-semiotic paradigm of health. Objective: Understanding health in this context allows the conceptualization of health as a balance between these four domains. Methods and Conclusions: This paper describes, through a systems-based methodology, the translation of the somato-psycho-socio-semiotic understanding of health into a flexible teaching approach for students and in a postgraduate setting for registrars. This teaching mode, by making the different dimensions that affect a person's health transparent, has helped learners to rapidly progress towards our goal of becoming holistically practicing clinicians.

Context: Research is a critical component to the continued growth and development of the quality of primary care. The common rules and values concerning research apply to general practice in the same way as to other specialties. Research should be an integral part. Objectives: To identify and discuss the elements and requirements needed in the promotion of research in general practice. Discussion: At the university level, undergraduate education is a start, but a university department of general practice must have responsibilities in postgraduate education. Academic departments of general practice must be adequately resourced to be able to conduct credible research and to organize training in research and research methods. They should provide advisory services and guidance to support the activities of motivated GP researchers in the field and also help them to get into contact with other researchminded clinicians. If GPs want to develop their knowledge and skills in research, they must be willing to pay for them in terms of time and effort, which are away from something else. In return, the service organizations and governments benefiting from these increased skills must be willing to create a system which recognizes the value of the activities and aspirations of these general practitioners by creating new career structures and bonus mechanisms. These incentives and value systems must be accepted by the profession. Conclusions: High quality applied clinical research can successfully be done in primary care. It needs a supportive climate, motivated researchers and adequate funding.

Purpose: To determine the opportunities and limitations of problembased learning (PBL) in psychosomatic medicine, especially in the field of somatoform disorders. Method: A written case of conversion neurosis of a 22-year-old subway worker, who had been suffering from dizziness for the past 18 months, was presented to students as one of seven cases during a ''Nervous System and Behaviour'' course. Results: Tutors and students are normally accustomed to focusing on organic lesions such as aetiologies for neuro-psychiatric disorders. Understanding behavioural and pseudo-neurological symptomatology without brain damage, accepting emotional and biographical factors and referring to the role of the unconscious seems to be a great challenge for tutors and students alike. Discussion: Studying the case of a somatoform syndrome in a PBL tutorial may teach the students skills in taking the psychosocial history into account and deepen their knowledge of neuro-psychiatric differential diagnosis.

Introduction: Determination of graduates' perceptions and suggestions is essential in the evaluation of educational programmes. Dokuz Eylul University School of Medicine (DEUSM), the country's first medical school implementing a Problem-Based Learning (PBL) and Task-Based Learning (TBL) programme, graduated the first students of its new educational programme starting from the 2002-2003 academic year. The aim of the present study is to determine first graduates' perceptions on their selfefficacy and school's educational programme's efficacy. Methods: In June 2003, 51 graduating students were asked to use five-point scales to evaluate: the content of the educational programme, the educational methods, communication with educators, assessment methods and instruments, the efficacy of each year of their undergraduate programme and the overall program, their satisfaction levels about educational programme regarding the acquisition of knowledge and skills, their self-efficacy and contentment level of being a physician. Results: In the content of educational programme, the highest score was attributed to ''acquisition of behavioural objectives'' and the lowest score to ''acquisition of basic science knowledge''. Regarding the efficacy of educational programme, the highest score was attributed to ''communication with educators''. The highest scores regarding the satisfaction levels on the acquisition of knowledge and skills provided by the School were attributed to ''implementing basic professional procedures'' and ''history taking'' and the lowest score to ''selecting appropriate treatment''. Conclusion: The graduating students' mainly positive evaluations regarding the efficacy of DEUSM's new educational programme were considered as supportive reflections on the new educational programme. Further studies to monitor our graduates' future professional performances are being envisaged.

Context: Male and female students behave differently in problem-based learning (PBL) tutorials. However, these differences could be partly attributed to faculty tutor behavior in male and female tutorials. Objectives: This study aims to examine the gender differences in learning outcomes between medical students when peer tutors facilitate PBL tutorials. Methods: A questionnaire-based study conducted in single-gender student-led (SLT) and faculty-led (FLT) tutorials. The study involved third year medical students (n = 91) divided into ten groups (five groups each). The SLT groups consisted of 16 male and 28 female students, while the FLT group consisted of 20 male and 27 female students. Students evaluated their individual and group performance in tutorials and also skills of tutors. Student performance in end-unit examinations and their perceptions about peer tutoring were also analyzed. Results: A total of 290 questionnaires (response rate = 63.7%) were collected over the five-week period of the study. Although individual performance in tutorials and achievement in examinations were comparable in both groups, there was significantly higher group performance in female compared with male student-led tutorials (p<0.01). This difference between male and female groups was not attributed to improvement in the performance of female groups, but rather to a decline in performance of the male SLT groups. In addition, both male and female students expressed facing difficulties in discussion and analysis of the problem in the first tutorial session. Conclusions: Understanding the gender differences in the group behavior in student-led tutorials is important for PBL programs adopting this approach.