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Table of Contents
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 52-57

Impact of community based training on medical undergraduates skills upgradation regarding infant and young child feeding practices: A mixed method study

1 Postgraduate Student, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Assistant Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
4 Medical Social Worker, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
5 Former Professor and Head, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
6 Professor and Head, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission06-Feb-2018
Date of Acceptance02-Jun-2018
Date of Web Publication1-Feb-2019

Correspondence Address:
Tovia Stephen
Postgraduate Student, Department of Community Medicine Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Village No.20, Kalapet, Puducherry- 605014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-2113.251350

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Background: Despite various reforms brought in health care service delivery there is always a gap between community and health care providers. Hence there is a need to explore the successful strategies to reorient the medical students towards public health relevant community needs. Objective: This study aimed to assess the feasibility and impact of community based field training imparted among medical undergraduates to identify problems related to infant and young child feeding practices and design appropriate interventions. Material and Methods: This study is a mixed method study where improvement of knowledge were assessed quantitatively through quasi experimental pre-post study design. Difference in cumulative score obtained after training was compared using student's t test. Perception of students and mentor's views on this approach in terms of benefits and challenges were explored during in-depth interviews. Transcripts of qualitative interviews were analysed using manual content analysis. Results: Total of 781 infant and young children from 30 villages were surveyed by 36 medical undergraduates. There was significant improvement in knowledge on feeding practices from the baseline [baseline mean (SD) score: 3.3 (1.5); post training mean (SD) score: 6.5 (1.1), p<0.001]. Mentors of the opinion that this community based approach had facilitated the students to acquire skills on management, communication, team spirit and professional attitude. Students had opportunity to assess spectrum of illness and the co-existing social conditions in their natural setting. Conclusion: Students as well as other stakeholders were more positive and overwhelmingly supporting this approach. This approach is feasible with better planning, institute cooperation and commitment.

Keywords: Children, Feeding practices, Community based education, Field based training, Medical education undergraduates

How to cite this article:
Stephen T, Selvaraj K, Bazroy J, Antony V, Singh Z, Purty AJ. Impact of community based training on medical undergraduates skills upgradation regarding infant and young child feeding practices: A mixed method study. Indian J Community Fam Med 2018;4:52-7

How to cite this URL:
Stephen T, Selvaraj K, Bazroy J, Antony V, Singh Z, Purty AJ. Impact of community based training on medical undergraduates skills upgradation regarding infant and young child feeding practices: A mixed method study. Indian J Community Fam Med [serial online] 2018 [cited 2021 Apr 19];4:52-7. Available from: https://www.ijcfm.org/text.asp?2018/4/1/52/251350

  Introduction Top

More than 60% of the Indian population live in rural area.[1] Despite the recent reforms brought under National Health Mission about 12% of sanctioned posts are vacant at primary health care level.[2] There has always been a gap between health care providers and the community. To reduce this gap Alma Atta declaration in 1978 emphasized on the need for community participation Reorientation of Medical Education suggested by World Health Organization is one such move to reduce this gap.[3],[4]

The Medical Council of India also says the primary objective of MBBS course is to make a culturally competent physician for the community.[5] Though hospital-based teaching has its own merits unless the students are exposed to field based/ community training, their perceptions of health care needs of the community maybe inaccurate. Community based education refers to teaching future health care providers either in the community or in the primary care facility settings.[6] There are several practical issues involved in teaching rural communities to the medical students. There is a great demand from the policy makers and regulating authorities of medical education (MCI) for the field based training in India.[5]

Of the total population, under-5 children constitute approximately 10-13% and they contribute about 20% of the out patients visiting the primary care settings.[1] Among the under-5 children, malnutrition contributes to more than 50% of deaths either directly or indirectly.[7] Faulty feeding practices followed among the infant and young children are the most predominant factors which cause malnutrition among children.[8] As per the recent surveys, 21% children are wasted, 38.7% are stunted and 35.7% are underweight (NFHS 4). Undernutrition is higher among children in rural areas as compared to urban areas. Not only the nutritional status, even the optimal feeding practices are found to be poor among rural children. Moreover, there are lots of food taboos, myths and misconceptions in the field of infant and young child feeding practices.[9],[10] Despite of the recent hike in literacy and institutional delivery rates, health literacy among care givers were found to be poor.[2],[11],[8] Hence, there is a strong potential need to sensitize the future physicians on infant and young child feeding practices and orient them towards community needs on this issue through community based education. According to Miller's pyramid improvement in knowledge or cognition is the first sign of effective learning.[12]

In this context, this study was planned to know whether the community based education provided through community based research project increases the knowledge and application on infant and young child feeding practices among medical undergraduates from South India.

  Material and Methods Top

Study Design and study duration: This is a quasi- experimental study where the study has assessed the impact of community based training on infant and young child feeding practices. In India, MBBS course of four and a half years duration spread over nine semesters. This community based training was held during the sixth semester for the duration of one month from January 2017 in Pondicherry Institute of Medical Sciences, Puducherry.

Study setting: This study was conducted in villages located around rural health training center affiliated to tertiary care academic institute. This center is functioning with the team of multi-disciplinary work force namely medical officers, staff nurses, Auxiliary Nurse Midwives, medical social workers, resident doctors and lab technicians. Once in a month the outreach team makes regular visit to all households in the field practice area. Accordingly, demography and morbidity profiles are updated periodically in the database of Community Health Information Management System.

Study population: A total of 150 students who were in sixth semester were divided into four groups. Community based medical education was implemented in the form of cross sectional community based public health oriented research projects. The group who were involved in assessing prevailing infant and young child practices formed the study population. Infant and young children included children born between 1st January 2015 to 31st December 2016 as per the list obtained from the Community Health Information Management System (CHIMS). Primary care givers of the eligible children were approached for further enquiry. Details of the training given are as per the following:-

I. Pretest

Before inception of this community based research project students were asked to fulfill the questionnaire anonymously which formed a base for the students’ knowledge on infant and young child feeding practices. The pretest had 10 questions related to appropriate feeding practices to be followed in various age group of children, nutritional assessment among under-5 children and management for under nutrition. Questions were framed in the form of multiple choice questions covering descriptive to case based scenarios. For each correct answer students were awarded one mark and wrong answers and unattended questions were awarded zero. At the end, cumulative score was calculated for each student.

II. Orientation to research

Following the pre-test assessment, students were oriented to research methodology through workshop which included sessions related to rationale for conducting research, framing research protocol, tool development for data collection, instrument standardization, validation of questionnaire, data management and report writing.

III. Briefing on infant and young child feeding practices

In the first week of CBE students were taught about optimal breast feeding practices, appropriate complementary foods suitable for different age group of children, dietary diversity, anthropometry, assessment and grading for nutritional status of the young infants using National Health Mission guidelines through lecture, case based learning and demonstrations.

IV. Situational Analysis

Students were divided into 17 teams comprising of 2 students in each team. Line list of children born between 1st January 2015 to 31st December 2016 were obtained from the Community Health Information Management System (CHIMS) and anganwadi centres whichever is available and up to date. Using the pretested proforma students made house to house visit in the selected villages in multiple teams. If eligible infant and young children were there in the selected house the care givers were interviewed regarding socio demographic status and feeding practices followed for the particular child. Anthropometric measures were recorded as per the training (Supplement 1: proforma; supplement 2: pre and post test questionnaire). After approval from the concerned faculty for data accuracy and completeness, Data entry was done team wise on day-to-day basis in EpiData entry software (EpiData version 3.1) using valid checks.

V. Project Intervention – Information, Education and Communication (IEC) campaign

At the end of the second week students compiled all valid records and analysed the key prevailing infant and young child feeding practices. Before the campaign, community mobilization especially among mothers of under-5 children was done through medical social workers. Based on the analysed results, they had planned for an IEC campaign on feeding practices. In the campaign various health education messages were displayed in an attractive way through posters, charts and food models. To increase the applicability among others some of the energy dense recipes which will be appropriate for young children were demonstrated in live counters. To involve the community in the IEC campaign and to share the best recipes available within them the cooking competition was arranged in the premises of health centre. There was also role play held by the students to emphasize the need for clarifying myths and misconceptions on child feeding practices.

VI. Post test

On the last day of the CBE, students were provided with the same questionnaire as like pre-test. Similar to pretest, in the post test cumulative score also was calculated for each individual student.

VII. Feedback

At the end of the project feedbacks were obtained for the open ended questions such as what do they perceive regarding positive aspect and challenges of community based education and key informant interview with the concerned medical social workers, residents and faculty supervisor.

Data Analysis:

Mean score obtained before the community based project was compared using students t’ test. Statistical significance was decided at <0.05 level. All the key informants (two medical social workers, two supervisors, Postgraduate and interns and one faculty supervisor) were interviewed by the trained qualitative researcher using topic guide. With their consent field notes were taken. Transcripts were made by one of the authors on the same day. Transcripts were read back to the key informants to increase the participant validation. Transcripts were analyzed through manual content analysis through iterative process independently by two authors.

  Results Top

Totally 36 students (13 male, 23 female) were there under the community based research project on “prevailing IYCF practices”. Of the 36, 32 students participated in the pretest and 29 students participated in the post test survey. Cumulative score obtained before the project was 3.3 ± 1.5. After the community based project, the students score was significantly improved to mean (SD): 6.5 (1.1) from the baseline (p<0.001) [fig 1]. Of the ten items included in the questionnaire seven items had significant improvement (p<0.01).

Key informant interviews and students written feedback were analysed using manual content analysis. The whole transcript was coded as six categories under the theme of effect of community based medical education. Similarly under the theme of challenges there were three categories made such as motivation, logistics, and manpower. The themes, categories and the important quotes which supports that category is given in [Table 2].
Table 1: Item wise comparison of improvement on knowledge related to infant and young child feeding practices

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Table 2: Theme, categories and the important quotes which supports that category

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  Discussion Top

This pedagogical exercise carried out among sixth semester students on community based medical education received overwhelming response from students as well as the other stakeholders such as medical social workers and faculty supervisors. Not only the team has perceived this learning as satisfied one it has resulted in knowledge gained in the selected topic. Knowledge of the students had significantly improved. Scores had improved twice compared to the baseline. Above all, students could utilize this knowledge in understanding the situation and plan for appropriate intervention and implementing the same. For the professional courses like MBBS the best learning outcome would be not only to acquire knowledge but to progress towards application as said in the educational theory of Bloom's hierarchy.[13]

After the Bhore committee recommendation various community based education models were tried such as community orientation programme, community diagnosis approach, Reorientation of medical education (ROME), family health advisory programme, in stay rural postings and adopting villages.[14] Some of the institutes of national importance had shown the successful model on these approaches. Of the several approaches WHO had strongly emphasized the “Reorientation Of Medical Education” at global level.[4] Gradually due to the lack of funding support and change in MCI norms and institutional disinterest at present not many institutes are following this pattern.

In this study students and faculty were of the opinion that this ROME has helped them to perceive various social determinants of health, build a team spirit and professional attitude. Similar to this Wee L En et al had reported home-based learning to be the better method to teach communication skills, team work, perception of social issues and applied knowledge.[15] Mudarikwa et al had said community based research projects are the best platform for mutual learning and the medical students to get real time experience. Gibbs et al from One of the Gulf University had compared the perception of students who learnt in the different environment namely urban tertiary care teaching hospitals, remote rural secondary referral hospital and rural community based programme. He concluded that rural community based programme was involved with more effective patient contact in contrary to other two settings where they spent majority of the timings in didactic lectures and tutorials. In the current study also less than one fifth of the time was spent in class rooms and rest of the time was spent in direct contact in the community or in the IEC campaign.[16]

Similarly, in India Dongre et al from Wardha had reported that the ROME programme was well regarded by all the students in all domains[17]. Krishnan A et al from All India Institute of Medical Sciences, New Delhi also had opined that the students were positive in community oriented approach and they prefer largely towards activity based learning.[18]

This study has several strengths. Firstly, this study systematically assessed the learning outcome of community based medical education in the form of “Reorientation of Medical Education” which was stopped by majority of the institutes in India. Secondly, the study used mixed method approach where the improvement in knowledge was assessed quantitatively and perceptions of the student and various stake holders were recorded using qualitative designs. Thirdly, we had insisted anonymity in the pre-post test questionnaire to reflect the real knowledge of the student.

In this study, number of students who participated in the post test survey does not match with pre test survey. To avoid the halo effect of the projects perception, we had collected the post test questionnaire two weeks after the project. That resulted in loss of these students. This study has following implications for the field of medical education. This study demonstrates the feasibility of carrying out this exercise and it is worth investing in the process of training community care physicians. Nevertheless, there should be strong commitment and planning before the execution of this task.

  Conclusion Top

Community based education imparted in the form of community based research project under Reorientation of Medical Education has improved the student's knowledge significantly and it facilitated to apply that knowledge in the field. Students as well as other stakeholders were more positive and overwhelmingly supporting this approach. This approach is feasible with better planning, institute cooperation and commitment.

  References Top

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Govt of India. Ministry of Health and Family Welfare SD. Rural Health Statistics [Internet]. Available from: http://www.wcd.nic. in/sites/default/files/RHS_1.pdf  Back to cited text no. 2
World Health Organization G. Alma-Ata 1978 Primary Health Care [Internet]. 1978. Available from: https://www.unicef.org/about/ history/files/Alma_Ata_conference_1978_report.pdf  Back to cited text no. 3
World Health Organization G. Reorientation of medical education:Guidelines for developing national plans for action [Internet]. New-Delhi; 1991. Available from: http://apps.searo. who.int/pds_docs/B0086.pdf  Back to cited text no. 4
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Bezner Kerr R, Dakishoni L, Shumba L, Msachi R, Chirwa M. "We grandmothers know plenty": breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi. Soc Sci Med [Internet]. 2008 Mar [cited 2017 Nov 8];66(5):1095-105. Available from: http://linkinghub.elsevier. com/retrieve/pii/S027795360700593X  Back to cited text no. 10
Kumar D, Goel NK, Kalia M, Swami HM, Singh R. Gap between awareness and practices regarding maternal and child health among women in an urban slum community. Indian J Pediatr [Internet]. 2008 May [cited 2017 Nov 8];75(5):455-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18537007  Back to cited text no. 11
Al-Eraky M, Marei H. A fresh look at Miller's pyramid: assessment at the “Is and Do” levels.Med Educ. 2016 Dec [cited 2017 Nov 8];50(12):1253-7. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/27873421  Back to cited text no. 12
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Govt of India. Report of Health Survey and Development commitee [Internet]. New-Delhi; 1946. Available from: https://www.nhp. gov.in/sites/default/files/pdf/Bhore_Committee_Report_VOL-1. pdf  Back to cited text no. 14
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  [Table 1], [Table 2]


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