|BRIEF RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 4 | Page : 391-395
Assessment of community-based education in community health officers' training at a Rural Medical College in Northern Ahmednagar District of Maharashtra, India: A longitudinal study
Mandar Padmakar Baviskar1, Deepak B Phalke2, Shubhada S Javadekar3, Kalpak Kadarkar1, Rajvir Bhalwar4
1 Associate Professor, Department of Community Medicine, Dr. Balasaheb Vikhe Patil Rural Medical College, PIMS (Deemed University), Loni, Maharashtra, India
2 Professor, Department of Community Medicine, Dr. Balasaheb Vikhe Patil Rural Medical College, PIMS (Deemed University), Loni, Maharashtra, India
3 Professor and Head, Department of Community Medicine, Dr. Balasaheb Vikhe Patil Rural Medical College, PIMS (Deemed University), Loni, Maharashtra, India
4 Dean, Department of Community Medicine, Dr. Balasaheb Vikhe Patil Rural Medical College, PIMS (Deemed University), Loni, Maharashtra, India
|Date of Submission||03-Jul-2020|
|Date of Decision||18-Feb-2021|
|Date of Acceptance||19-Oct-2021|
|Date of Web Publication||29-Dec-2021|
Mandar Padmakar Baviskar
Department of Community Medicine, Rural Medical College, PIMS (Deemed University), Loni, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We evaluated the Community Health Officer (CHO) training program in northern Ahmednagar district of Maharashtra, India. A longitudinal study was conducted among 110 CHO trainees from August 2019 to January 2020. The trainees undertook field visits and survey with lectures and clinical postings. Evaluation was based on pre- and post-Multiple Choice Question tests, the WHO Education of Health Personnel Checklist, Journals, and Logbooks. MannWhitney U-test, Wilcoxon-rank test were used to compare nonnormal variables while t-test was used for comparison of age. Initially, nursing graduates performed better than Ayurveda graduates, especially in punctuality, grasp on problems, and problem-solving ability. Nursing graduates kept better journals and logbooks. Female trainees performed better than male trainees. Ayurveda and nursing graduates were comparable at the end of the training. Need-based training and upskilling of mid-level healthcare providers can be done at scale by roping in medical colleges.
Keywords: Community health worker, public health manpower, training, teaching-learning
|How to cite this article:|
Baviskar MP, Phalke DB, Javadekar SS, Kadarkar K, Bhalwar R. Assessment of community-based education in community health officers' training at a Rural Medical College in Northern Ahmednagar District of Maharashtra, India: A longitudinal study. Indian J Public Health 2021;65:391-5
|How to cite this URL:|
Baviskar MP, Phalke DB, Javadekar SS, Kadarkar K, Bhalwar R. Assessment of community-based education in community health officers' training at a Rural Medical College in Northern Ahmednagar District of Maharashtra, India: A longitudinal study. Indian J Public Health [serial online] 2021 [cited 2022 Jan 22];65:391-5. Available from: https://www.ijph.in/text.asp?2021/65/4/391/333984
Ayushman Bharat envisions upgrading subcenters to Health and Wellness Centres (HWCs). HWCs will be manned by Community Health Officers (CHOs), a cader of mid-level healthcare providers recruited from nursing and Bachelor of Ayurvedic Medicine and Surgery (BAMS) graduates. The intension is to overcome the deficit of trained healthcare providers in rural areas for the provision of comprehensive primary healthcare. Maharashtra University of Health Sciences conducts a mandatory 6 month Modern Mid-level Service Provider Certification for CHOs. Rural Medical College, Loni is one of the affiliated Program Study Centers (PSC) for this course. Community-based education is a means of achieving the educational objectives of health professionals by aligning it with community needs. The training program espouses classroom, clinical, and field-based teaching. The success of the program depends on how well the CHOs can deliver services in the community. We stipulated that a formative evaluation approach would be better to assess the effectiveness of community-based education. The ability of the program to address the training needs of nursing and Ayurveda graduates also required study. The current study compared the performance of trainees from AYUSH and nursing backgrounds and assessed the implementation of community-based training of CHOs in a rural area.
- To assess the effectiveness of CHO training program
- To compare the performance of Ayurveda and nursing students
- To compare the performance of male and female students.
A prospective longitudinal study was carried out at Rural Medical College, Loni. A batch of 110 CHO trainees was evaluated from August 2019 to January 2020. All trainees who gave consent were included in the study. The study was approved by the Institutional Ethics Committee (IEC, Reg. no. PIMS/DR/RMC/2019/288 dated July 08, 2019). The public health curriculum included lectures of 123 h,60 h of case presentation and small group discussion, and 1 day per week was reserved for community visits with a requirement of attendance over 80%.
Multiple Choice Question (MCQ)-based pretest at baseline and posttest at 6 months were conducted following lectures to evaluate improvement in knowledge of CHO trainees on community health survey and health promotion methods.
At the first visit, families from the field area were allotted to each trainee. Each family was assigned with a code. Rapport building with families was facilitated and the purpose of visits was explained. Over 6 months, the trainees visited each family at least 6 times. The trainees were expected to gain insights into the problems of the families, conduct IEC activities pertaining to relevant public health topic and help linking the families to health services. Topics reflected the package of services that would be provided in the community such as maternal, child and adolescent health services, family planning, screening and prevention of noncommunicable diseases, communicable diseases, oral health, common ophthalmic problems, common mental health issues, and healthcare of elderly. Data collection in family folders and descriptive analysis using Excel was taught followed by the presentation of the family survey. In addition, the CHOs gave health talks, conducted school health check-ups, routine immunization activities, Non-Communicable Diseases surveys, observance of World AIDS Day, Health check-up, and IEC for tribal school children. Worked with mobile clinics and learned how to provide effective outreach services.
The trainees were accompanied by teachers, tutors, social workers, and nurses trained to conduct formative on-site assessments. This was done twice, the first during the third visit and the second during the final visit. The WHO checklist for Community-based Education of Health Personnel, which is 13 item instrument rated on a 5-point Likert scale with scores ranging from 13 to 65 was used as a reference for assessment.
Quality inputs about the trainee were gained from the feedback of the families in the field practice area after completion of visits.
The trainees were also required to keep journals and logbooks of their field visits. They were evaluated at the end of 6 months and scores were given out of 10. The evaluation used recommendations from Principles of Assessment in Medical Education.
After completion of training, theory and practical examinations were conducted at the university level. The scores were noted and compared.
MCQ-based test scores, on-site assessment by the WHO Community-based Education of Health Personnel Checklist, Journals, and Logbook evaluation (scored out of 10), Score in University certification exam (%).
Descriptive statistical analysis was performed using percentage, mean, standard deviation (SD), median, and 95% confidence intervals of the median (95% CI). Shapiro-Wilk test for normality was applied. Unpaired t-test was used to compare age which was normally distributed. Nonparametric tests such as Mann-Whitney U-test, Wilcoxon test, and Spearman's rank correlation were used for nonnormal data.
Of the 110 CHOs, 75 (68.2%) were Ayurveda graduates (BAMS) and 35 (31.8%) were nursing graduates. There were 65 (59.1%) male and 45 (40.9%) female trainees. The average age was 30.33 years (SD = 5.3). The average age of nursing graduates was 24.6 (SD = 1.6) and that of BAMS was 33.01 (SD = 4.17), (t = 11.475, df = 108, P = 0.0001).
Applying Mann-Whitney U-test, there was no significant sex-wise difference in MCQ scores at baseline (P = 0.292) and at the end of 6 months (P = 0.935). Comparing MCQ scores among BAMS and nursing graduates, there was a statistically significant difference in scores at baseline (P = 0.037) with nursing graduates scoring higher than Ayurveda graduates. However, scores were comparable at end of 6 months of training (P = 0.235). Applying Wilcoxon test, there was signification overall improvement (P < 0.001) in MCQ test scores at 6 months (median = 46; 95% CI: 39.55–48.00) as compared to baseline scores [median = 30; 95% CI 13.10–44.00; [Table 1]].
|Table 1: Qualification and sex wise comparison of Multiple Choice Question test scores, final exam scores and Journal assessments of community health officer trainees|
Click here to view
On mid posting evaluation, nursing graduates had a median score of 26 (95% CI: 22.0–31.0) as compared to Ayurveda graduates 24 (95% CI: 22.4–28.20; P < 0.001). Specifically in terms of punctuality (P < 0.001), ability to identify problems (P < 0.001), and ability to suggest new approaches to problem-solving (P < 0.001) nursing graduates scored higher initially, but there was no significant difference at 6 months [Table 2]. Female trainees scored better on appearance and general behavior (P = 0.014) in the ability to relate findings to community health problems (P = 0.036) initially. They showed better improvement over the training period than male trainees. The median scores were better in female trainees 54 (95% CI: 50–57.7) as compared to male trainees 51 (95% CI: 48–54) at 6 months [P < 0.001; [Table 2]].
|Table 2: Qualification and sex wise comparison of World Health Organization check list scores of community health officer's|
Click here to view
The community members were satisfied with the trainees. They appreciated the health advice and help in linking with local health care services. Trainees also followed up on patients after hospital visits and used WhatsApp to share health information with the families. The trainees were approachable and helpful in solving health issues faced by families.
The nursing graduates scored better on journal and logbook evaluations compared to BAMS (P = 0.002) [Table 1]. Journals helped summarize, reflect, interpret data, and comment on the community diagnosis. Trainees could describe health events, comment on people's behavior, and its context. They understood other factors such as ethical and sociopolitical context while collecting information. They were encouraged to pursue reflective thinking and test new ideas in practice. They also analyzed the survey data and gave a short presentation on the findings of the family survey.
Of the 110 students, 109 became eligible to appear for final examinaions and 106 passed. One student did not appear for the examination despite eligibility and 2 students failed. There was no significant difference in final examinationpercentage scores sex wise (P = 0.857) or in BAMS and nursing trainees [P = 0.904; [Table 1]]. There was a weak positive correlation between posttest MCQ scores and final examination scores (rho = 0.244, P = 0.011). There was no significant correlation between final examination scores and WHO checklist scores.
Karan et al. while commenting on needs of the Indian health workforce, state that substantial proportion of active health workers were found not adequately qualified, and advocate for up-skilling programs for less qualified care providers. The current training program was in keeping with the operational guidelines for HWCs and addressed the needs of a heterogeneous group of trainees from nursing and AYUSH backgrounds. We find that medical colleges can collaborate with the public health system to provide a model for rapid scaling up of services and capacity building of the health workforce.
Awareness of BAMS trainees about national health programs, screening, health education, referral procedures, and family survey study was limited. Nursing graduates were well trained in imparting health education, hospital and referral procedures, conducting community-based surveys, and family studies. They were meticulous in record-keeping and more disciplined. They however needed exposure in diagnosing, prescription of medications, and acting with agency. Vasan et al. on reviewing mid-level care provider training in low- and middle-income countries found supportive supervision, mentoring, use of standardized tools and aids, continuous quality improvement, and coaching to be important in addressing the skill gaps. We found that community visits, small group teaching, active interaction between trainees, and participation in outreach activities succeeded in filling the gaps. Formative evaluation could gauge the strength and weakness of students better and helped refine teaching. The use of local language in teaching was found to be effective. Utilizing experience in medical education technology for training the CHOs proved beneficial. A competent mid-level supervisory health workforce can strengthen the performance of the existing workers.
Possible bias in the study includes hawthorne effect, as the participants knew they were being evaluated. The study included a single PSC, and did not evaluate the performance of CHOs in the community after certification. Despite proper training untimely payments, other operational issues and unfavorable attitudes may lead to poor delivery of care at the rural level. Impact evaluation of CHOs on the health of the community would be the true litmus test of the program.
We thank the Management and Directorate of Research, Pravara Institute of Medical Sciences (Deemed University) for their support. We thank NHM, Mumbai, Health and Family Welfare Training Centre Nashik, District Health Office, Ahmednagar and Maharashtra University of Health Sciences, Nashik for their support and guidance in the implementation of the training.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Angell BJ, Prinja S, Gupt A, Jha V, Jan S. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance. PLoS Med 2019;16:e1002759.
Desai S, Bishnoi RK, Punjot P. Community health officer: The concept of mid-level health care providers. Int J Community Med Public Health 2020;7:1610.
Community-based education of health personnel. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1987;746:1-89.
Singh T. Principles of Assessment in Medical Education. 1st
ed.,New Delhi, Jaypee Brothers Medical Publisher; 2012.
Karan A, Negandhi H, Hussain S, Zapata T, Mairembam D, De Graeve H, et al.
Size, composition and distribution of health workforce in India: Why, and where to invest? Hum Resour Health 2021;19:39.
Vasan A, Mabey DC, Chaudhri S, Brown Epstein HA, Lawn SD. Support and performance improvement for primary health care workers in low- and middle-income countries: A scoping review of intervention design and methods. Health Policy Plan 2017;32:437-52.
Ahmed FU. Public health manpower: An alternative model. Indian J Public Health 2010;54:137-44.
] [Full text]
Rao KD, Sundararaman T, Bhatnagar A, Gupta G, Kokho P, Jain K. Which doctor for primary health care? Quality of care and non-physician clinicians in India. Soc Sci Med 2013;84:30-4.
[Table 1], [Table 2]