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1.  E-Learning as New Method of Medical Education 
Acta Informatica Medica  2008;16(2):102-117.
CONFLICT OF INTEREST: NONE DECLARED
Distance learning refers to use of technologies based on health care delivered on distance and covers areas such as electronic health, tele-health (e-health), telematics, telemedicine, tele-education, etc. For the need of e-health, telemedicine, tele-education and distance learning there are various technologies and communication systems from standard telephone lines to the system of transmission digitalized signals with modem, optical fiber, satellite links, wireless technologies, etc. Tele-education represents health education on distance, using Information Communication Technologies (ICT), as well as continuous education of a health system beneficiaries and use of electronic libraries, data bases or electronic data with data bases of knowledge. Distance learning (E-learning) as a part of tele-education has gained popularity in the past decade; however, its use is highly variable among medical schools and appears to be more common in basic medical science courses than in clinical education. Distance learning does not preclude traditional learning processes; frequently it is used in conjunction with in-person classroom or professional training procedures and practices. Tele-education has mostly been used in biomedical education as a blended learning method, which combines tele-education technology with traditional instructor-led training, where, for example, a lecture or demonstration is supplemented by an online tutorial. Distance learning is used for self-education, tests, services and for examinations in medicine i.e. in terms of self-education and individual examination services. The possibility of working in the exercise mode with image files and questions is an attractive way of self education. Automated tracking and reporting of learners’ activities lessen faculty administrative burden. Moreover, e-learning can be designed to include outcomes assessment to determine whether learning has occurred. This review article evaluates the current status and level of tele-education development in Bosnia and Herzegovina outlining its components, faculty development needs for implementation and the possibility of its integration as official learning standard in biomedical curricula in Bosnia and Herzegovina. Tele-education refers to the use of information and communication technologies (ICT) to enhance knowledge and performance. Tele-education in biomedical education is widely accepted in the medical education community where it is mostly integrated into biomedical curricula forming part of a blended learning strategy. There are many biomedical digital repositories of e-learning materials worldwide, some peer reviewed, where instructors or developers can submit materials for widespread use. First pilot project with the aim to introduce tele-education in biomedical curricula in Bosnia and Herzegovina was initiated by Department for Medical Informatics at Medical Faculty in Sarajevo in 2002 and has been developing since. Faculty member’s skills in creating tele-education differ from those needed for traditional teaching and faculty rewards must recognize this difference and reward the effort. Tele-education and use of computers will have an impact of future medical practice in a life long learning. Bologna process, which started last years in European countries, provide us to promote and introduce modern educational methods of education at biomedical faculties in Bosnia and Herzegovina. Cathedra of Medical informatics and Cathedra of Family medicine at Medical Faculty of University of Sarajevo started to use Web based education as common way of teaching of medical students. Satisfaction with this method of education within the students is good, but not yet suitable for most of medical disciplines at biomedical faculties in Bosnia and Herzegovina.
doi:10.5455/aim.2008.16.102-117
PMCID: PMC3789161  PMID: 24109154
Medical education; Distance learning; Bosnia and Herzegovina
2.  Evaluation of a novel nutrition education intervention for medical students from across England 
BMJ Open  2012;2(1):e000417.
Objectives
Problems such as hospital malnutrition (∼40% prevalence in the UK) may be managed better by improving the nutrition education of ‘tomorrow's doctors’. The Need for Nutrition Education Programme aimed to measure the effectiveness and acceptability of an educational intervention on nutrition for medical students in the clinical phase of their training.
Design
An educational needs analysis was followed by a consultative process to gain consensus on a suitable educational intervention. This was followed by two identical 2-day educational interventions with before and after analyses of Knowledge, Attitudes and Practices (KAP). The 2-day training incorporated six key learning outcomes.
Setting
Two constituent colleges of Cambridge University used to deliver the above educational interventions.
Participants
An intervention group of 100 clinical medical students from 15 medical schools across England were recruited to attend one of two identical intensive weekend workshops.
Primary and secondary outcome measures
The primary outcome measure consisted of change in KAP scores following intervention using a clinical nutrition questionnaire. Secondary outcome measures included change in KAP scores 3 months after the intervention as well as a student-led semiqualitative evaluation of the educational intervention.
Results
Statistically significant changes in KAP scores were seen immediately after the intervention, and this was sustained for 3 months. Mean differences and 95% CIs after intervention were Knowledge 0.86 (0.43 to 1.28); Attitude 1.68 (1.47 to 1.89); Practice 1.76 (1.11 to 2.40); KAP 4.28 (3.49 to 5.06). Ninety-seven per cent of the participants rated the overall intervention and its delivery as ‘very good to excellent’, reporting that they would recommend this educational intervention to colleagues.
Conclusion
Need for Nutrition Education Programme has highlighted the need for curricular innovation in the area of clinical health nutrition in medical schools. This project also demonstrates the effectiveness and acceptability of such a curriculum intervention for ‘tomorrow's doctors’. Doctors, dietitians and nutritionists worked well in an effective interdisciplinary partnership when teaching medical students, providing a good model for further work in a healthcare setting.
Article summary
Article focus
Hospital malnutrition has been a challenge for decades in the UK due to its cost and impact on patient care.
The focus was to examine whether a novel 2-day course could make a significant improvement in the understanding of clinical nutrition, among senior medical students.
Key messages
This study summarised the need for improved training in clinical nutrition among medical students in England, a need noted in other countries too.
Statistically significant changes in KAP scores were seen immediately after the intervention among the 98 students, and this was sustained for 3 months.
Ninety-seven per cent of the participants rated the overall intervention and its delivery as ‘very good to excellent’, reporting that they would recommend this educational intervention to colleagues.
Strengths and limitations of this study
The learning outcomes seemed appropriate and the teaching intervention appeared effective.
A multidisciplinary teaching team helped emphasise the roles of various team members, in dealing with nutrition-related problems in a healthcare setting.
Comparing change to a parallel student control group would have been preferable to monitoring within-group change.
doi:10.1136/bmjopen-2011-000417
PMCID: PMC3277906  PMID: 22327628
3.  Evaluation of a web-based ECG-interpretation programme for undergraduate medical students 
Background
Most clinicians and teachers agree that knowledge about ECG is of importance in the medical curriculum. Students at Karolinska Institutet have asked for more training in ECG-interpretation during their undergraduate studies. Clinical tutors, however, have difficulties in meeting these demands due to shortage of time. Thus, alternative ways to learn and practice ECG-interpretation are needed. Education offered via the Internet is readily available, geographically independent and flexible. Furthermore, the quality of education may increase and become more effective through a superior educational approach, improved visualization and interactivity.
Methods
A Web-based comprehensive ECG-interpretation programme has been evaluated. Medical students from the sixth semester were given an optional opportunity to access the programme from the start of their course. Usage logs and an initial evaluation survey were obtained from each student. A diagnostic test was performed in order to assess the effect on skills in ECG interpretation. Students from the corresponding course, at another teaching hospital and without access to the ECG-programme but with conventional teaching of ECG served as a control group.
Results
20 of the 32 students in the intervention group had tested the programme after 2 months. On a five-graded scale (1- bad to 5 – very good) they ranked the utility of a web-based programme for this purpose as 4.1 and the quality of the programme software as 3.9. At the diagnostic test (maximal points 16) by the end of the 5-month course at the 6th semester the mean result for the students in the intervention group was 9.7 compared with 8.1 for the control group (p = 0.03).
Conclusion
Students ranked the Web-based ECG-interpretation programme as a useful instrument to learn ECG. Furthermore, Internet-delivered education may be more effective than traditional teaching methods due to greater immediacy, improved visualisation and interactivity.
doi:10.1186/1472-6920-8-25
PMCID: PMC2394519  PMID: 18430256
4.  Development of a quality assurance handbook to improve educational courses in Africa 
Background
The attainment of the Millennium Development Goals has been hampered by the lack of skilled and well-informed health care workers in many developing countries. The departure of health care workers from developing countries is one of the most important causes. One of the motivations for leaving is that developed countries have well-established health care systems that incorporate continuing medical education, which enables health care workers to develop their skills and knowledge base. This provision is lacking in many developing countries. The provision of higher-education programmes of good quality within developing countries therefore, contributes to building capacity of the health care workforce in these countries.
Methods
The Liverpool School of Tropical Medicine is involved in delivering off-site higher educational programmes to health care workers in Africa. Our colleagues at one of these sites requested a guide to help them ensure that their professional development courses met international educational standards. We reviewed published literature that outlines the principles of quality assurance in higher education from various institutions worldwide. Using this information, we designed a handbook that outlines the quality assurance principles in a simple and practical way. This was intended to enable institutions, even in developing countries, to adapt these principles in accordance with their local resource capacity. We subsequently piloted this handbook at one of the sites in Ghana. The feedback from this aided the development of the handbook. The development of this handbook was participatory in nature.
Results
The handbook addresses six main themes that are the minimum requirements that a higher education course should incorporate to ensure that it meets internationally recognized standards. These include: recruitment and admissions, course design and delivery, student assessments, approval and review processes, support for students and staff training and welfare. It has been piloted in Ghana and the feedback was incorporated into the handbook. The handbook is currently available free of charge online and being used by various institutions across the world. We have had responses from individuals and institutions in Africa, Asia, North America and Europe.
Conclusion
The principles outlined in the handbook provide a regulatory framework for locally establishing higher education courses of good quality that will contribute to enhancing the teaching and learning experience of students in courses in the developing world. This would contribute to providing a skilled and sustainable health care workforce that would reduce the need for health care workers to travel overseas in search of good higher education courses.
doi:10.1186/1478-4491-6-28
PMCID: PMC2615788  PMID: 19094199
5.  The Long-Term Effects of a Peer-Led Sex Education Programme (RIPPLE): A Cluster Randomised Trial in Schools in England 
PLoS Medicine  2008;5(11):e224.
Background
Peer-led sex education is widely believed to be an effective approach to reducing unsafe sex among young people, but reliable evidence from long-term studies is lacking. To assess the effectiveness of one form of school-based peer-led sex education in reducing unintended teenage pregnancy, we did a cluster (school) randomised trial with 7 y of follow-up.
Methods and Findings
Twenty-seven representative schools in England, with over 9,000 pupils aged 13–14 y at baseline, took part in the trial. Schools were randomised to either peer-led sex education (intervention) or to continue their usual teacher-led sex education (control). Peer educators, aged 16–17 y, were trained to deliver three 1-h classroom sessions of sex education to 13- to 14-y-old pupils from the same schools. The sessions used participatory learning methods designed to improve the younger pupils' skills in sexual communication and condom use and their knowledge about pregnancy, sexually transmitted infections (STIs), contraception, and local sexual health services. Main outcome measures were abortion and live births by age 20 y, determined by anonymised linkage of girls to routine (statutory) data. Assessment of these outcomes was blind to sex education allocation. The proportion of girls who had one or more abortions before age 20 y was the same in each arm (intervention, 5.0% [95% confidence interval (CI) 4.0%–6.3%]; control, 5.0% [95% CI 4.0%–6.4%]). The odds ratio (OR) adjusted for randomisation strata was 1.07 (95% CI 0.80–1.42, p = 0.64, intervention versus control). The proportion of girls with one or more live births by 20.5 y was 7.5% (95% CI 5.9%–9.6%) in the intervention arm and 10.6% (95% CI 6.8%–16.1%) in the control arm, adjusted OR 0.77 (0.51–1.15). Fewer girls in the peer-led arm self-reported a pregnancy by age 18 y (7.2% intervention versus 11.2% control, adjusted OR 0.62 [95% CI 0.42–0.91], weighted for non-response; response rate 61% intervention, 45% control). There were no significant differences for girls or boys in self-reported unprotected first sex, regretted or pressured sex, quality of current sexual relationship, diagnosed sexually transmitted diseases, or ability to identify local sexual health services.
Conclusion
Compared with conventional school sex education at age 13–14 y, this form of peer-led sex education was not associated with change in teenage abortions, but may have led to fewer teenage births and was popular with pupils. It merits consideration within broader teenage pregnancy prevention strategies.
Trial registration:
ISRCTN (ISRCTN94255362).
Judith Stephenson and colleagues report on a cluster randomized trial in London of school-based peer-led sex education and whether it reduced unintended teenage pregnancy.
Editors' Summary
Background.
Teenage pregnancies are fraught with problems. Children born to teenage mothers are often underweight, which can affect their long-term health; young mothers have a high risk of poor mental health after the birth; and teenage parents and their children are at increased risk of living in poverty. Little wonder, then, that faced with one of the highest teenage pregnancy rates in Western Europe, the Department of Health in England launched a national Teenage Pregnancy Strategy in 2000 to reduce teenage pregnancies. The main goal of the strategy is to halve the 1998 under-18 pregnancy rate—there were 46.6 pregnancies for every 1,000 young women in this age group in that year—by 2010. Approaches recommended in the strategy to achieve this goal include the provision of effective sexual health advice services for young people, active engagement of health, social, youth support, and other services in the reduction of teenage pregnancies, and the improvement of sex and relationships education (SRE).
Why Was This Study Done?
Although the annual under-18 pregnancy rate in England is falling, it is still very high, and it is extremely unlikely that the main goal of the Teenage Pregnancy Strategy will be achieved. Experts are, therefore, looking for better ways to reduce both teenage pregnancy rates and the high rates of sexual transmitted diseases among teenagers. Many believe that peer-led SRE—the teaching (sharing) of sexual health information, values, and behaviours by people of a similar age or status group—might be a good approach to try. Peers, they suggest, might convey information about sexual health and relationships better than teachers. However, little is known about the long-term effectiveness of peer-led SRE. In this randomized cluster trial, the researchers compare the effects of a peer-led SRE program and teacher-led sex education given to13- to 14-y-old pupils on abortion and live birth numbers among young women up to age 20 y. In a cluster randomized trial, participants are randomly assigned to the interventions being compared in “clusters”; in this trial, each “cluster” is a school.
What Did the Researchers Do and Find?
Twenty-seven schools in England (about 9,000 13- to 14-y-old pupils) participated in the RIPPLE (Randomized Intervention of PuPil-Led sex Education) trial. Each school was randomly assigned to peer-led SRE (the intervention arm) or to existing teacher-led SRE (the control arm). For peer-led SRE, trained 16- to 17-y-old peer educators gave three 1-h SRE sessions to the younger pupils in their schools. These sessions included practice with condoms, role play to improve sexual negotiating skills, and exercises to improve knowledge about sexual health. The researchers then used routine data on abortions and live births to find out how many female study participants had had an unintended pregnancy before the age of 20 y. One in 20 girls in both study arms had had one or more abortions. Slightly more girls in the control arm than in the intervention arm had had live births, but the difference was small and might have occurred by chance. However, significantly more girls in the intervention arm (11.2%) self-reported a pregnancy by age 18 than in the intervention arm (7.2%). There were no differences between the two arms for girls or boys in any other aspect of sexual health, including sexually transmitted diseases.
What Do These Findings Mean?
These findings indicate that the peer-led SRE program used in this trial had no effect on the number of teenage abortions but may have led to slightly fewer live births among the young women in the study. This particular peer-led SRE program was very short so a more extended program might have had a more marked effect on teenage pregnancy rates; this possibility needs to be tested, particularly since the pupils preferred peer-led SRE to teacher-led SRE. Even though peer-led SRE requires more resources than teacher-led SRE, this form of SRE should probably still be considered as part of a broad teenage prevention strategy, suggest the researchers. But, they warn, their findings should also “temper high expectations about the long-term impact of peer-led approaches” on young people's sexual health.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050224.
This study is further discussed in a PLoS Medicine Perspective by David Ross
Every Child Matters, a Web site produced by the UK government, includes information on teenage pregnancy, the Teenage Pregnancy Strategy, and teenage pregnancy statistics in England
Directgov, an official government Web site for UK citizens, provides advice for parents on talking to children about sex and teenage pregnancyand advice for young people on sexual health and preventing pregnancy
Teachernet, a UK source of online publications for schools, also provides information for parents about sex and relationships education and the UK government's current guidance on SRE in schools
Avert, an international AIDS charity, also provides a fact sheet on sex education
The Sex Education Forum in the UK is the national authority on Sex and Relationships Education
doi:10.1371/journal.pmed.0050224
PMCID: PMC2586352  PMID: 19067478
6.  Better learning in schools to improve attitudes toward abstinence and intentions for safer sex among adolescents in urban Nepal 
BMC Public Health  2013;13:244.
Background
School-based sex education is an effective medium to convey health information and skills about preventing sexually transmitted infections (STIs) and unwanted pregnancies among adolescents. However, research on school-based sex education is limited in many developing countries, including Nepal. This study thus had two main objectives: (1) to assess students’ evaluation of school-based sex education, and (2) to examine the associations between students’ evaluations of school-based sex education and their (a) attitudes toward abstinence and (b) intentions for safer sex.
Methods
This cross-sectional study was conducted among 634 students from six schools in the Kathmandu Valley during May–June 2010. We used a self-administered questionnaire to assess students’ evaluations of school-based sex education, attitudes toward abstinence, and intentions for safer sex. The data were then analyzed using multiple linear regression models.
Results
Regarding “information on HIV and sexual health”, many students perceived that they received the least amount of information on HIV counseling and testing centers (mean 2.29, SD 1.00) through their schools. In terms of “support and involvement of teachers and parents” in sex education, parents’ participation ranked as the lowest (mean 1.81, SD 1.01). Audiotapes were reported as the least used among the listed “teaching aids for sexual health education” (mean 1.54, SD 0.82). In multivariate analysis, receiving more “information on HIV and sexual health” was positively associated with more positive “attitudes toward abstinence” (β = 0.11, p = <0.018) and greater “intentions for safer sex” (β = 0.17, p = <0.001) among students. Similarly, increased “support and involvement from teachers and parents” was also positively associated with more positive “attitudes toward abstinence” (β = 0.16, p = <0.001) and greater “intentions for safer sex” (β = 0.15, p = <0.002).
Conclusion
Our results suggest that students’ needs and expectations regarding HIV and sexual health education are not being met through their schools. Moreover, comprehensive information on HIV and sexual health along with increased support and involvement of teachers and parents in sex education might help to improve adolescents’ attitudes toward abstinence and intentions for safer sex. Adapting future school-based interventions to incorporate such elements may thus be an effective strategy to promote adolescent sexual health.
doi:10.1186/1471-2458-13-244
PMCID: PMC3608152  PMID: 23509909
Students; School health services; Sex education; Attitudes; Intentions; Abstinence; Safer sex; Nepal
7.  Long-Term Biological and Behavioural Impact of an Adolescent Sexual Health Intervention in Tanzania: Follow-up Survey of the Community-Based MEMA kwa Vijana Trial 
PLoS Medicine  2010;7(6):e1000287.
David Ross and colleagues conduct a follow-up survey of the community-based MEMA kwa Vijana (“Good things for young people”) trial in rural Tanzania to assess the long-term behavioral and biological impact of an adolescent sexual health intervention.
Background
The ability of specific behaviour-change interventions to reduce HIV infection in young people remains questionable. Since January 1999, an adolescent sexual and reproductive health (SRH) intervention has been implemented in ten randomly chosen intervention communities in rural Tanzania, within a community randomised trial (see below; NCT00248469). The intervention consisted of teacher-led, peer-assisted in-school education, youth-friendly health services, community activities, and youth condom promotion and distribution. Process evaluation in 1999–2002 showed high intervention quality and coverage. A 2001/2 intervention impact evaluation showed no impact on the primary outcomes of HIV seroincidence and herpes simplex virus type 2 (HSV-2) seroprevalence but found substantial improvements in SRH knowledge, reported attitudes, and some reported sexual behaviours. It was postulated that the impact on “upstream” knowledge, attitude, and reported behaviour outcomes seen at the 3-year follow-up would, in the longer term, lead to a reduction in HIV and HSV-2 infection rates and other biological outcomes. A further impact evaluation survey in 2007/8 (∼9 years post-intervention) tested this hypothesis.
Methods and Findings
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 young people aged 15–30 y who had attended trial schools during the first phase of the MEMA kwa Vijana intervention trial (1999–2002). Prevalences of the primary outcomes HIV and HSV-2 were 1.8% and 25.9% in males and 4.0% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV (males adjusted prevalence ratio [aPR] 0.91, 95%CI 0.50–1.65; females aPR 1.07, 95%CI 0.68–1.67) or HSV-2 (males aPR 0.94, 95%CI 0.77–1.15; females aPR 0.96, 95%CI 0.87–1.06). The intervention was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime (aPR 0.87, 95%CI 0.78–0.97) and an increase in reported condom use at last sex with a non-regular partner among females (aPR 1.34, 95%CI 1.07–1.69). There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study population was likely to have been, on average, at lower risk of HIV and other sexually transmitted infections compared to other rural populations, as only youth who had reached year five of primary school were eligible.
Conclusions
SRH knowledge can be improved and retained long-term, but this intervention had only a limited effect on reported behaviour and no significant effect on HIV/STI prevalence. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
Trial Registration
ClinicalTrials.gov NCT00248469
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 2.5 million people become infected with the human immunodeficiency virus (HIV), the virus that causes AIDS. HIV is most often spread through unprotected sex with an infected partner, so individuals can reduce their risk of HIV infection by abstaining from sex, by delaying first sex, by having few partners, and by always using a condom. And, because nearly half of new HIV infections occur among youths (15- to 24-year-olds), programs targeted at adolescents that encourage these protective behaviors could have a substantial impact on the HIV epidemic. One such program is the MEMA kwa Vijana (“Good things for young people”) program in rural Tanzania. This program includes in-school sexual and reproductive health (SRH) education for pupils in their last three years of primary education (12- to 15-year-olds) that provides them with the knowledge and skills needed to delay sexual debut and to reduce sexual risk taking. Between 1999 and 2002, the program was trialed in ten randomly chosen rural communities in the Mwanza Region of Tanzania; ten similar communities that did not receive the intervention acted as controls. Since 2004, the program has been scaled up to cover more communities.
Why Was This Study Done?
Although the quality and coverage of the MEMA kwa Vijana program was good, a 2001/2002 evaluation found no evidence that the intervention had reduced the incidence of HIV (the proportion of the young people in the trial who became HIV positive during the follow-up period) or the prevalence (the proportion of the young people in the trial who were HIV positive at the end of the follow-up period) of herpes simplex virus 2 (HSV-2, another sexually transmitted virus). However, the evaluation found improvements in SRH knowledge, in reported sexual attitudes, and in some reported sexual behaviors. Evaluations of other HIV prevention programs in other developing countries have also failed to provide strong evidence that such programs decrease the risk of HIV infection or other biological outcomes such as the frequency of other sexually transmitted infections or pregnancies, even when SRH knowledge improves. One possibility is that it takes some time for improved SRH knowledge to be reflected in true changes in sexual behavior and in HIV prevalence. In this follow-up study, therefore, researchers investigate the long-term impact of the MEMA kwa Vijana program on HIV and HSV-2 prevalence and ask whether the improvement in knowledge, reported attitudes and sexual risk behaviours seen at the 3-year follow up has persisted.
What Did the Researchers Do and Find?
In 2007/8, the researchers surveyed nearly 14,000 young people who had attended the trial schools between 1999 and 2002. Each participant had their HIV and HSV-2 status determined and answered questions (for example, “can HIV be caught by sexual intercourse (making love) with someone,” and “if a girl accepts a gift from a boy, must she agree to have sexual intercourse (make love) with him?”) to provide three composite sexual knowledge scores and one composite attitude score. 1.8% of the male and 4.0% of the female participants were HIV positive; 25.9% and 41.4% of the male and female participants, respectively, were HSV-2 positive. The prevalences were similar among the young people whose trial communities had been randomly allocated to receive the MEMA kwa Vijana Program and those whose communities had not received it, indicating that the MEMA kwa Vijana intervention program had not reduced the risk of HIV or HSV-2. The intervention program was associated, however, with a reduction in the proportion of men reporting more than four sexual partners in their lifetime and with an increase in reported condom use at last sex with a non-regular partner among women. Finally, although the intervention had still increased SRH knowledge, it now had had no impact on reported attitudes to sexual risk, reported pregnancies, or other reported risky sexual behaviors beyond what might have happened due to chance.
What Do These Findings Mean?
These findings indicate that, in the MEMA kwa Vijana trial, SRH knowledge improved and that this improved knowledge was retained for many years. Disappointingly, however, this intervention program had only a limited effect on reported sexual behaviors and no effect on HIV and HSV-2 prevalence at the 9-year follow-up. Although these findings may not be generalizable to other adolescent populations, they suggest that intervention programs that target only adolescents might not be particularly effective. Young people might find it hard to put their improved skills and knowledge into action when challenged, for example, by widespread community attitudes such as acceptance of older male–younger female relationships. Thus, the researchers suggest that the integration of youth HIV prevention programs within risk reduction programs that tackle sexual norms and expectations in all age groups might be a more successful approach and should be evaluated.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000287.
This study is further discussed in a PLoS Medicine Perspective by Rachel Jewkes
More information about the MEMA kwa Vijana program is available at their Web site
Information is available from the Programme for Research and Capacity Building in Sexual and Reproductive Health and HIV in Developing Countries on recent and ongoing research on HIV infection and other STIs
Information is available from the World Health Organization on HIV and on the health of young people
Information on HIV is available from UNAIDS
Information on HIV in children and adolescents is available from UNICEF
Information on HIV prevention interventions in the education sector is available from UNESCO
Information on HIV infection and AIDS is available from the US National Institute of Allergy and Infectious Diseases
The US Centers for Disease Control and Prevention provide information on HIV/AIDS and on HIV/AIDS among youth (in English and Spanish)
HIV InSitehas comprehensive information on all aspects of HIV/AIDS, including links to information on the prevention of HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS prevention and AIDS and sex education (in English and Spanish)
doi:10.1371/journal.pmed.1000287
PMCID: PMC2882431  PMID: 20543994
8.  Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe 
PLoS Medicine  2007;4(3):e102.
Background
HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.
Methods and Findings
We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).
Conclusions
Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.
In cluster-randomised trial in Zimbabwe integrated peer education, condom distribution, and management of sexually transmitted infections did not reduce incidence of population-level HIV-1.
Editors' Summary
Background.
Sub-Saharan Africa has been hit heavily by HIV/AIDS, and Zimbabwe in particular has been very badly affected, with over one-fifth of its adult population infected with HIV. However, this proportion has been declining slowly in recent years, and the same trend has also been seen in a few other African countries. It is not clear whether these trends are related to changes in the way people behave, perhaps as a result of public health and prevention campaigns, or rather are due to changes in the natural spread of the HIV epidemic. However, there is considerable uncertainty about how we should carry out campaigns that try to get people to change their behavior. One possible approach for achieving behavior change involves peer education: that is, education carried out within the community, by at-risk community members themselves. Another approach involves tying together a set of related programs that deliver information and education through health clinics and directly in the community. Such programs are termed “integrated community and clinic-based HIV prevention.”
Why Was This Study Done?
The researchers wanted to find out whether providing integrated community and clinic-based strategies for HIV prevention in Eastern Zimbabwe could reduce the proportion of people within the community infected with HIV. If successful, then the strategies could be effective elsewhere, for example in other African countries where behavior patterns and the HIV epidemic are similar to the situation studied here.
What Did the Researchers Do and Find?
The research was done as a cluster-randomized trial. This means that different communities were assigned by chance to one of two trial arms, either an “intervention arm”, where the community and clinic-based strategies would be delivered, or a “control” arm which would not have additional services. Six pairs of communities in Eastern Zimbabwe were compared, each of which had its own health center. Control communities received the standard government services for preventing HIV. The other communities received a package of various additional strategies. These included education and condom distribution amongst sex workers and their clients; better services at sexually transmitted infection (STI) clinics (STIs can increase the risk of HIV infection); and educational HIV/AIDS open days at health centers. The researchers planned to compare, between the two arms, the number of people who became infected with HIV over the course of the trial. They found that there was no statistical difference in the number of people in the intervention arm who became infected with HIV over the course of the trial, as compared to people in the control arm. Men in the intervention communities were more likely to have effective treatment for STIs, but women were more likely to show risky behaviors, such as having sex at a younger age, and having unprotected sex. However, men in the intervention communities were more knowledgeable about HIV/AIDS than men in the control communities. One strategy in the intervention arm (delivery of education and condom distribution among sex workers and their clients) may have been less successful because of the economic situation at the time, which meant that the income-generating projects that were supposed to support this initiative were impossible.
What Do These Findings Mean?
Some of the results from this trial are encouraging, for example an improvement in male participants' knowledge and behavior. However, overall, the intervention did not have an impact on the HIV infection rate in the community. Some other trials have also shown similar results. These results mean that other strategies need to be developed, and tested, which will encourage people to change their behavior patterns and reduce the risk of getting HIV. However, trials such as this are very difficult to design, carry out, and interpret. In particular, if a complex intervention such as this fails, it is often hard to tell whether it did so because the intervention was not delivered successfully, or because it did not work.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040102.
Information from Avert, an international HIV/AIDS charity, on HIV and AIDS in Zimbabwe
Information from UNAIDS, the United Nations Programme on HIV/AIDS, on strategies for HIV prevention
HIV/AIDS minisite from the World Health Organization
The Web site of the Manicaland HIV/STD Prevention Project discusses this project
doi:10.1371/journal.pmed.0040102
PMCID: PMC1831737  PMID: 17388666
9.  STI prevention and the male sex industry in London: evaluating a pilot peer education programme 
Sexually Transmitted Infections  2000;76(6):447-453.
Objective: To evaluate the effectiveness of a pilot peer education STI prevention programme with male sex workers.
Design: A process and outcome evaluation of the pilot programme undertaken in three London male escort agencies, using a quasi-experimental design.
Subjects: Workers in three London escort agencies, including 88 who completed a questionnaire, five peer educators, and a further 16 men (including management) working in two of these agencies.
Methods: A peer education STI prevention programme run by the Working Men Project (WMP), a specialist sexual health service for male sex workers, was piloted in two London escort agencies. Five male sex workers participated in a 2 day peer education training programme. They then returned to their respective agencies to disseminate information and condoms, in an attempt to influence norms of behaviour.
An outcome evaluation aimed to assess changes in STI related knowledge, high risk sexual behaviour, and attendance at a sexual health service. A pre-intervention questionnaire assessing variables such as STI related knowledge, sexual behaviour, and demographic information was administered in both agency A and agency B and a third agency, C, which acted as a control. Ten weeks after the peer educators returned to their agencies, the same questionnaire was administered in the same agencies. Peer educator referrals to the WMP were also recorded over this time period. The process evaluation involved interviews and focus groups with peer educators, and the completion of diaries about their experiences in the role. A further 16 men working in the agencies (including managers and an owner) were interviewed about their experience of the programme. Participant observation was also undertaken through regular outreach work to the agencies.
Results: 57 men completed the questionnaire at time 1 and 44 at time 2. Unfortunately, only 13 of these were matched, precluding any meaningful analysis of change in STI related knowledge and sexual behaviour. The questionnaire provided a profile of the men working in the agencies. Of the 88 men who completed the questionnaire at least once, the majority were homosexual, and in their late teens/early 20s. Most were of a "white" ethnic group, though there was some range within these categories. Most preferred to speak English and education levels were high. Relative STI knowledge revealed a high understanding of HIV and hepatitis B, moderate understanding of gonorrhoea, syphilis, genital warts and herpes, and little knowledge of non-specific urethritis (NSU) or chlamydia. Sexual behaviour suggested a highly sexually active population with both male and female paying and non-paying partners. Condom use was highest for paying partners, particularly for anal sex. Condom use for oral sex with all partners was less consistent, and condom use for all types of sex with regular partners was lower than with other partners. The small number of men engaging in vaginal sex with paying and regular partners were less likely to use condoms. 26 new patients registered at the WMP as a result of peer educator referrals, representing 65% of all new contacts over the study period. The process evaluation revealed that while the training programme was considered adequate and while peer educators felt the programme and their roles to be a success, their experience of the role was difficult. The role of management support was crucial in supporting the programme. The assumption that "peers" are particularly effective educators was not borne out by the results. While peers were considered suitable to discuss some aspects of the industry, many preferred to consult "professionals" about health related matters. The concept of "peers" was problematic with most of the men drawing "peers" from subgroups within the agencies. Other constraints on behaviour such as a lack of power, particularly with regard to a lack of management support, or poverty, had a substantial impact on behaviour which were not influenced by the peer educators.
Conclusions: The study illustrated the difficulties of utilising quasi-experimental evaluation methodology with this client group. It also demonstrated the limitations of peer education based on information provision health education models which focus on individual behaviour change. Suggestions are given for future interventions.
Key Words: male sex workers; peer education; evaluation
doi:10.1136/sti.76.6.447
PMCID: PMC1744253  PMID: 11221127
10.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
Background
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Conclusions
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001037.
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
doi:10.1371/journal.pmed.1001037
PMCID: PMC3101205  PMID: 21629685
11.  Drug education in victorian schools (DEVS): the study protocol for a harm reduction focused school drug education trial 
BMC Public Health  2012;12:112.
Background
This study seeks to extend earlier Australian school drug education research by developing and measuring the effectiveness of a comprehensive, evidence-based, harm reduction focused school drug education program for junior secondary students aged 13 to 15 years. The intervention draws on the recent literature as to the common elements in effective school curriculum. It seeks to incorporate the social influence of parents through home activities. It also emphasises the use of appropriate pedagogy in the delivery of classroom lessons.
Methods/Design
A cluster randomised school drug education trial will be conducted with 1746 junior high school students in 21 Victorian secondary schools over a period of three years. Both the schools and students have actively consented to participate in the study. The education program comprises ten lessons in year eight (13-14 year olds) and eight in year nine (14-15 year olds) that address issues around the use of alcohol, tobacco, cannabis and other illicit drugs. Control students will receive the drug education normally provided in their schools. Students will be tested at baseline, at the end of each intervention year and also at the end of year ten. A self completion questionnaire will be used to collect information on knowledge, patterns and context of use, attitudes and harms experienced in relation to alcohol, tobacco, cannabis and other illicit drug use. Multi-level modelling will be the method of analysis because it can best accommodate hierarchically structured data. All analyses will be conducted on an Intent-to-Treat basis. In addition, focus groups will be conducted with teachers and students in five of the 14 intervention schools, subsequent to delivery of the year eight and nine programs. This will provide qualitative data about the effectiveness of the lessons and the relevance of the materials.
Discussion
The benefits of this drug education study derive both from the knowledge gained by trialling an optimum combination of innovative, harm reduction approaches with a large, student sample, and the resultant product. The research will provide better understanding of what benefits can be achieved by harm reduction education. It will also produce an intervention, dealing with both licit and illicit drug use that has been thoroughly evaluated in terms of its efficacy, and informed by teacher and student feedback. This makes available to schools a comprehensive drug education package with prevention characteristics and useability that are well understood.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000079842
doi:10.1186/1471-2458-12-112
PMCID: PMC3305421  PMID: 22321131
Prevention; Drug education; Harm reduction; Schools; Students
12.  Behavioural intervention trials for HIV/STD prevention in schools: are they feasible? 
Sexually Transmitted Infections  1998;74(6):405-408.
OBJECTIVE: To assess the feasibility of conducting a large randomised controlled trial (RCT) of peer led intervention in schools to reduce the risk of HIV/STD and promote sexual health. METHODS: Four secondary schools in Greater London were randomly assigned to receive peer led intervention (two experimental schools) or to act as control schools. In the experimental schools, trained volunteers aged 16-17 years (year 12) delivered the peer led intervention to 13-14 year old pupils (year 9). In the control schools, year 9 pupils received the usual teacher led sex education. Questionnaire data collected from year 9 pupils at baseline included views on the quality of sex education/intervention received, and knowledge and attitudes about HIV/AIDS and other sexual matters. Focus groups were also conducted with peer educators and year 9 pupils. Data on the process of delivering sex education/intervention and on attitudes to the RCT were collected for each of the schools. Analysis focused on the acceptability of a randomised trial to schools, parents, and pupils. RESULTS: Nearly 500 parents were informed about the research and invited to examine the study questionnaire; only nine raised questions and only one pupil was withdrawn from the study. Questionnaire completion rates were around 90% in all schools. At baseline, the majority of year 9 pupils wanted more information about a wide range of sexual matters. Focus group work indicated considerable enthusiasm for peer led education, among peer educators and year 9 pupils. Class discipline was the most frequently noted problem with the delivery of the peer led intervention. CONCLUSION: Evaluation of a peer led behavioural intervention through an RCT can be acceptable to schools, pupils, and parents and is feasible in practice. In general, pupils who received the peer led intervention responded more positively than those in control schools. A large RCT of the long term (5-7 year) effects of this novel intervention on sexual health outcomes is now under way. 



PMCID: PMC1758164  PMID: 10195048
13.  Integrated medical school ultrasound: development of an ultrasound vertical curriculum 
Background
Physician-performed focused ultrasonography is a rapidly growing field with numerous clinical applications. Focused ultrasound is a clinically useful tool with relevant applications across most specialties. Ultrasound technology has outpaced the education, necessitating an early introduction to the technology within the medical education system. There are many challenges to integrating ultrasound into medical education including identifying appropriately trained faculty, access to adequate resources, and appropriate integration into existing medical education curricula. As focused ultrasonography increasingly penetrates academic and community practices, access to ultrasound equipment and trained faculty is improving. However, there has remained the major challenge of determining at which level is integrating ultrasound training within the medical training paradigm most appropriate.
Methods
The Ohio State University College of Medicine has developed a novel vertical curriculum for focused ultrasonography which is concordant with the 4-year medical school curriculum. Given current evidenced-based practices, a curriculum was developed which provides medical students an exposure in focused ultrasonography. The curriculum utilizes focused ultrasonography as a teaching aid for students to gain a more thorough understanding of basic and clinical science within the medical school curriculum. The objectives of the course are to develop student understanding in indications for use, acquisition of images, interpretation of an ultrasound examination, and appropriate decision-making of ultrasound findings.
Results
Preliminary data indicate that a vertical ultrasound curriculum is a feasible and effective means of teaching focused ultrasonography. The foreseeable limitations include faculty skill level and training, initial cost of equipment, and incorporating additional information into an already saturated medical school curriculum.
Conclusions
Focused ultrasonography is an evolving concept in medicine. It has been shown to improve education and patient care. The indications for and implementation of focused ultrasound is rapidly expanding in all levels of medicine. The ideal method for teaching ultrasound has yet to be established. The vertical curriculum in ultrasound at The Ohio State University College of Medicine is a novel evidenced-based training regimen at the medical school level which integrates ultrasound training into medical education and serves as a model for future integrated ultrasound curricula.
doi:10.1186/2036-7902-5-6
PMCID: PMC3701608  PMID: 23819896
Curriculum; Focused ultrasound; Medical education; Ultrasonography; Undergraduate medical education
14.  An international survey of medical ethics curricula in Asia. 
Journal of Medical Ethics  1999;25(6):514-521.
SETTING: Medical ethics education has become common, and the integrated ethics curriculum has been recommended in Western countries. It should be questioned whether there is one, universal method of teaching ethics applicable worldwide to medical schools, especially those in non-Western developing countries. OBJECTIVE: To characterise the medical ethics curricula at Asian medical schools. DESIGN: Mailed survey of 206 medical schools in China, Hong Kong, Taiwan, Korea, Mongolia, Philippines, Thailand, Malaysia, Singapore, Indonesia, Sri Lanka, Australia and New Zealand. PARTICIPANTS: A total of 100 medical schools responded, a response rate of 49%, ranging from 23%-100% by country. MAIN OUTCOME MEASURES: The degree of integration of the ethics programme into the formal medical curriculum was measured by lecture time; whether compulsory or elective; whether separate courses or unit of other courses; number of courses; schedule; total length, and diversity of teachers' specialties. RESULTS: A total of 89 medical schools (89%) reported offering some courses in which ethical topics were taught. Separate medical ethics courses were mostly offered in all countries, and the structure of vertical integration was divided into four patterns. Most deans reported that physicians' obligations and patients' rights were the most important topics for their students. However, the evaluation was diverse for more concrete topics. CONCLUSION: Offering formal medical ethics education is a widespread feature of medical curricula throughout the study area. However, the kinds of programmes, especially with regard to integration into clinical teaching, were greatly diverse.
PMCID: PMC479305  PMID: 10635508
15.  THE VAXED PROJECT: An Assessment of Immunization Education in Canadian Health Professional Programs 
BMC Medical Education  2010;10:86.
Background
Knowledge & attitudes of healthcare providers (HCP) have significant impact on frequency with which vaccines are offered & accepted but many HCP are ill equipped to make informed recommendations about vaccine merits & risks. We performed an assessment of the educational needs of trainees regarding immunization and used the information thus ascertained to develop multi-faceted, evaluable, educational tools which can be integrated into formal education curricula.
Methods
(i) A questionnaire was sent to all Canadian nursing, medical & pharmacy schools to assess immunization-related curriculum content (ii) A 77-item web-based, validated questionnaire was emailed to final-year students in medicine, nursing, & pharmacy at two universities in Nova Scotia, Canada to assess knowledge, attitudes, & behaviors reflecting current immunization curriculum.
Results
The curriculum review yielded responses from 18%, 48%, & 56% of medical, nursing, & pharmacy schools, respectively. Time spent on immunization content varied substantially between & within disciplines from <1 to >50 hrs. Most schools reported some content regarding vaccine preventable diseases, immunization practice & clinical skills but there was considerable variability and fewer schools had learning objectives or formal evaluation in these areas. 74% of respondents didn't feel comfortable discussing vaccine side effects with parents/patients & only 21% felt they received adequate teaching regarding immunization during training.
Conclusions
Important gaps were identified in the knowledge of graduating nursing, medical, & pharmacy trainees regarding vaccine indications/contraindications, adverse events & safety. The national curriculum review revealed wide variability in immunization curriculum content & evaluation. There is clearly a need for educators to assess current curricula and adapt existing educational resources such as the Immunization Competencies for Health Professionals in Canada.
doi:10.1186/1472-6920-10-86
PMCID: PMC3002370  PMID: 21110845
16.  Attitudes and perceptions of Australian pharmacy students towards Complementary and Alternative Medicine – a pilot study 
Background
With the increased usage of CAM worldwide comes the demand for its integration into health professional education. However, the incorporation of CAM into health professional curricula is handled quite differently by different institutions and countries. Furthermore, the evaluation of CAM curricula is complicated because students' ability to learn about CAM may be influenced by factors such as student's prior knowledge and motivation, together with the perceptions and attitudes of clinical preceptors.
The study aimed to describe the attitudes, perceptions and beliefs of second, third and fourth year pharmacy students towards complementary and alternative medicine (CAM) and to explore factors that might affect attitudes such as learning, preceptors and placements.
Methods
Pharmacy students from a University in South East Queensland, Australia participated in the study. The study consisted of a cross-sectional survey (n = 110) and semi-structured interviews (n = 9).
Results
The overall response rate for the survey was 75%, namely 50% (36/72) for second year, 77.3% (34/44) for third year and 97.6% (40/41) for fourth year students. Overall, 95.5% of pharmacy students believe that pharmacists should be able to advise patients about CAM and most (93.7%) have used CAM prior to course enrolment. Students' attitudes to CAM are influenced by the use of CAM by family, friends and self, CAM training, lecturers and to a lesser degree by preceptors. The majority of pharmacy students (89.2%) perceive education about CAM as a core and integral part of their professional degree and favour it over an additional postgraduate degree. However, they see a greater need for education in complementary medicines (such as herbal medicines, vitamins and minerals) than for education in complementary therapies (such as acupuncture, meditation and bio-magnetism). Knowledge and educational input rationalised rather than marginalised students' attitudes towards CAM.
Conclusion
Pharmacy students perceive education about CAM as a core and integral part of their professional degree. Students' attitudes towards CAM can be influenced by learning, lecturers, preceptors and practice experience. The content and focus of CAM education has to be further investigated and tailored to meet the professional needs of our future health professionals.
doi:10.1186/1472-6882-8-2
PMCID: PMC2267156  PMID: 18221569
17.  A Controlled Pre-Post Evaluation of a Computer-based HIV/AIDS Education on Students’ Sexual Behaviors, Knowledge and Attitudes 
Online Journal of Public Health Informatics  2012;4(1):ojphi.v4i1.4017.
Unlike traditional approaches to sexuality and HIV education which can be constrained by the sensitive nature of the subject, Information Technology (IT) can be an innovative teaching tool that can be used to educate people about HIV. This is especially relevant to interventions targeting young people; the population group fond of using IT, and the same group that is more vulnerable to HIV/AIDS. Yet, there are significantly few empirical studies that rigorously evaluated computer-assisted school-based HIV/AIDS interventions in developing countries. The modest studies conducted in this area have largely been conducted in developed countries, leaving little known about the effectiveness of such interventions in low resource settings, which moreover host the majority of HIV/AIDS infections.
This research addresses this gap by conducting a controlled pre-post intervention evaluation of the impacts of the World Starts With Me (WSWM), a computer-assisted HIV/AIDS intervention implemented in schools in Uganda. The research question was: did the WSWM intervention significantly influence students’ sexual behaviors, HIV/AIDS knowledge, attitudes and self-efficacy? To address this question, questionnaires were simultaneously administering to 146 students in an intervention group (the group receiving the WSWM intervention) and 146 students in a comparison group (the group who did not receive the WSWM intervention), before (February 2009) and after the intervention (December 2009).
Findings indicate that the intervention significantly improved students’ HIV/AIDS knowledge, attitudes self-efficacy, sex abstinence and fidelity, but had no significant impact on condom use. The major reason for non-use of condoms was lack of knowledge about condom use which can be attributed to teachers’ failure and inabilities to demonstrate condom use in class. To address this challenge, intervention teachers should be continuously trained in skills-based and interactive sexuality education. This training will equip them with self-confidence and interactive teaching skills, including tactics for emphasizing building students’ skills through role plays and interactive assignments. In addition, the HIV interventions themselves should include interactive virtual condom use demonstrations that can be accessed by students themselves.
doi:10.5210/ojphi.v4i1.4017
PMCID: PMC3615807  PMID: 23569630
ICT for HIV/AIDS; WSWM; sexual behaviors, knowledge and attitudes; school
18.  Attitudes and perceptions of medical students about family medicine in Spain: protocol for a cross-sectional survey 
BMJ Open  2011;1(2):e000231.
Background
Despite the fact that family medicine (FM) has become established as a specialty in the past 25 years, this has not been reflected in the inclusion of the specialty in the majority of medical schools in Spain. Almost 40% of the students will work in primary care but, in spite of this, most universities do not have an assessed placement as such. There are only specific practice periods in health centres or some student-selected components with little weight in the overall curricula.
Objectives
To evaluate the attitudes and perceptions of medical students about FM in the health system and their perception about the need for specific training in FM at the undergraduate level. To explore change over time of these attitudes and perceptions and to examine potential predictive factors for change. Finally, we will review what teaching activity in FM is offered across the Spanish schools of medicine.
Methods
Descriptive cross-sectional survey. Each one of the different analyses will consist of two surveys: one for all the students in the first, third and fifth year of medical school in all the Spanish schools of medicine asking about their knowledge, perceptions and attitudes in relation to primary care and FM. There will be an additional survey for the coordinating faculty of the study in each university about the educational activities related to FM that are carried out in their centres. The repetition of the study every 2 years will allow for an analysis of the evolution of the cohort of students until they receive their degree and the potential predictive factors.
Discussion
This study will provide useful information for strategic planning decisions, content and educational methodology in medical schools in Spain and elsewhere. It will also help to evaluate the influence of the ongoing changes in FM, locally and at the European level, on the attitudes and perceptions of the students towards FM in Spain.
Article summary
Article focus
There is a need to explore further the reasons for which students choose a specific specialty for training and future practice. This protocol outlines the design of a cross-sectional survey to evaluate attitudes and perceptions of medical students about family medicine.
The project will assess the potential impact of medical school teaching on the final profiles of students, both in perceptions and expectations and in the choice of specialty.
Key messages
This is a protocol of a multicentre survey that will take place in Spanish medical schools. The study includes a survey for students and one for the coordinators of family medicine in each centre.
The repetition of the student survey every 2 years will allow for an analysis of the evolution of student cohorts until the end of their studies.
The results of this study will provide valuable information for curriculum development related to family medicine in the different schools of medicine and will help to prioritise those activities that are likely to be most effective for promoting this specialty.
Strengths and limitations of this study
The research team for this study includes coordinating faculty from 22 of the 27 universities throughout Spain. The study will be repeated every 2 years and will explore change over time of the issues addressed.
The principal limitations of this study are related to its design, of observational nature. The results observed will serve as hypotheses generating and cannot be regarded as definitive. Finally, the fact that the survey will be anonymous will impede the evaluation, at an individual level, of change over time.
doi:10.1136/bmjopen-2011-000231
PMCID: PMC3278481  PMID: 22189348
19.  Mental health first aid training for high school teachers: a cluster randomized trial 
BMC Psychiatry  2010;10:51.
Background
Mental disorders often have their first onset during adolescence. For this reason, high school teachers are in a good position to provide initial assistance to students who are developing mental health problems. To improve the skills of teachers in this area, a Mental Health First Aid training course was modified to be suitable for high school teachers and evaluated in a cluster randomized trial.
Methods
The trial was carried out with teachers in South Australian high schools. Teachers at 7 schools received training and those at another 7 were wait-listed for future training. The effects of the training on teachers were evaluated using questionnaires pre- and post-training and at 6 months follow-up. The questionnaires assessed mental health knowledge, stigmatizing attitudes, confidence in providing help to others, help actually provided, school policy and procedures, and teacher mental health. The indirect effects on students were evaluated using questionnaires at pre-training and at follow-up which assessed any mental health help and information received from school staff, and also the mental health of the student.
Results
The training increased teachers' knowledge, changed beliefs about treatment to be more like those of mental health professionals, reduced some aspects of stigma, and increased confidence in providing help to students and colleagues. There was an indirect effect on students, who reported receiving more mental health information from school staff. Most of the changes found were sustained 6 months after training. However, no effects were found on teachers' individual support towards students with mental health problems or on student mental health.
Conclusions
Mental Health First Aid training has positive effects on teachers' mental health knowledge, attitudes, confidence and some aspects of their behaviour.
Trial registration
ACTRN12608000561381
doi:10.1186/1471-244X-10-51
PMCID: PMC2908569  PMID: 20576158
20.  International partnerships in telehealth: healthcare, industry and education 
Project background
In 2010 an internationally renowned American healthcare organisation partnered with Irish industry and higher education in Waterford with the goal to expand their telehealth services. Combining the skills and expertise of Nurse Consultants, Nurse Educators, IT Specialists and Healthcare Executives, these collaborative partnerships led to the delivery of telehealth services to North America from an Irish base, and to the development of new European telehealth programmes and telehealth training in Ireland. The telehealth service includes the provision of telephone triage, health information and advice, disease management and hospital discharge programmes to clients in Ireland, the UK and the USA. Telehealth nursing is an evolving specialty that requires the development of competence in key areas of information and communication technologies, assessment, triage and critical thinking in clinical decision-making within an environment where distance separates the nurse from the client.
Aims and objectives
The aim of this paper is to report on the development, implementation and evaluation of the telehealth service with a focus on the telephone triage and advice service and the hospital discharge programmes. Objectives of this paper include describing this telehealth initiative with reference to the changing nature of global healthcare provision; discuss the educational strategy and accredited programme for training competent telehealth nurses; report the results of the evaluation of nurse performance in telephone triage and present the data relating to the impact of hospital discharge programmes on patient satisfaction and readmission rates.
Methods and results
The evaluation of the telehealth training programme was undertaken six months post initial training and service commencement. One hundred triage and health information calls were reviewed, against best practice standards and programme learning outcomes, during a four-month period. Quantitative and qualitative data that demonstrates evidence of learning transfer from training to practice and the development of nurse competence from advanced beginner to levels of proficiency will be presented. The hospital discharge programmes have undergone continuous monitoring and reporting since commencement. This has enabled the collection of evidence that supports this brief telephone intervention as a method of reducing hopsital re-admissions and increasing patient satisfcation. Quantitative results will be presented and analysed in relation to the impact on patient satisfaction and readmission rates for patients discharged from cardiovascular, renal and digestive disease services.
Conclusions
This project has demonstrated the effectiveness of partnerships in healthcare, industry and education in achieving the development, implementation and evaluation of international telehealth services. Initial education, training and ongoing support and development of nurses is essential for quality telehealth provision. Weekly call review, constructive feedback and reflection on practice are effective strategies for performance assurance and improvement. As a growing element of integrated healthcare, telehealth modules should be included in pre and post-registration nursing education curricula. Further collaboration between industry, healthcare and education are necessary in moving the telehealth agenda forward for the benefit of integrating services that impact positively on service users.
PMCID: PMC3571125
telephone triage; hospital discharge programmes; partnerships
21.  Students teaching AIDS to students: addressing AIDS in the adolescent population. 
Public Health Reports  1989;104(1):75-79.
Adolescents are at high risk for developing acquired immunodeficiency syndrome (AIDS) because of their sexual curiosity and exploration, drug experimentation, and lack of knowledge. At present, the only way to reduce this risk is through education. In an effort to increase AIDS education among adolescents, a program called Students Teaching AIDS to Students (STATS) is proposed. The goal of this project is to help train medical students to become AIDS educators in the schools, churches, and youth organizations of their local communities. The project involves preparation and distribution of a package of materials which can be used by medical students to initiate a STATS program. The package consists of a manual which explains the essentials of starting a youth health education project, suggests how to gain approval for the project within the community, and contains curriculums with basic AIDS information and exercises. The curriculum material is tailored for presentation to students over two school-class periods on separate days and contains age-appropriate information. Another component of the package is the slide show tailored to explain STATS to school boards, parent groups, and the leaders of other youth organizations. A video tape to help answer difficult questions put by students has been selected to be part of the curriculum for school grade levels 7 to 12. These materials are geared to facilitate the start of a successful AIDS education program for adolescents.
PMCID: PMC1580293  PMID: 2493665
22.  Developing a competency-based curriculum in HIV for nursing schools in Haiti 
Background
Preparing health workers to confront the HIV/AIDS epidemic is an urgent challenge in Haiti, where the HIV prevalence rate is 2.2% and approximately 10 100 people are taking antiretroviral treatment. There is a critical shortage of doctors in Haiti, leaving nurses as the primary care providers for much of the population. Haiti's approximately 1000 nurses play a leading role in HIV/AIDS prevention, care and treatment. However, nurses do not receive sufficient training at the pre-service level to carry out this important work.
Methods
To address this issue, the Ministry of Health and Population collaborated with the International Training and Education Center on HIV over a period of 12 months to create a competency-based HIV/AIDS curriculum to be integrated into the 4-year baccalaureate programme of the four national schools of nursing.
Results
Using a review of the international health and education literature on HIV/AIDS competencies and various models of curriculum development, a Haiti-based curriculum committee developed expected HIV/AIDS competencies for graduating nurses and then drafted related learning objectives. The committee then mapped these learning objectives to current courses in the nursing curriculum and created an 'HIV/AIDS Teaching Guide' for faculty on how to integrate and achieve these objectives within their current courses. The curriculum committee also created an 'HIV/AIDS Reference Manual' that detailed the relevant HIV/AIDS content that should be taught for each course.
Conclusion
All nursing students will now need to demonstrate competency in HIV/AIDS-related knowledge, skills and attitudes during periodic assessment with direct observation of the student performing authentic tasks. Faculty will have the responsibility of developing exercises to address the required objectives and creating assessment tools to demonstrate that their graduates have met the objectives. This activity brought different administrators, nurse leaders and faculty from four geographically dispersed nursing schools to collaborate on a shared goal using a process that could be easily replicated to integrate any new topic in a resource-constrained pre-service institution. It is hoped that this experience provided stakeholders with the experience, skills and motivation to strengthen other domains of the pre-service nursing curriculum, improve the synchronization of didactic and practical training and develop standardized, competency-based examinations for nursing licensure in Haiti.
doi:10.1186/1478-4491-6-17
PMCID: PMC2535593  PMID: 18759986
23.  Knowledge, attitudes and practices regarding HIV/AIDS among male high school students in Lao People's Democratic Republic 
Introduction
Inadequate knowledge, negative attitudes and risky practices are major hindrances to preventing the spread of HIV. This study aimed to assess HIV-related knowledge, attitudes and practices (KAPs) of high school students in Lao People's Democratic Republic (PDR).
Methods
A cross-sectional study on unmarried male students aged between 16 and 19 years old was undertaken in 2010 to evaluate their KAPs. We selected 300 eligible grade VII students through systematic random sampling from different high schools in one province of Lao PDR.
Results
The majority of students surveyed were aware that HIV can be transmitted by sexual intercourse (97.7%), from mother to child (88.3%) and through sharing needles or syringes (92.0%). Misconceptions about transmission of HIV were observed among 59.3% to 74.3% of respondents. Positive attitudes towards HIV/AIDS were observed among 55.7% of respondents. Nearly half of the surveyed students (45.3%) said that they would be willing to continue studying in a school with HIV-positive friends, and 124 (41.3%) said they would continue attending a school with HIV-positive teachers. Ninety-four (31.3%) students had a history of sexual intercourse, and 70.2% of these students had used a condom. However, only 43.9% said they used condoms consistently. Students with medium and high levels of knowledge were 4.3 (95% CI=2.1–9.0, P<0.001) and 13.3 (95% CI=6.5–27.4, P<0.001) times more likely to display positive attitudes towards people living with HIV. Similarly, safe practices related to safe sex were also observed among students with medium (OR=2.8, 95% CI=0.9–8.8, P=0.069) and high levels of knowledge (OR=1.9, 95% CI=0.6–6.2, P=0.284). More than three-quarters of students mentioned television and radio as major sources of information on HIV/AIDS.
Conclusions
Despite adequate knowledge about HIV/AIDS among the school students, misconceptions about routes of transmission were found. Negative attitudes to HIV/AIDS and risky practices were also present. Educational programmes with specific interventions are recommended to increase KAPs and to prevent new HIV infections among students in Lao PDR.
doi:10.7448/IAS.16.1.17387
PMCID: PMC3595419  PMID: 23481130
knowledge; attitudes; practices; HIV/AIDS; Lao PDR
24.  The resident-as-teacher educational challenge: a needs assessment survey at the National Autonomous University of Mexico Faculty of Medicine 
BMC Medical Education  2010;10:17.
Background
The role of residents as educators is increasingly recognized, since it impacts residents, interns, medical students and other healthcare professionals. A widespread implementation of resident-as-teacher courses in developed countries' medical schools has occurred, with variable results. There is a dearth of information about this theme in developing countries. The National Autonomous University of Mexico (UNAM) Faculty of Medicine has more than 50% of the residency programs' physician population in Mexico. This report describes a needs assessment survey for a resident as teacher program at our institution.
Methods
A cross-sectional descriptive survey was developed based on a review of the available literature and discussion by an expert multidisciplinary committee. The goal was to identify the residents' attitudes, academic needs and preferred educational strategies regarding resident-as-teacher activities throughout the residency. The survey was piloted and modified accordingly. The paper anonymous survey was sent to 7,685 residents, the total population of medical residents in UNAM programs in the country.
Results
There was a 65.7% return rate (5,186 questionnaires), a broad and representative sample of the student population. The residents felt they had knowledge and were competent in medical education, but the majority felt a need to improve their knowledge and skills in this discipline. Most residents (92.5%) felt that their role as educators of medical students, interns and other residents was important/very important. They estimated that 45.5% of their learning came from other residents. Ninety percent stated that it was necessary to be trained in teaching skills. The themes identified to include in the educational intervention were mostly clinically oriented. The educational strategies in order of preference were interactive lectures with a professor, small groups with a moderator, material available in a website for self-learning, printed material for self-study and homework, and small group web-based learning.
Conclusions
There is a large unmet need to implement educational interventions to improve residents' educational skills in postgraduate educational programs in developing countries. Most perceived needs of residents are practical and clinically oriented, and they prefer traditional educational strategies. Resident as teachers educational interventions need to be designed taking into account local needs and resources.
doi:10.1186/1472-6920-10-17
PMCID: PMC2830225  PMID: 20156365
25.  The introduction of medical humanities in the undergraduate curriculum of Greek medical schools: challenge and necessity 
Hippokratia  2010;14(4):241-243.
Background and Aim: Medical humanities is a multidisciplinary field, consisting of humanities (theory of literature and arts, philosophy, ethics, history and theology), social sciences (anthropology, psychology and sociology) and arts (literature, theater, cinema, music and visual arts), integrated in the undergraduate curriculum of Medical schools. The aim of the present study is to discuss medical humanities and support the necessity of introduction of a medical humanities course in the curriculum of Greek medical schools.
Materials, Methods and Results: Through the relevant Pub-Med search as well as taking into account various curricula of medical schools, it is evident that medical education today is characterized by acquisition of knowledge and skills and development of medical values and attitudes. Clinical observation with the recognition of key data and patterns in the collected information, is crucial in the final medical decision, i.e. in the complex process, through which doctors accumulate data, reach conclusions and decide on therapy. All sciences included in medical humanities are important for the high quality education of future doctors. The practice of Medicine is in large an image-related science. The history of anatomy and art are closely related, already from the Renaissance time. Studies have shown that attendance of courses on art critics improves the observational skills of medical students. Literature is the source of information about the nature and source of human emotions and behavior and of narratives of illness, and increases imagination. Philosophy aids in the development of analytical and synthetical thinking. Teaching of history of medicine develops humility and aids in avoiding the repetition of mistakes of the past, and quite often raises research and therapeutic skepticism. The comprehension of medical ethics and professional deontology guides the patient-doctor relationship, as well as the relations between physicians and their colleagues. The Medical Humanities course, which is already integrated in the undergraduate curriculum of many medical schools of Europe, USA and Australia, includes lectures by experts and students presentations on the above-mentioned areas and could be offered, for a semester, during the first years.
Conclusion: The aim of Medical Humanities course is the development of imagination and interpretation of data through analytical complex procedures, the development of skills of close observation and careful interpretation of the patient "language" and the enhancement of empathy for the patients, as well as the development of the physician-patient relationship and finally the conceptualization/construction of personal and professional values.
PMCID: PMC3031316  PMID: 21311630
medical humanities; Greece; medical school; review

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