Portfolio based approach for teaching Community Medicine among medical undergraduates and assessment of their learning in a medical college in rural India

Objective: The study was undertaken to explore what and how first year medical undergraduates could learn about Community Medicine using a portfolio-based learning approach during the period of Social Service Camp in the village Pulai. Methods: Study participants were 65 first year medical undergraduates participating in Social Service Camp in the village Pulai, during 10 24 October 2008. The first step was to set Specific, Measurable, Actionable, Realistic and Time bound (SMART) learning goals focused on Community Medicine. These learning goals were to be achieved during the fifteen days and within the existing curriculum, using existing resources and opportunities. The portfolio based records of students who accomplished their learning objectives were subjected to qualitative content analysis. Results: Of 65 students, 41 (63.1%) completed and reflected on their portfolios. Methods adopted for learning were; interaction with community based groups (48.8%), interaction with allotted family members (43.9%), lectures series, role plays and demonstrations (36.6%), interactions with village level healthcare providers (31.7%) and journal exercises (26.8%). The portfolio based exercises were useful to 30 (46.2%) students to understand the social, economic and health problems of the villagers and their life style. Twenty four (36.9%) students said that it improved their communication skills. This exercise helped 11 (16.9%) students to explore weaknesses such as poor communication skills, poor knowledge of local language, inability to adjust in new environment. Conclusion: The Social Service Camp in the village Pulai offered opportunities for portfolio based leaning to medical undergraduates. The students learned about the major topics of primary health care through self-directed learning.


Introduction
Innovations in current educational research have shifted education from being a traditional teacher-centered process to one that is student-centered.
1 Dr Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, India.
Corresponding Author: P.R. Deshmukh, Professor Dr Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram, India, Pin -442102 Phone: 91-7152-284617 Fax: 91-7152-284730 Email: prdeshmukh@gmail.comprdeshmukh@yahoo.comParboosingh (1996) has pointed out that the role of today's teacher is not so much to impart knowledge, but to ensure that learning has taken place.Since Portfolios offer the opportunity to assess what students are learning, it is becoming a popular option among educationists.The International Association for Medical Education (AMEE) defines the portfolio as a framework containing evidence of achievement of learning outcomes over time (Davis, 2008).This evidence is supplemented by the portfolio builders' reflections on their learning and can be used to provide feedback to the learner.Despite the increasing popularity of portfolio-based learning, its usage is not widespread, especially among Asian medical schools (Elango et al., 2005).The Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram has been implementing its community-based public health teaching with the aim to build doctors for rural poor by orienting them to the prevalent public health problems in rural areas and empowering them with required social, medical and public health skills.Garg et al. (1996) and Narayanan (2006) have described the community based teaching in Social Service Camp and Re-orientation of Medical Education (ROME) camp for medical undergraduates.MGIMS offers wide scope for self-directed learners to learn from its ongoing community based participatory action research, field based camps for medical undergraduates with integration of public health, para-clinical and clinical disciplines and committed teaching faculty for adequate coaching and assessment (Figure 1).

Study area
The present study was undertaken during the Social Service Camp for medical undergraduates in the village Pulai.It is situated four kilometers away from the Primary Health Centre, Anji and 28 kilometers from the District Place Wardha.The study site is located in a rural area of the eastern Maharashtra state of India.At the time of the study, the population of the village was 946.There was one women's self help group, one Kishori Panchayat (KP, forum of adolescent girls), one Kisan Vikas Manch (KVM, farmers' club) and one Village Co-ordination Committee (VCC, representative committee of SHG, KP, KVM and Gram-Panchayat -local self government).All these community based organizations (CBOs) were formed under a community based project called 'Community Led Initiative for Child Survival' (CLICS) programme (CLICS, 2006).There was one CLICS doot (local female health worker) in village for delivery of maternal and child healthcare.There was one Anganwadi centre, government primary school and Grampanchayat office in the village.

Study participants and duration
The study participants were 65 first year medical undergraduates (38 males) participating in Social Service Camp during 10 to 24 October 2008.These students were selected through the national level competitive entrance examination.

Building portfolios by the students
On the first day, a faculty member gave an introductory lecture to all 65 undergraduates on the expected content and the guidelines for developing a reflective portfolio, its importance as a learning tool, the need to become a self-directed learner and various learning opportunities available in the village.The students were divided into small groups.The facilitator of each group used clear guidelines for portfolio development and offered students practical recommendations to develop portfolios in stepwise manner (Professional portfolio guide, 2008) The first step in portfolio development was to set Specific, Measurable, Actionable, Realistic and Time bound (SMART) learning goals focused on Community Medicine.These learning goals were to be achieved during the fifteen days and within the existing curriculum of the camp, using the existing resources and opportunities.Later, the students were encouraged to plan for learning activities and implement it over the next fifteen days.Students were asked to maintain a daily diary to document and reflect on their planned learning goals, methods adopted to accomplish the goals, outcomes of learning and barriers to the learning process.Every evening the students would self reflect on the daily activities and summarize the findings in their diaries.

Reflections on portfolios and semistructured interviews
On the final day of the stay students were asked to develop a one page portfolio based descriptive report using notes on experiences from their daily diary and self reflections on the learning process.Most of these records were written in English, which is the medium of instruction in medical education.
However, for better self reflection, students' were given freedom to express themselves in the local languages of Marathi or Hindi.A semi-structured interview of each student was undertaken based on the portfolio record to verify the learning goals, methods adopted, accomplishment of learning goals and students' self reflection on portfolio exercise.Students' feedback on various facilitating factors and inhibiting factors in the portfoliobased learning approach and how this leaning woudl help them in future studies was obtained.Any new information obtained during semi-structured interviews with the students was incorporated as a note in their portfolio based records.

Analysis of data
The portfolio based records of students who accomplished their learning objectives were subjected to qualitative content analysis to explore what and how students accomplished their leanings (Lofland et al., 1995).For the better understanding and planning of analysis, the descriptive data of portfolio records were read word by word and any clarification or additional information if required was obtained from the concerned student.
A code list was prepared for the manual coding of textual data.The units of analysis were words and statements under a given coding category.The coding of data was done until saturation point to avoid any loss of qualitative information.The data was classified according to a simple non-hierarchical typology of various categories i.e. public health subjects covered by the portfolios, leaning objectives, methods adopted and ultimately the student's learning as outcomes.
The data on various facilitating factors and inhibiting factors in the portfolio-based learning approach and how this learning was going to help them in the future was presented as simple frequency tables.To increase the validity of results, two faculty members of Community Medicine subject, who had more than five years of experience of using qualitative research methods, undertook the analysis of data.

Results
Out of 65 students, 41 (63.1%) completed and reflected on their portfolios.The methods adopted for learning were interaction with members of community based groups (48.8%), and interaction with allotted family members (43.9%), lectures series, role plays and demonstrations (36.6%), interactions with village level healthcare providers (31.7%) and journal exercises (26.8%).Among the 24 (36.9%)students who could not complete their portfolios, 12 (50%) students could not complete it due to the short time period given, 8 (33%) students had deviated from their learning objective and could yield no meaningful learning and 4 (17%) could not follow the concept of portfolio.
The broad themes that emerged from these portfolio reports were personal hygiene (5 students), nutrition (8 students), environment and sanitation (7 students), healthcare delivery and community participation (5 students), addiction (4 students), communication skills and behaviour change communication (8 students), school health (3 students) and old age care (1 student).Table 1 gives information on objectives, methods adopted for learning and lessons learned by the students.
The analysis of students' feedback explored some positive and negative responses.Allotment of families in the village and interaction with them was useful for learning to 59 (90.7%) students.Fifty (76.9%) students felt that interactive lectures, demonstrations and role plays in the camp curriculum were helpful to their portfolio exercise.Interaction with the members of community based groups and other villagers was a positive factor for 26 (40%) students.According to one third students, staying in village setting (30.8%) and the session on communication skills (29.2%) helped their field based portfolio exercises.Five (7.7%) students took help of their friends from the local geographical area for communicating in local language.
Among negative responses, 21 students (32.3%) had problems in communication in the local village language.High expectations of villagers from the services offered during the camp acted as a barrier to 8 (12.3%) students.Seven (10.8%) students felt that the duration of camp was short for portfolio exercise.Seven (10.8%) students said that the villagers were busy and not available during their home visits.Five (7.7%) students had a problem of poor co-operation from the villagers at the time of interview.Two students felt that the process of learning through portfolio based exercise was slow (Table 2).Among the purposes of the portfolio based learning is to encourage self-directed learning and explore the weaknesses of the students during a reflective process.In the present study, the portfolio based exercise helped most students understand rural health problems, improve their communication skills and explore their weaknesses.Although very few students accepted that it would help them to become a self-directed learner, the results of the present study were encouraging, as it was carried out in the existing teaching curriculum which relies heavily on records based teaching exercises.Students could actively assess their learning needs and utilize the opportunities available to fulfill the objectives of their portfolios.Sahu et al. (2008) found that the students' involvement in framing objectives, developing a mechanism of selfreflection and self-assessment in portfolio based learning can significantly improve the learning of the students.

Table 1: Status of portfolio based learning among medical undergraduates
The portfolio-based learning covered some major topics of public health such as personal hygiene, nutrition, environment and sanitation, health care delivery and community participation, addiction, communication skills and behavior change communication, school health and old age care.These topics are of public health concern in developing countries and understanding is required for ensuring primary healthcare.The students perceived benefits from portfolio based exercises which could be useful to their future course of learning.The limitations of the present study should be kept in mind.It was a small scale study done on pilot basis in short fifteen days duration of camp period.Its feasibility should be tested in the existing curriculum of a longer duration.

Conclusions
The Social Service Camp in village Pulai offered opportunities for portfolio based leaning to medical undergraduates.The students were able to learn about the major topics of primary health care through selfdirected learning.