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Medical Education 1992, 26, 38W01
Problem-based learning in distance! education: a first exploration in continuing medical education
C. E. ENGEL, E. B R O W N E t , P. N Y A R A N G O S , S . AKORS, A. KHWAJA., A. A KARIM. & A. TOWLET
Centre for Higher Education Studies, Institute of Education, University of London, tDepartment of Community Health, School of Medical Science, University of Scicwce and Technology, Kumasi, Ghana, $Department of Surgery, Medical School, Moi University, Eldor~t, Kenya, §Regional Health Office, Ministry ofHealth, Sunyani, Brong-Ahafo, Ghana and .Aga Khan Health Service, Karachi-5, Pakistan
Summary. The Wellcome Tropical Institute has assisted countries in the tropics to establish viable systems of continuing medical education, par- ticularly for young doctors practising in rural areas. As part of this strategy the Institute has developed material for use in distance learning. The first attempt to apply the problem-based learning approach to written material for use by an individual learner in the absence of a tutor led to a trial in Ghana, Kenya and Pakistan to compare a conventionally designed module with a problem-based learning module on the same topic for their respective acceptability, effectiveness and efficiency. The design, implementation and results of these three com- parative trials are presented.
Key words: *education, medical, continuing; teaching/*methods; *problem-solving; moti- vation; teaching material; learning; tropical medicindeduc
Introduction
A major aim of the Wellcome Tropical Institute has been the development ofeducationally viable systems of continuing medical education (CME) in tropical countries. Particular attention was focused on support for recently qualified medical
IPresent address: King’s Fund Centre, London NWl.
Correspondence: C. E. Engel, Centre for Higher Education Studies, Institute of Education, University of London, London W C l H ONT, UK.
graduates who serve in rural hospitals. In many instances these practitioners face professional isolatioa, mainly due to difficulties of transport and limited telephone facilities. Yet frequent attendance at courses, conferences or workshops is not practicable. Their absence would seriously affect local medical care and place an additional burden on very limited financial resources and manpower. Distance learning was, therefore, explored as a method that would enable these practitioners to continue their education at their hospital or at home.
The aim of C M E tends to concentrate on the acquisition of further knowledge as a means towards the maintenance and, possibly, the improvement of quality of health care. The Wellcorne Tropical Institute enlarged this aim to include the maintenance of j o b satisfaction through, offering intellectual stimulation, reduc- ing professional isolation, and continuing per- sonal development.
A number of factors combine to make this extended aim less than easy to accomplish. These doctors work under difficult conditions, fre- quently under considerable pressure and without extrinsic: incentives to devote time and effort to further study. Unreliability and cost of technolo- gical facilities counsel against undue reliance on television or radio broadcasting, telephone con- ferences or video- and audiotapes. The challenge was therefore to support intrinsic motivation through the medium that is simplest to use but unfortunately least personal and farthest removed from real life - the printed word
389
conibincd with two-dimensional images. This challenge, coupled with the wish to satisfy the rcquircmcnts of cffcctivc learning, led to the dcvclopment o f distance learning modules that incorporate the problem-based learning approach (Barrows &- Tamblyn 1980). Problem- based learning (PBL) provides learners with an opportunity to apply their existing knowledge, understanding and experience to the manage- ment of an unfamiliar situation, such as the problem presented by a patient. As learners attempt to deal with the problem they arc encouraged to consider what further knowledge and understanding are required to progress with the management o f the problem, to seek out the nccessary information, and to apply it to the problem. The 1’BL approach should ensure that learning is relevant to the interests and needs o f learners, that new learning is built on existing knowledge and understanding, that learning takes place in the context in which it is t o be applied in daily practice, that learners can identify their o w n personal needs for further study, and that they can practise the application o f new learning to realistic problems (Engel 1991).
An important additional component o f PBL is th.at learners should receive rapid confirmation o f the accuracy and adequacy of their learning. Whcn PBL is based on small-group tutorial scssions, peers and tutor can provide such feed- back. However, when practitioners have to study entirely on their o w n , feedback has to be provided as part o f the printed module but cannot accommodate thc infinitely variable responses o f different learners.
The comparative trial
This first at tempt to apply 1’BL to distance learning with printed texts raised three ques- tions. First, h o w acceptable would this approach be for graduates with little time and incentive for further study and for graduates w h o were taught rather than helped to learn at school and uni- versity? Second, h o w eflectiue would this approach be i n helping learners to master the educational objectives o f a distance learning prograninic or module? Third, even if the module proved to be acceptable and effective, h o w <fficient would it be - h o w realistic and worth-while would the expenditure of time,
energy and actual cost bc on the pArt o f t h e user and the provider of the module?
Distaticc Ieavrriry tnaterials to he cotnpnrrd
Two modules were compared with each other in Ghana, Kenya and Pakistan. Particularly in Africa thc authors had gained considerable experience in the organization o f distance learn- ing for CME. The modules shared the same topic (Obstructed labour), as well as identical objectives and content, but they differed in their educational design. Module A had been con- structed as a conventional text and was presented as a single volume. T h e presentation o f a discrete aspect o f information is followed by questions or exercises, t o provide opportunities for the lcarncr to apply what had been learned. T h e module includes the learning objectives; a section to make the topic important and interesting: ‘Why study obstructed labour?’; a guide ‘How to study with this module’; a pre-test t o allow learners to decide which sections o r units of the module would meet their specific needs; separate units on epidemiology of obstructed labour and its complications, prevention of the consequences, and management o f clinical problems, each with its o w n objectives; a post-test; and a set of reprints from the literature which arc referred to in the text.
Module B, a first attempt to apply the PBL approach, was presented as three separate booklets: a study booklet, an answer booklet and a reference booklet with an extended set of rcprints. The study booklet contains the learning objectives, identical with those in module A; the same motivating section; its o w n guide on h o w to study with the module; the identical pretest ; the content in the form of problem presentations, divided into the same units as in module A; and the identical post-test.
In module B PBL makes use o f the modified essay question approach (Hodgkin 8r Knox) 1975). Each unit contains a number o f problems. Each problem presents a brief description o f the presenting situation, followed by a question o r task. In most instances the problem develops further with additional information, questions or tasks. Learners are encouraged to consider the problem and the related task, decide what further learning would be desirable, use the reference
PBL in distance learrriny 391
booklet, then answer the question or completc thc task, and finally compare their answer with that suggested in the answer booklet.
Planning the trials
Detailed guide-lines were agreed with the coordinators in Ghana, Kenya and Pakistan to ensure compatibility among the three trials. The Guide for Coordinators containing an explanatory introduction and sections on recruitment of learners, recruitment of subject specialists and the learners, monitoring during the study; debriefing meetings; a check-list for the issue of materials, and a check-list for the assembly of information to be returned to the Wellcome Tropical Institute in London.
Recruitment of participants was to avoid bias in selection and any overt inducements or incen- tives. Each country was to recruit two groups of at least 10 medical graduates within approxi- mately 4 years of their graduation and practising in a rural district. The areas in which the two groups were located would be sufficiently distant from each other to ensure that the participants did not become aware of the comparative nature of the project. In each country group A would use module A, the conventionally designed module, and group B would study with module B, the PBL module.
Briefing meetings, to be held separately for each group, would bring the participants together to explain the purpose of the programme, namely to assess the usefulness of the module under actual field conditions. The participants were to answer the pre-test, so that they could identify their respective strengths and weaknesses by comparing their answers with the model answers provided. After a discussion of the structure, content and method of studying with the module, the participants were to be introduced to ways in which they might timetable and organize their studies. This part of the briefing meeting was to be identical to the briefing in the existing system of distance learning for CME. However, guidance in their role as evaluators would form an addition to the normal programme for brief- ing. The participants were to be told how to use the front part ofa notebook as a diary. Here they were to record the date and times of each of their
study periods, which part ofthc modulc they had studied and the reasons for any interruption or early termination oftheir study. The sccond part oftheir notebook was intcnded for commcnts on their experience with the instructional method and the content of thc module.
Monitoring was to bc an cssential part of thc programme during the 8 weeks allocated for individual study. Previous expcricnce had emphasized the importance of encouragement to persist in the lonely task of studying on one’s own, under difficult conditions and beset with numerous distractions. Thus, whoever was to be appointed as coordinator of the programme would assume responsibility for contacting each participant once in every 2 weeks during the 8-week period.
Debriefng meeting3 werc to bc identical to those of the systems of distance learning that had been established in Africa but not yet on the Indian subcontinent. The participants would comc togethe:r once more to find out how much they had gained from the programme by comparing their performance in the post-test with the model answers,. They would complete a questionnaire on their perceptions of the module, and they would hand in their notebooks as well as that part of their module which contained their answers to questions, tasks and exercises.
Role of .iubject specialirts
In this instance, the obstetricians had three tasks. They were asked to review the pre- and post-test questions and their respective model answers to ensure that these were appropriate for their respective country. They were asked to discuss the test questions and model answers with the participants during the briefing and debriefing meetings. As a part of this task the obstetricians were to mark the test papers by using the model answers as the criterion for satisfactory answers (S) and for non-satisfactory arkwers (NS). The specialists’ third task was to assist during the study period of the trial, when- ever the coordinator could not resolve a query posed by the participants in relation to the subject matter of the module. Each country was asked to recruit two obstetricians.
392 C . E . Ergel et a1
Additiotas to Ieavnittg nt A distance
The objectives, as stated in the modules, were oriented towards everyday practice and they included not only the cognitive, but also the psychomotor and affective domains. The system of continuing education, as designed with the Wellcome Tropical Institute. would normally include a secondment to a designated centre for supervised practical experience, and one or more workshops for group discussions. role play, etc., and a field project, in addition to distance learn- ing with printed material. These practical exer- cises were omitted on this occasion. The additional expense could not bejustified for trials that were solely concerned with evaluation of the distance learning material.
Organization
Recruitment ofpartiripants
In Ghana the first 10 rural medical officers, who were approached in the Ashanti and Brong- Ahafo regions respectively, accepted the invita- tion to participate. In Kenya the invitations were issued through the respective district medical officers. All 12 doctors in Machakos, Eastern Province and all 10 doctors in Kakamega, Western Proviiice agreed to participate. In Pakis- tan obstetrics in rural areas is practised exclusively by wonien doctors. The
Table 1. Characteristics of the participants
(a) Ghana
Government Health Department was, therefore, asked to nominate 10 women medical officers from the district of Hyderabad and 10 from other areas of the division of Hydcrabad. Both groups wcrc to be within the same age group, within 4 years from graduation and not involved in formal programmes of postgraduate education. Table 1 shows that the average length of service since graduation in Ghana and Pakistan was more extensive than the years of service of the partici- pants in Kenya. As Table 1 indicates, drop-outs reduced the number of participants, leaving in Ghana: group A = 9, group B = 10; Kenya: group A = 10, group B = 9; and Pakistan: group A = 9, group B = Y.
Bviefitig
In Ghana one meeting was held in the Brong- Ahafo region by one ofthe authors (SA), and two meetings wcre held on consecutive days in the Ashanti region by another author (EB). One of his meetings was for the five doctors who worked in the same hospital and the other meeting was held at a different hospital for those doctors who worked at separate centres. In Kenya, another of the authors (PN) travelled to the two districts on consecutive days. In the Kakemega district one doctor was not able to attend the group briefing and had to be inducted
Group A (n = 10) Group B ( n = 10) -
Years since Years since Agc Sex graduation Rank Age Sex graduation Rank
2Y* M 29* M 30* M 31* M 31 M 31 M 32' M 34 M 35 M 35 M
2 2 2 4 3 4 4 4 4 5
Medical Officer 31 M Medical Officer 31 M Medical Officer 31 M Medical Officer 31 M Senior Medical Officer 33 M Medical Officer 33 M Medical Officer 34 M Medical Officer 35 M Medical Officcr 35 M Senior Medical Officert 40 M
2 4 4 4 4 4 7 4 6
12
Medical Officer District Medical Offiiccr District Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Senior Medical Officer
* Worked at the same hospital. t Dropped out, single handed and too busy
PBL in distance learnin,? 393
(b) Kenya
Group A ( n = 10) Group B ( n = 12)
Years since Years since Age Sex graduation Rank Age Sex graduation Rank
28 M 1.5 Medical Officer 26 F 1.5 Medical Officer 28 M 1.5 Medical Officer 27 Ivi 1.5 Medical Officer 28 M 2 Medical Officer 28 Ivl 1.5 Medical Officert 28 F 2 Medical Officer 28 M 0.5 Medical Officer 28 F 2 Medical Officer 29 M 2.75 Medical Officer 29 M 1.5 Medical Officer 29 F 2.5 Medical Officer 29 M 1.5 Medical Officer 29 F 2.5 Medical Officer 29 M 1.5 Medical Officer 29 M 1.5 Medical Officer 29 M 2 Medical Officer 29 lvi 1.5 Medical Officer 29 M 2 Medical Officer 30 M 2.5 Medical Officer
31 M 1.5 Medical Officer$ 32 M 4 Medical Officer$
t Dropped out: coordinator unable to contact, no telephone. $ Dropped out: single handed and very mobile. $ Dropped out: unable to concentrate, heavy duties.
(c) Pakistan
Group A (n = 10) Group B ( n = 10)
Sex
26 27 28 28 28 29 30 30 32 34
F F F F F F F F F F
Years since graduation
2 3 3 3 3 3 4 4 4 5
Rank
Medical Officer Medical Officer Medical Officer Medical Officer Medical Officert Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer
27 28
29 29 29 30 30 30 30
28
sex
F F F F F F F F F F
--
Ycars since graduation
2 2 2 3 3 4 2 3 3 4
Rank
Medical Officer Medical Officer$ Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer Medical Officer
t Dropped out: lost study material and interest. $ Dropped out: lost interest and was transferred to another city.
separately. In Pakistan, the t w o groups assem- bled in Hyderabad within 2 days o f each other. One participant in group A had to be briefed separately one week later.
Monitoring
All the participants in the t w o Ghanaean regions were visited three times during the 8 weeks. In Kenya, the coordinator attempted t o contact each of the participants once in every
week. His success rate was 70% with group A in the Kakamega district. However, it did not prove possible for the coordinator t o contact four of the '12 participants in group B in Machakos district. In Pakistan, the coordinator attempted to reach all participants by telephone on three occasions wi th a success rate of 50%, 75% and 55% respectively. Letters were sent to those w h o could n o t be contacted during the first session, and telegrams were sent after the third moni- toring session t o give the date of the debriefing
304 c. E . Ell'y
Table 2. Conscicntious iii thr usc of the iiiodulc
(d) (;h.lllJ
Numbcr of item5 completed adcqudtcly completed adequately (Maxim uni 20) (Maximum 51)
Number of itcms
Group A ( J I = 10) c; lOUp B ( J I 10)
'e l et dl
21 I 51 2( 1 51 19 47 18 4 i I X 37 13 31 0 ZH 4 12
12 t * (mo)
(;roup A ( J I = 10) Group B ( p i = 12)
20 1 0 I X 17 1 .5 1 i 15 * (three)
i 1 i 1 49 48 29 27 24
7 t (three)
(cj Pakistan
Group A 01 = 9) Group B ( w = 9)
17 1 i 13 1 1
X 4 4 0 ( J
51 SO 49 4'J 33 30 17 14 0
* Modules were not available for inspection. t Participants did not complete the programnic
meeting. Six o f 10 participants had not started their studies 4 weeks after the briefing meeting, four o f 15 had not yet commenced 2 weeks later, and one participant had not begun her studies 2 weeks before the debriefing nieeting.
Dt+uiefiricq
I n Ghana t w o separatc meetings were again held for the same subgroups of group A, and a single meeting was held for group B. All three onc-day sessions took place during the week after the elid o f t h e %week individual study pcriod. I n Kenya the coordinator conducted the t w o sessions within 4 days ofeach other, both during the week following the cud o f the individual study period. The two groups in Pakistan were debriefed withiti one day of each other, with only six from group A and eight from group €3 in attendancc.
Results
T h e results for Ghana, Kenya and Pakistan arc reviewed in parallel, so that a coniparisoii can be made between the t w o modules and their affect and effect in the three countries. The first qucs- tion to be explored M d l be: how conscientiously did the participants pursue their study with thc module? While the answer may condition the degree of confidence in the participants' pcrccp- tions it may also assist in the analysis o f pcrforni- ancc. T h e next questions will be: h o w acceptable were the modules as the resource for distance learning? How effective were the modules in helping the participants towards mastery in the objectives? How efficient were the modules as a means for distance learning!
ConsLirritiotisriess itr the us(' c f t l i r m o d u l e
This aspect was explored in two ways. First by inspection o f the niodulcs to see h o w the partici- pants had entered their answers to the questions, tasks and exercises. Table 2 is based on a quantitative evaluation. However , a broad quali- tative judgement was apphcd to dctcrrninc whcthcr a question, task or exercise could be accepted as having been completed satisfactorily.
T h e second approach to assessing h o w con- scientiously the programme had been carried through by the participants was to inspect the diary section o f the notebooks.
T h e evidence is that four o f the eight availablc diaries for group A and five of the nine available diaries for group B from Ghana showed entries
PBL in distance learning 395
for all the units of the module. For Kenya six of the seven available diaries from group A and one of only four available diaries from group B carried adequate entries. In Pakistan, five out of nine participants in group A, and six out of nine in group B produced adequate entries.
Acceptability of the modules
Direct evidence was taken from the ques- tionnaire which the participants completed during the debriefing meeting. The questions have been abbreviated, and the responses are presented in summary form in Table 3. Eight out of nine questionnaires from group A and all 10 questionnaires from group B were returned from Ghana. Seven out of 10 questionnaires from group A and eight out of 10 questionnaires from group B were made available for analysis from Kenya. Groups A and B from Pakistan returned a full complement of questionnaires. Direct and indirect evidence was also obtained from the notebooks, and from comments in the printed module material.
Table 4 lists the main responses to the item in the questionnaire that called for suggestions to make the module more profitable and enjoyable.
Effectiveness of the modules
The modules were designed to be part of a system of continuing education, where distance learning would be integrated with sccondment for supervised practical experience and occas- ional meetings in small groups. Thus, the learn- ing objectives of the modules were restricted to tasks that called for reasoned decision-making. The effectiveness of the modules was, therefore, to be measured by establishing what advance had been achieved in reasoned decision making between the modified essay question pre- and post-tests (Feletti & Engel 1980). Table 5 presents the results of the participants' responses to the pre- and post-tests that were administered under controlled conditions during the briefing and debriefing meetings respectively. The answers were marked satisfactory (S) or not satisfactory (NS) by the same obstetrician, without knowing which group had been exposed to which module. In Pakistan, the post-test ofgroup B was marked by a different obstetrician. However, a review of
the marking did not reveal any obvious difference in the standards applied by the two specialists.
Efficiency offhe modules
Efficiency should be judged by the amount of time, energy and resources that were expended on the production and use of the modules in relation to their effectiveness. In this comparative trial the financial cost of producing the modules was ignored. Although it would be fair to predict that PBL modules are likely to cost more for the duplication of a larger number of reprints from the literature, the time and, therefore, the fee for authorship is likely to differ but little. In the present trials actual time spent and perceived expenditure of effort on study were identified, primariiy from responses to a specific question in the que:stionnaire and from entries in the note- book (Table 6).
Discussion
From the outset it must be admitted that the sample :size in the three countries could not claim to conform to statistical requirements. It would have been unrealistic to have insisted on adequate numbers for an appropriate level ofconfidence in the presence of factors that could not be con- trolled absolutely. The main purpose of the comparative trial was to undertake a first explor- ation of the hypothesis that a PBL approach in distance education would not be acceptable to conventionally educated, busy rural medical practitioners in Africa and on the Indian subcon- tinent, where they enjoy little if any overt extrinsic motivation for continuing their edu- cation a t work or at home. As conditions of employment and of the working environment tend to differ from country to country, it seemed advisable to include at least one country from each side of Africa. The inclusion of a sample from India did not prove possible in the time available for the project. The size ofthe sample in each country was constrained by the pool of potential participants within a given geo- graphic;d area, and the limitations imposed by restricted transport and telecommunication in the face of considerable distances between rural
Tab
le 3
. Ans
wer
s to
the
debr
iefi
ng q
uest
ionn
aire
Gha
na
Ken
ya
Paki
stan
Gro
up A
(8)
Gro
up B
(10)
G
roup
A(7
) G
roup
B(8
) G
roup
A
(9)
Gro
up
B(9
)
(1)
Is o
bstr
ucte
d la
bour
a s
erio
us
(2)
Do
the
obje
ctiv
es c
over
the
mor
e
(3) H
ow in
tere
stin
g w
as t
he m
odul
e?
prob
lem
impo
rtan
t asp
ects
(4)
How
cle
ar o
r m
isle
adin
g w
ere
the
(5)
How
com
preh
ensi
ve w
as th
e
(6)
Was
the
info
rmat
ion
too
elem
enta
ry
(7)
How
cle
ar o
r co
nfus
ing
wer
e la
yout
(8)
Shou
ld m
odel
ans
wer
s be
sho
rter
or
(9)
Shou
ld m
ore
or le
ss r
efer
ence
ques
tions
, tas
ks?
info
rmat
ion
cont
ent?
or to
o co
mpl
ex?
and
sequ
ence
?
long
er?
mat
eria
l be
prov
ided
?
Yes
6
Yes
8
Fairl
y 6
ti*
Som
ewha
t am
bigu
ous 4
V
ery
7
Abo
ut r
ight
8
Cle
ar 7
C
onfu
sion
2
Abo
ut r
ight
5
Mor
e 5
Yes
7
Yes
10
Ver
y 8
t Alm
ost
all c
lear
9
Ver
y 9
Abo
ut r
ight
9
Cle
ar 1
0 C
onfu
sing
2
Abo
ut r
ight
6
Just
righ
t 3
Mor
e 3
Shor
t pap
ers
4
Yes
5
Yes
6
Inte
rest
ing
3 Fa
irly
2
Cle
ar 4
Fa
irly
2 V
ery
6
Abo
ut r
ight
5
Cle
ar 6
Abo
ut r
ight
4
Mor
e 6
Yes
8
Yes
7
V. i
nter
estin
g 4 Fa
irly
2 ti
* C
lear
4
Fairl
y 3
Ver
y 6
Abo
ut r
ight
h
Cle
ar 7
Abo
ut r
ight
3
Lon
ger 3
M
ore
4 A
bout
rig
ht 2
Fe
wer
2
Yes
9
Yes
7 N
o 2
Fairl
y 6 N
ot
very
3
Cle
ar 6
Not
cl
ear 3
Ver
y 8 N
ot 1
Too
co
mpl
ex 4
Too
el
emen
tary
5 C
lear
7
Lon
ger 6
Shor
ter 3
Mor
e 6 Fe
wer
3
Con
fusi
ng 2
Yes
8 N
o 1
Yes
7 N
o 2
Fairl
y 7 N
ot
very
2 9
Not
1 h
Cle
ar
7
Not
cl
ear 2
Ver
y 8 h
Too
co
mpl
ex 4 5 T
oo
elem
enta
ry 5 0,
Cle
ar 7
E
Con
fusi
ng 2
Lon
ger 6
Shor
ter 3
Mor
e 3 Fe
wcr
6
t Mor
e ill
ustr
atio
ns w
ould
add
rea
lity
and
mor
e in
tere
st.
* More
cas
e pr
esen
tatio
ns w
ould
cre
ate
mor
e in
tere
st.
* N
ot u
sed
to a
nsw
erin
g qu
estio
ns w
ithou
t fi
rst p
repa
ring
mys
elf
Tor
it.
Nee
d m
ore
ince
ntiv
e an
d pe
rson
al s
uppo
rt f
or le
arni
ng li
ke th
is o
n m
y ow
n
PBL in distance learning 397
Table 4. How learning with the module can be made more profitable and enjoyable
Ghana Kenya Pakistan -
Suggestions Group A Group B Group A Group B Group A Group B
More real-life examples More illustrations Use films, videotapes Include this topic at meetings for discussion with
experts and peers Provide opportunities for practice More up to date and locally relevant references Provide meetings as a group between periods of
Module in local language Access to a supervisor with whom to discuss and
Allocate more time for completion of the
Help with provision of the facilities and
individual study
to clarify queries
module
resources to translate what is learned into actual practice
X X X X X X X X X
X X
X X X X X X X X
x X X X
X X x
X
X X X X
X X
medical centres. Most African countries experi- ence a low doctor:population ratio, which is exacerbated by maldistribution and a relative dearth of indigenous doctors. Thus the need to match control group and experimental group by age, sex and years since graduation and to ensure a sufficient geographical distance between groups to avoid competition severely limited thc number available for each group. In one instance the number had to be increased to 12 for purely diplomatic reasons. The 12 doctors represented the total pool of eligible doctors in their region, and it would have been unacceptable to reject any two of them. In Pakistan religious and cultural constraints limited the sample to women doctors.
Table 1 indicates a relatively low overall
attrition rate, but Tables 2, 3, 5 and 6 denion- strate that the coordinators were not able to retrieve the full set of evidence from all the participants. The voluntary nature of the project, the problems of time and distance, and other competing interests and distractions may be advanced as explanations.
Against this background of small sample size and incomplete raw data any interpretation can yield no more than tentative indicators. Thus the difference in the performance between pre- and post-test indicates only a modest ifany advantage for the PBL module (Table 5). The restricted range of performance may have two expla- nations. The tests did not discriminate satisfac- torily in all the questions ofone test or the other. While it must be recognized that the participants
Table 5. Pre- and post-test results
Ghana Kenya Pakistan
Group A Group B Group A Group B Group A Group B
Pre-test ( n = 10) ( n = 11) ( n = 9) ( n = 12) ( n = 10) ( n = 10) (1 1 questions) 53 64 71 51 42 64 Post-test ( n = 9) ( n = 10) (n = 7) ( n = 7) ( n = 9) ( n = 9) (10 questions) 78 92 78 66 42 51 Percentage gain 25 28 7 14 0 - 13
W
0
X
Tab
le 6
. Inf
orm
atio
n re
late
d to
tim
e an
d ef
fort
dev
oted
to
the
mod
ules
Paki
stan
G
hana
K
enya
Gro
up A
(n
= 9
) G
roup
B (n
= 9
) G
roup
A (
ti =
8)
Gro
up B
(b
= 0
) G
roup
A (ti
=
7)
Gro
up B
(ti
=
4)
(A)
From
the
Not
eboo
k A
vera
ge l
engt
h of
a st
udy
sess
ion:
-
betw
een
1 an
d
- le
ss th
an 1
hou
r -
irre
gula
r, w
hen
poss
ible
-
No
info
rmat
ion
(B) F
rom
the
Not
eboo
k C
omm
rnts
Src
tioti
3 ho
urs
8 -
6 1 4 2
7 -
5 1
-
-
7
1 I
1 1
2 1
-
We
deal
mai
nly
with
W
e do
not
ope
rate
T
oo a
cade
mic
, not
E
ncou
rage
d to
appl
y C
ritic
al
of
advi
ce
out-
patie
nts
(2)
suff
icie
nt fo
r ac
tual
ne
w le
arni
ng in
that
w
as
not
rcco
n-
We
do n
ot h
ave
sys-
C
are
of m
y ch
ildre
n,
prac
tice
prac
tice
men
ded by
th
eir
tem
for
col
lect
ion
of
own
preg
nanc
y,
Lack
of f
acili
ties
for
Lack
of f
acili
ties
for
teac
hers
so
cial
dut
ies
disr
upt
priv
ate
stud
y pr
ivat
c st
udy
stud
y (2
) T
rans
ferr
ed t
wic
e du
ring
stu
dy p
erio
d
data
We
do n
ot u
se
labo
ur g
raph
s W
e do
not
hav
e T
AB
S
We
do n
ot p
ract
ise
syni
phys
ioto
my
or
dest
ruct
ivc
man
oeuv
rcs
Lack
of e
duca
tion
of th
e pe
ople
, lac
k of
tr
ansp
ort
and
heal
th
pers
onne
l mak
e th
e m
odul
e im
prac
tical
Dis
tric
t M
edic
al
Off
icer
doe
s no
t ha
ve a
utho
rity
for
ch
ange
M
akin
g an
ind
cx o
f th
e co
nten
t of t
he
refe
renc
e bo
okle
t w
ould
req
uire
th
orou
gh s
tudy
N
ot w
illin
g to
wri
te
dow
n as
one
wou
ld
spea
k to
a p
atie
nt
2 -
Enc
oura
ged to
appl
y ne
w
~car
ning
0 in
pr
actic
e 111 D
iffi
cult to
ad
opt 5 th
is
diff
crcn
t w
ay
of
5 R p-
0
lear
ning
N
eede
d m
ore
effo
rt
and
self-
disc
iplii
ic '
The
re a
re n
o re
fere
nces
to o
ur
liter
atur
e 40
hou
rs f
or th
e co
mpl
etio
n of
the
mod
ule
crea
ted
tens
ion
Gro
up A
(n
= 9
) 40
hou
rs fo
r co
mpl
etio
n of
the
mod
ule
was
not
en
ough
tim
e Pr
efer
lear
ning
fro
m
prac
tical
exp
erie
nce
Tim
e an
d ef
fort
on
mod
ule
wer
e la
rgel
y w
aste
d du
e to
dif
fer-
en
ces b
etw
een
Afr
ica
and
Paki
stan
In s
taf-
fi
ng, t
ask
allo
catio
n an
d pr
actic
e
(C) F
rom
Que
stio
nnai
re
How
did
you
stu
dy
with
the
mod
ule?
Not
eno
ugh
time
to
com
plet
e st
udy
of
the
mod
ule
Gro
up B
(n =
9)
Gro
up A
(n
= 8
) I f
ollo
wed
the
stu
dy
Onl
y tim
c av
aila
ble
(X4)
4-5
am
gu
ide
(x 7)
in n
o
Gro
up B
(n =
10)
I f
ollo
wed
the
stud
y
othe
r w
ay c
ould
I ha
ve c
ompl
eted
the
1 e
njoy
ed t
his
way
of
mod
ule
lear
ning
(x3
) St
udie
d af
ter 2
hou
rs
I rea
d al
l ref
eren
ces
1 fe
lt en
cour
aged
to
rest
in th
e ev
enin
g fi
rst t
hen
answ
ered
ap
ply
new
lear
ning
th
e qu
estio
ns (
x2)
in p
ract
ice
I rea
d sc
quen
tially
I u
sed
a fi
xed
timc-
ta
ble
and
carr
ied
the
refe
renc
e bo
okle
t to
coul
d (
~)
2
Mad
e m
e th
ink
(~
5)
and
answ
ered
the
ques
tions
as
they
ar
ose
rcad
whe
neve
r I
I fee
l mor
e co
nfid
ent
I rea
d ri
ght t
hrou
gh
in d
iagn
osis
and
an
d fi
nish
ed w
ithi
n a
man
agem
ent o
f fe
w d
ays,
as
I was
ob
stru
cted
labo
ur
fam
iliar
wit
h th
e to
pic
Use
d th
e m
odul
e to
pr
actis
e le
arni
ng o
n m
y ow
n
Gro
up
A
(n
=
7)
Gro
up B (n
=
8) I
trie
d to
stud
y an I
had so
little
ti
me I
entir
e un
it at a
sing
le
trea
ted it
as a
cras
h se
ssio
n pr
ogra
mm
e I re
ad
the
rcfc
rcnc
cs I
follo
wcd
th
c st
udy p
com
plet
ing a
unit I
re
ad
the
refe
renc
es
%
then
an
swer
ed
the 5 1
used
a sh
ort-
cut, 3,
just
to
ge
t it
over
&
w
ith: I
look
ed
at
the
ques
tions
an
d th
en
the
mod
el
answ
ers z
like a
text
book
, : -_
se
para
tely
af
ter
guid
e (
~4
)
3
ques
tions
;a
400 C . E. Encqrl et a1
were graduates and some had considerable prac- tice experience, several of the test questions proved to be inappropriate in the local context, particularly so in Pakistan. Consultation among the two authors from Pakistan has advanced the following possible explanation for the puzzling post-test results: (1) English had become a distinct barrier to communication; (2) much of the material in the module did not apply to these doctors in Pakistan; (3) demands of a domestic nature and repeated transfers for several partici- pants would have absorbed a great deal of their energy; (4) professional workloads, especially for women doctors in rural areas, would leave little enthusiasm for education.
Indeed, the notebooks gave the strong impres- sion that many of these doctors had worked their way through the module, some farther than others, as a perceived duty rather than as an interesting challenge. The adjective ‘boring’ occurred repeatedly, though it was totally absent in the African notebooks. Boredom, or at least lack ofinterest, niight certainly have been due to the total absence ofany reference to health service and clinical practice in Pakistan in material that had been designed for use in Africa.
There is some indication that greater seniority in age and in years of clinical experience may predispose towards readier acceptance of dis- tance learning and the PBL approach (Table h) . However, this difference may be due to no more than the natural impatience ofthe young with yet more learning, when they are preoccupied with proving themselves as capable clinicians.
More detailed analysis indicated that the con- ventional module tended to be used rather like a textbook and less as an instrument for active learning. While many participants adhered to the suggested use of the PBL module, and thus practised active learning, several commented on the need for self-discipline and greater expendi- ture of time and effort, without the benefit of extrinsic incentives. Even so, there appeared to be an appreciation that the PBL module was more closely related to actual practice. The plea for more real-life examples or case histories was made only by those who had used the conven- tional modules (Table 4).
The most important contribution that the PBL approach may perhaps be able to make in dis- tance learning is to help graduates in continuing
to develop broader professional conipctcnces, such as critical reasoning, problem-solving and self-directed learning. This tentative prediction rcsts on comments that appeared repeatedly among the responses of the B groups. Verifi- cation will have to await further development of the design and use of PBL in distance education,
Conclusions
Distance education had its origins in corrcspon- dence courses that set out to help students to pass examinations without personal attendance a t an educational institution. The iniportancc of dis- tance education, particularly for students who cannot afford rising tuition fees and the cost of living away from home, has received world- wide recognition through the establishment of the Commonwealth of Learning. An extension of distance learning for continuing education would seem a logical development, espccially in countries with an adverse doctor:patient ratio where frequent absences at courses o r workshops would seriously affect health care. Although continuing education is now seen as perhaps the main phase in medical education (World Health Organization 1990), only limited attention has been paid so far to its practice at a distance from tutors. This application is especially relevant for doctors who practise in isolated locations, par- ticularly where communication facilities are restricted, as in many countries of the developing world.
Much work remains to be done in the organ- ization of viable systems of continuing edu- cation, and this must include the provision of adequate incentives and effective study materials. The Wellcome Tropical Institute explored the design of written study material for situations where the use of audio- or videocassettes and teleconferences via telephone or radio is not practicable. Wide-ranging enquiries indicated that the PBL approach had not yet been explored to any serious extent in the design of distance learning material. This made it desirable to compare the first design of a PBL module by the Institute with a more conventionally constructed module on the same topic.
Analysis of the results from a relatively restric- ted study permits no more than a tentative identification of indicators. These suggest that a
PBL in distance learning 40 1
PBL approach is not less acceptable or less effective than a more conventional method for distance learning. Furthermore, the evidence suggests that the small margin in favour of the problem-based approach could be cnhanced in a number of ways. This would include allowing more time for the completion of a module or presenting only a sub-unit o fa module at any one time. Further savings in time and effort would be possible through careful selection of reading material that is truly relevant to the practitioner’s local interests and learning needs. Perhaps the least amenable to rectification is the problem of making quite unambiguous the tasks that the practitioner is to accomplish, without providing undue guidance or cueing. Further trials will bc needed to find ways to make feedback more flexible and thus able to accommodate a wider range of responses from different learners.
T w o imperatives became apparent: the need for very careful briefing in the use of PBL modules, and the value of consistent, active support for the isolated learner by the doctor who has been appointed as his mentor. Both are of very real importance because there is clear indication that those practitioners who were prepared to use the problem-based approach for active learning were encouraged to think deeply and creatively and gained much more than knowledge. A third aspect that was highlighted in Pakistan is the absolute need to ensure that the material for distance learning is adapted to local conditions. The learning problems, the tasks for the learners and the reference material must relate closely to the local health service, its organization
and practices, as well as the local population, its cultural, religious, educational and economic conditions and its problems in health and disease.
Acknowledgements
The authors wish to thank the medical officers in Ghana. Kenya and Pakistan who gave their time and energy to participate in these trials. The support of Professor E.H.O. Parry, Director of the Wellcome Tropical Institute, and the assis- tance of Professor C. W. Vellani, Associate Dean for Education, Medical College, Aga Khan Uni- versity, are gratefully acknowledged.
References
Barrows H.S. & Tamblyn R.M. (1980) Problem-Based Learning: A n Approach to Medical Education. Springer Publishing Co., New York.
learning. In: The Challenge ofProblem-Based earning (ed. by D. Boud & G. Feletti), pp. 23-33. Kogan Page, London.
Feletti G.1. & Engel C.E. (1980) The modified essay question for testing problem-solving skills. Medical Journal of Australia 1, 79-80.
Hodgkin K. & Knox J.D.E. (1975) Problem Centred Learning: The Modified Essay Question in Medical Education. Churchill Livingstone, London.
World Health Organization (1990) International Conrul- tatiori on Health Manpower Education for Health for All. Eur ICP.HMD 157. World Health Organ- ization, Copenhagen.
Received 28 November 1990; editorial comments to authors 14 February 1991; acceptedfor publication 1 May 1492
Engel C.E. (1991) Not just a method but a way o f
