Community-university partnership : key elements for improving field teaching in medical schools in Vietnam

Introduction: Medical education in many countries includes periods that students spend in the community. In Vietnam, a move towards more community-oriented teaching has increased the need for rural community-based education for medical students during recent years. At the same time, new policies and social changes have created difficulties for community-based education. The eight main medical schools have worked together since 1999 to improve their curriculum, including sharing and adopting new approaches in their field teaching programs. Objective: To establish more systematic, integrated and participatory field teaching in rural communities in the curricula of eight medical schools, based on community–university partnerships. Methods: Eight medical schools together analyzed their field teaching programs and identified issues still needing attention. A pilot intervention explored how to involve community and local health staff actively in field teaching programs. From the results of the workshop and the pilot intervention, plans were made for sets of activities to improve weaknesses. Feedback and evaluation surveys among local health staff and students who participated in field training were performed after 3 years’ intervention, to check the appropriateness of the field teaching programs and methods. Results: All eight schools had made improvements in selected aspects of their community-based education programs. There was still considerable variation in the programs but all were more systematic and better integrated into the revised curriculum.


Introduction
Medical schools around the world include a range of programs that expose their students to practice situations outside the classroom and teaching hospital.Communitybased medical education gives students opportunities to learn about the health needs and demands of the people they will later serve while, at the same time, learning from practising health workers 1,2 .The training for doctors who will work in rural communities should include time spent in such communities during their period of study [3][4][5][6] .Rural training sites are appropriate for students to learn more about the range of social, political and economic forces that affect health in every society 3,7 .In Vietnam, the time and quality of study periods in the community were limited until the 1990s for several reasons.The curriculum was then still hospitalbased, teachers lacked experience in organizing and conducting field teaching (FT) in the new social context, and extramural teaching was (and is) more costly than teaching in classrooms.In addition, most of the FT was aimed at serving the needs of the students, with little regard to the needs of the teachers, the local health services and especially the communities.
In 1990, the Vietnamese Government established a policy aimed at training medical doctors in a more communityoriented fashion (Decision 58/TTg of the Vietnam Government, dated 03/02/1994).They planned that by the year 2000 medical doctors would be available in 40% of the more than 10 000 commune health centers (CHC) in Vietnam (Resolution no.37/CP of the Vietnam Government dated 20/06/1996).This target was met because more than 45% of CHC had doctors at the end of 2000 (Decision no.However, at the same time the introduction of the market economy and private enterprise in Vietnam began to create barriers to the community accepting large numbers of students, especially if community members could see no benefit for themselves.The market economy and the rise of private practice also reduced the enthusiasm of teaching staff for spending time in rural areas with the students.These changes presented the schools with serious challenges in implementing FT.However, from 1999 the eight main medical schools received support from a Dutch project that provided technical and financial assistance to strengthen community-oriented teaching, including FT. The project aim was to enhance the capacity of the eight medical schools in community-oriented curriculum development and to improve the quality of the teaching.To be systematic, the program commenced with identifying the knowledge, attitude and skills (KAS) that a general medical doctor graduating from any medical school in Vietnam should have 8 .The KAS were first identified by teachers from the eight schools, then checked with newly practising doctors 9 and final year students about to graduate from the eight schools 10 .From the agreed KAS came curriculum renovation, teaching/learning material development, then updating teaching/learning methods and student assessment tools to fit with the identified community-oriented KAS.One important aspect was to improve FT so that it would contribute more to the training of community-oriented doctors, who would then have a better understanding of the rural community's health needs, and better skills to meet those needs.
The method of curriculum evaluation designed by Coles and Grant 11 includes three phases: first the written plan, then the actual teaching process and last the results, checking the latter two against the first.This approach has also been used to evaluate a community-based period in the medical curriculum by Kristina, Majoor and van der Vleuten 12,13 .In the present study a similar approach was used, but an additional phase was added to the preparation: a trial phase in which we explored the building of a communityuniversity partnership model to identify appropriate ways to involve the community in FT.Finally, feedback from local health staff, communities and the students who participated in FT were collected to evaluate the program.Looking at the inputs and outputs through these phases, the eight medical schools could clearly recognize the benefits of involving all stakeholders actively and of working on the basis of commitment to an approach of mutual benefit.The factors affecting participation by all stakeholders are discussed here, based on theories of motivation.This approach produced more appropriate and effective FT programs in the context of the change in Vietnam.
The aim of this article is to identify strategies and approaches that were successful in involving different stakeholders effectively to improve FT in the eight medical schools.It is hoped that this case study will be useful to others developing similar initiatives in other settings.

Methods
The four steps in the intervention are outlined (Fig1).The

Data collection and analysis
The research method used in this study is case study

Challenges to field teaching before the intervention
Before 1986 (ie before the market economy was introduced in Vietnam), when all the training activities of medical schools were centrally subsidized and private practice by teaching staff was not allowed, it was relatively easy to carry out FT. Teachers in both preventive medicine and clinical departments had time and the willingness to go into the field with students; while people in the rural community at the FT sites were happy to receive both teachers and students, because it would offer them access to a higher quality of medical care.Since market mechanisms were introduced in 1986 and the private sector started to develop, budget allocation to medical schools became more decentralized, and teachers started to set up private practices and so were less willing to take the time to go with students for FT.Rural residents at the FT sites were also influenced by the market mechanism, having greater access to medical care on the one hand, and paying more attention to other kinds of benefits on the other.These changes made FT more difficult to organize.
At the same time, the Ministry of Health (MOH) requested that the schools provide doctors with a more communityoriented background to prepare them better for service in the community.
At the first inter-school workshop in 2001, a number of key challenges and barriers were identified for all stakeholders For schools, FT was complicated and costly to organize because schools had to identify and prepare the rural FT sites, pay for transport, accommodation and mission allowances for teaching staff and organizers, and supervise students more carefully than in the university environment.
These difficulties had considerable influence on the practice of FT in Vietnam's medical schools.The quality of FT no longer met the needs and requirements of the MOH policy or of society (Fig3).
During the first workshop it became clear that improving partnerships among the stakeholders, respecting each one's need for benefits and motivating them would be the main approach to improve FT in the eight schools.The community-university partnership was especially targeted for improvement.Because most of the teachers in the medical schools were still inexperienced in ensuring that communities were actively involved in FT, a pilot intervention was planned to test an approach that could motivate and involve local health staff and communities.

Building a community-university partnership model
Senior and junior teaching staff of HMU worked with three communes in a densely-populated, urbanizing rural area near Hanoi to build a model that supported health staff and volunteers at community level in solving local health problems using an evidence-based planning approach.1.For schools: Field training was complicated and costly to organize because schools had to identify and prepare the rural FT sites, pay for transport, accommodation and mission allowances for teaching staff and organizers, and supervise students more carefully than in the university environment.2. For teaching staff: Because of their low salaries from the university, most teachers needed additional jobs or a practice in private clinics to earn sufficient money.If they joined the FT at rural sites, they would lose that extra income.Also, many were still inexperienced in teaching students in the field.3.For students: Because the quality of FT was not high and not easy to assess, some schools did not assign marks or credits for the field periods, which did not encourage students to take them seriously as a learning experience.
The attitudes of the doctors supervising them may have strengthened this perception.

For the community and local health staff:
The FT programs were designed mainly for the learning needs of students and availability of expertise and resources of the schools, but did not pay enough attention to needs and benefits of other stakeholders, such as teachers accompanying the students, the local health staff and services or the people in the rural communities where the FT took place.At the same time, due to the introduction of the market economy, the people in the community were often busy with activities to earn money, and had come to expect to receive some benefit for any service provided, so they were not always as willing to have students to stay and study in their community as they had been previously.5.For policy-makers: Policies related to FT were formulated by education experts and did not encourage teachers to go to the field.For example, 4 hours' teaching in the field were weighted as equivalent to one hour's teaching in the classroom or 2 hours' practical teaching in hospitals or laboratories, while other incentives for teachers to go into the field did not compensate for this discrepancy.
6.For all: All eight schools had different periods and timing for FT, and the objectives not only varied but were often not clearly formulated.The approaches to involving local health workers and the communities also varied greatly, including them being given very little attention at all.

School leaders did not enthusiastically support costly FT
Teachers did not want to go into the field for teaching

Community was not willing to accept students
Students were not enthusiastic about study in the field • Field teaching was mostly done by teachers in the faculty of public health, because many schools considered 'community' to be the business of public health teachers missed opportunities for community-oriented clinical practice.
• Topics for FT were mostly in public health and preventive medicine and were selected on the basis of ease of organization, rather than the learning needs of students working in the field missed opportunities for learning about clinical and basic medicine in the community.
• Local health staff were involved only as guides, and did not have the chance to share their medical experience with students.They were not involved in supervising or assessing students, but schools did not have enough teachers in the field students lacked support and supervision student behavior in learning and working with community was often inappropriate low quality of FT and low level of partnership with community.• Because FT quality was low, several schools did not assign marks to these sessions students were not very motivated to learn during FT.They also learned how to teach evidence-based planning and management for health workers at grassroots level.A pilot model for a community-university partnership was established that respected the needs of, and ensured benefits for, all partners 15 .At the same time, experience from the other projects supporting community-based teaching in other medical schools was reviewed.In the Thai Nguyen Medical Faculty, for example, students were assigned to follow at least 10 households in their catchment area during their 6 years in the medical school; they helped the families improve their health, both in preventive and curative aspects.That project also shared the experience of how to guide learning for students at district hospitals and commune health centers, and how to ensure that local health staff had clear roles in the FT.In Hue Medical College, experience from the RH project and another project focused on FT contributed ideas about how to recruit, assess, train and reward district health staff for participation in training, supervising and assessing students.With all of these inputs, a model for community-university partnership was developed and adopted for intervention at all eight medical schools.

Main strategies and activities to improve field teaching in the eight schools
An important question as we developed new strategies and activities for FT was how to involve and motivate all stakeholders so that they could and would continue to contribute after the end of the project.Using the theories of motivation proposed by Herzberg 14 and our experiences during the pilot intervention and from other projects, we analyzed the motivation of the four main stakeholders whose involvement was needed in the FT. Figure 5 shows the areas and activities identified for improvement of FT, and the roles of the different stakeholders.
The selection of the most appropriate strategies and activities for each stakeholder was based on the application of Herzberg's motivation theory 14 as presented (Table 1).In this way, the FT program could ensure benefits and motivating factors for all stakeholders.
Once the plans were prepared, the intervention to improve FT programs began in the eight medical schools.The FT programs were not identical in each school because they were adapted to fit the local situation; however, all worked towards the community-university partnership with attention to and respect for the needs and benefits of all stakeholders.

Intervention activities for field teaching
The main activities of the intervention are summarized (Table 2).

Results after interventions
The results and achievements of the intervention are summarized (Table 3), comparing columns according to the situation before and after intervention.• teach students and health staff how to train and conduct action research, evidencebased planning and management using participatory approach in the community.
Health staff from three levels learned: • how to involve CHW in identifying health issues, planning and managing health programs actively; • how to work effectively with teaching staff from university.

Evaluation of the intervention by different stakeholders
To evaluate the improvements in FT and achievements of the community-university partnership approach, surveys were performed among the three important FT stakeholders: (i) local health staff who now become preceptors for FT; (ii) community members and local authorities at the FT sites; and (iii) the students.The results of these surveys are summarized (Table 4).• Not clear and not the same in every school, depended on the teachers involved, characteristics of the field sites, availability of resources and feasibility to organize

•
Listed in a learning objectives book as follows: ÷ have gained ability to approach the community ÷ have practised the 10 key issues in primary health care in Viet Nam ÷ able to identify priority health problems at the field site.÷ able to make intervention plans to solve priority health problems at the field ÷ have attended and learned how to manage a basic health station 3. Departments involved in FT

•
Only a few teachers in public health departments involved in organizing and implementing FT

•
Training department and public health departments organize the FT, with 6-10 clinical departments (depending on school) now involved in FT

•
In each school, all 15-18 departments involved in the project now aware of need to teach their KAS in the field and willing to do it Students and trainers often have one week together before going to FT to prepare for the contents of field learning, and to experience working with the community 7. Topics taught in the field • Topics were mainly from departments of public health, such as health education, health organization, nutrition, environment and immunization • Topics were easy to organize (not based on needs of stakeholders) • Topics based on which skills identified as needing to be taught in the field in the book of learning objectives, but each time they are selected differently, depending on the stakeholders involved, especially the needs and interests of local health staff and community, but also the level of students and departments involved • FT teams work closely with other stakeholders to identify content and training methods for each topic, based on clear objectives 8. FT sites • Each school had 1-2 field sites, often commune health centers that were upgraded to be models for students not representative of work places for students after graduation • Each school has 3-6 field sites in districts, including district hospitals.Students can go (on rotation) to different communes and hospitals at these sites • All schools set up partnerships with FT sites to have mutual support for the mutual benefit of official involvement in the teaching of medical students 9. Field teaching, learning materials • Produced by a few teachers in public health departments who were assigned to organize FT • Field teaching, learning materials produced according to learning objectives with involvement of teachers assigned for FT in all departments involved in FT.Main materials have been published as school text books for FT 10.Assessment of students in FT • Students had to write a report to show what they did and learned in the field but, due to lack of supervision, this was not awarded marks towards their study progress • All schools now use standardized checklists, tools and questionnaires for self-assessment and peer assessment; assessment by local health staff and by community members where the students stay during FT, as well as assessment by teachers, and students' final reports were assessed by teachers with a mark that contributes to overall assessment for study progress 11.Support of schools for FT • FT had become a relatively unimportant activity; the focus was on hospital-based teaching • Four schools have already set up an FT unit that belongs to the training department that organizes FT • Financial support is provided for teachers and students going into the field • Teachers who join FT obtain a favourable performance appraisal, which also motivates them  In addition to the direct benefits of FT for all stakeholders, the results of the surveys also revealed that the medical schools and their teachers gained many indirect benefits.
Indirect benefits for the teachers included: • Their KAS were improved by greater exposure to the community and by sharing experiences with local health staff when teaching in the field.They also shared duties in organizing and supervising students during FT.
• Student assessment was more objective with input from the local preceptors so the teachers have more confidence in it.
• The quality of teaching and learning in the field was much better using the new model that involved all stakeholders.
Indirect benefits for the schools included: • It was easier to conduct FT when local health staff are actively involved and motivated.
• Local authorities paid more attention and assisted the students more in the field.
• The schools could reduce financial support for teachers and students because community members were willing to provide accommodation (due to the FT benefits for themselves and their community).
• The relationship between the community and schools was better when they shared planning and implementation as a collaboration.

What we have learned
Field teaching has been applied widely in many medical schools, especially in developing countries and in countries where there is a need for medical practitioners in rural areas 2,3,12,[16][17][18][19] .These periods are believed to develop students' ability to integrate their knowledge in the basic and behavioral sciences in relation to practice in a real situation 20 .It also helps students better understand the doctor-patient relationship, the decision-making processes in the real life context, and how the health care environment is changing 21 .As Kaufman said, 'If learning in medical schools is to be suitable for rural practice, students must receive early and sustained exposure to rural communities and to rural physician role models' 7 .Many programs aim to influence medical students to choose rural practice after graduation, although it is not yet clear whether that is always the program outcome [1][2][3]20,22 . Thereis evidence that FT can lead to better communication between the primary-care level and the referral levels and better community-based care for those with chronic conditions 23 .In Vietnam, FT at rural sites has a long history, but since 1986 when the market economy and private sectors were introduced to the country, medical schools faced many challenges in its implementation.The general objective of FT should be to expand the students' perception of community health problems and their learning through providing service and performing research in the community 3,24 .At the same time students should contribute to improving the health of the community in which the program is conducted.
In Vietnam, the eight medical schools worked together to build a community-university partnership in their FT programs that would benefit both the students and the communities.The greatest challenge was to motivate all stakeholders to be involved actively and effectively, especially the local health services and the community.
Using the theories of motivation outlined by Herzberg 14 and by Adams and Maslow 25 , we considered the motivation of different stakeholder FT participants (Fig5; Table 1).
In the case of the students and teachers, who already knew that FT was necessary and that they had to be involved, by applying Herzberg's theory we recognized a need to provide them with maintenance factors.These could be, for example, providing good learning and teaching environments, Using a multi-stakeholder approach that addressed appropriate motivating factors for each stakeholder, the FT project interventions appear to have been successful in gaining the support and involvement of all main stakeholders, as is illustrated (Table 5).

Conclusion
Eight medical schools in Vietnam recognized a need to improve their rural FT programs and worked together to achieve this.The situation analysis guided the selection of issues to be addressed, then pilot FT interventions were carried out at rural field sites before applying them to all medical schools.The development of strategies for involving stakeholders at the field sites was informed by theories of motivation.This resulted in an effective communityuniversity partnership model that satisfied all stakeholders.
This step-by-step approach demonstrated a number of successful strategies to creating conditions for continued stakeholder contribution to FT.Such a 'win-win' approach to community-campus collaboration should be considered in every activity to maintain, develop and strengthen the community-university partnerships in FT in Vietnam and in other countries.
35/2001/QD-TTg of the Vietnam Government dated 19/03/2001).A new target was set for 2010: 100% of the CHC in lowland and midland areas would have doctors, as well as 50% of the remaining CHC in mountainous and remote areas (Master Plan for the Domestic Health Care System between 2006 and 2010).Medical schools were asked to increase their attention to both community needs and practice, by making classroom teaching more community oriented, and by improving the teaching in the communities (FT or community-based education, CBE).
baseline data were obtained during the first inter-school FT workshop in 2001 (before the intervention), from the pilot intervention and from experience as the project was implemented.Before the first workshop, a representative team from each school prepared a report on their existing situation, challenges and plans for FT.The reports also served for comparison among the schools.Stakeholder analysis identified the roles and needs of each stakeholder in each location, which lead to a plan to improve the FT programs in the eight medical schools.One large challenge was to involve the local health staff and rural community effectively and in a way that motivated and satisfied them.Therefore, a pilot intervention was performed by Hanoi Medical University (HMU) at three communes in a rural district to explore a model of community-university partnership.At the same time, experiences from a project on CBE in Thai Nguyen Medical School and another project on FT for reproductive health (RH) in Hue Medical School (both with international financial and technical support) were also taken into consideration in completing the communityuniversity partnership model.The interventions were then carried out in all eight medical schools from 2002 to 2005.To check the achievements and lessons learnt from the FT intervention, in 2005 the eight schools collaborated in a multi-centre survey.They interviewed 144 rural health staff involved in their FT programs as preceptors as well as 300 community members.They also conducted 12 focus group discussions (FGD) among local authorities at rural FT sites to obtain their opinions.Additional information came from a feedback survey performed by the HMU team using a structured questionnaire among 240 students who had just returned from their FT period in rural districts of nearby provinces.

Figure 1 :
Figure 1: Four steps to improving field teaching in medical schools in Vietnam.CBE, Community-based education; FT, field teaching; RH, reproductive health.

First
, the HMU and MOH staff visited the district and the three communes to discuss with them what they needed and what the university could provide.They agreed that the local people needed to be better able to analyze their own problems and find solutions for them, using the skills of action research.That was something the university could provide.

Figure 2 :
Figure 2: Barriers to field teaching in medical schools before 2001: results of stakeholder analysis.FT: Field teaching.

Figure 3 :
Figure 3: Barriers to field teaching and their effects on community-oriented learning before 2001.FT, Field teaching.

A
pool of trainers was established, including HMU staff and staff from the Department of Science and Training, MOH, and a few experienced staff at provincial and district levels.The pool included both experienced and junior staff, to provide opportunities for learning and sharing experiences and to ensure supervision during action research and implementation of interventions.Together, the staff trained and supervised six staff of the CHC and 27 village health workers in three communes.The participants learned to identify problems and to collect data (existing and new) to describe and prioritize the problems and then look for solutions.They learned by participating in a series of training courses alternating with practice periods, as presented (Fig4).The participants selected three topics for action research and intervention: malnutrition in children under five; pesticide abuse by farmers; and traffic accidents in an urbanizing area.By participating in all project activities, staff from HMU learned how to work with community health workers and others in a participatory way.

Figure 4 :
Figure 4: Process of evidence-based planning and project management and its achievements.CHW, Community health workers; HMU, Hanoi Medical University; MOH, Ministry of Health.

Figure 5 :
Figure 5: The role of each stakeholder in strategies to improve field teaching.KAS, knowledge, attitude and skills.

FT,
Field teaching; KAS, knowledge, attitude and skills; MOH, Ministry of Health.*The standard Herzberg hygiene and motivation factors are listed in the first column, while the related issues in FT development are shown in the subsequent columns, followed by numbers representing the relevant Herzberg factor.Not all Herzberg factors could be identified in the FT programs and perhaps because the FT largely concerned teachers outside the university, most of the factors fell in the category 'motivation'.

•
FT was conducted based on the needs of students only teachers, local authority, local health staff and community people were not satisfied • All stakeholders are now motivated to join: health problems in FT sites can be identified and partly resolved during FT; local health staff become paid preceptors of the university which gives them status.Teachers are willing to go because they consider it their duty and want other rewards (see 11). • Relationships and mutual support have increased between the community and schools FT, Field teaching; KAS, knowledge, attitude and skills.
integrating the learning with social and entertainment activities, combining the learning and teaching in the field with implementing research and providing health services, thereby giving both students and teachers more opportunities to learn and to share their experiences.Motivation factors for teachers in FT started with giving them responsibility, first asking teachers from each department to identify and plan for the KAS that they should teach in the field.The departments and the faculties supported that request and the teachers felt responsible.The teachers could also learn from other stakeholders and get involved in community research and services; these actions would contribute to their career advancement and provide recognition and appreciation from students, local health staff, the community and their colleagues.For students, the opportunities for self-learning, enjoying life in the community with social activities, and the freedom to explore new areas were the main motivational factors.They were also motivated by their responsibilities and achievements, once we introduced a good supervision and assessment system with the participation of all stakeholders.Students gained the recognition of classmates, teachers and the community when they performed well in the field learning sessions.These benefits were recognized by students who had been on rural placements in other countries1,2,20,26 .Efforts to improve FT and make it sustainable included capacity building for individuals like teaching staff and students, and also for their organizations and institutions.In all eight medical schools, the teaching staff received support to produce the new FT program involving all stakeholders, with appropriate teaching and learning materials, including tools and procedures for student assessment.Once the systems were established and the materials available, maintenance costs were relatively low.Some schools set up an FT unit under their training department to coordinate all FT activities, but others have not yet made that move and have left FT to the public health department to organize and implement.It remains difficult to motivate the clinical and basic science departments to become involved.This may be in part because of financial losses they may incur by remaining rural, but it is also a attitudinal problem with a belief that there is not enough relevant work during a rural attachment.In the schools that made a specific effort to include clinical teaching in their rural FT periods there were a few key clinical departments (such as obstetrics or pediatrics), actively involved.For the local authorities, health staff and community members, Adams' theory25 of job motivation may provide a better basis for analysis, because they may not consider FT their responsibility.To involve them actively, we had to consider the balance between what we wanted them to contribute to FT and the benefit they could gain from their involvement.In Tasmania, Australia, field preceptors felt excluded from the educational process until a program to provide them with training skills and more involvement with the students was instituted1,27 .When the Vietnamese program was adapted to give the local health staff and others more responsibility and clearer benefits, the feedback from all community groups was very positive.

Table 2 : Relationships between aims and actions in field teaching Aim Activities
1. To have consensus about the main difficulties and challenges of FT and possible solutions • Conducted first inter-school workshop on FT for 40 staff in charge of FT in eight medical schools and FT experts (FT, Field teaching; HMU, Hanoi Medical University; KAS, knowledge, attitude and skills.

Table 4 : Feedback from the three important field teaching stakeholders Issue Survey among local health staff involved in FT †
Hanoi Medical University; FGD, focus group discussion; FT, field teaching.†Results of this survey were presented at an International Conference 'Making Primary Health Care Work: Challenges for the Education and Practice of the Health Workforce' organized by The Network: Towards Unity for Health (TUFH), in Ho Chi Minh City, Vietnam November, 2005.

Table 5 : Summary of benefits for stakeholders from each intervention in field teaching Benefits for each stakeholder Intervention activities
COT, Community-oriented teaching; FT, field teaching; KAS, knowledge, attitude, skills; LHS, local health staff.