African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 6, Num. 1, 2002, pp. 15-19

African Journal of Reproductive Health, Vol. 6, No. 1, April, 2002 pp. 15-19

Curriculum Reform for Reproductive Health

Olufemi A Olatunbosun¹ and Lindsay Edouard²

¹Dr O. A. Olatunbosun, Department of Obstetrics, Gynaecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada. Tel: (306) 966-8033; Fax (306) 966-8040; E-mail olatunbosun@sask.usask.ca²196 Larchmont Avenue, Larchmont, New York 10538, USA.
Correspondence: Dr O. A. Olatunbosun, Department of Obstetrics, Gynaecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada. Tel: (306) 966-8033; Fax (306) 966-8040; E-mail olatunbosun@sask.usask.ca

Code Number: rh02005

ABSTRACT

A new model of reproductive health care delivery is unfolding, driven by emerging health issues, expanding technology and increasing public expectations. Additional imperatives in service provision for women's health compel reforms to undergraduate medical education using reproductive health as the basis for restructuring curriculum contents. These developments provide an opportunity for implementing the recommendations from various international conferences through continuing professional development and an evidence-based approach to clinical decision-making. A three-pronged approach based on reproductive health, problem-based learning and evidence-based medicine, has much potential for improving subsequent clinical practice and the overall reproductive health of the community. Appropriate changes to existing curricula will facilitate integration of the principles of reproductive health and the new philosophy of doctor-patient relationship into clinical supervision and training of students. (Afr J Reprod Health 2002; 6[1]: 15–19)

RÉSUMÉ

Réforme du Programme Scolaire Pour la Santé Reproductive. Il y a un nouveau modèle de l'assurance des soins médicaux qui s'expose dans le domaine de reproduction, et qui est poussé par les questions de la santé naissante, la technologie en expansion et les attentes croissantes du public. Les impératives supplémentaires dans l'assurance des services pour la santé de la femme, rendent obligatoire les reformes dans l'éducation médicale au niveau de la licence en se servant de la santé  reproductive comme base pour la restructuration des contenus des programmes scolaires. Ces développements offrent l'opportunité qui permettent de mettre en oeuvre les recommendations des diverses conférences internationales à travers des développements professionels continus et une approche basée sur des constatations à l'égard de la prise de décision clinique. Cette approche à trois dents qui est basée sur la santé reproductive, l'apprentissage fondé sur les problèmes et la médecine basée sur des constatations, a beaucoup de potentiel pour améliorer la pratique clinique ultérieure et l'ensemble de la santé reproductive de la communauté. Des changements appropriés sur le programme en vigeur faciliteront l'intégration des principes de la santé reproductive et la nouvelle philosophie du rapport médecin-malade dans la surveillance clinique et dans la formation des étudiants. (Rev Afr Santé Reprod 2002; 6[1]: 15–19)

KEYWORDS: Women's health, curriculum reform, evidence-based medicine, problem-based medicine, problem-based learning, continuing professional development

INTRODUCTION

A new model of reproductive health care delivery is unfolding, driven by emerging health issues, expanding technology, and increasing public expectations. The International Conference on Population and Development held in Cairo in 1994 and the Fourth World Conference on Women held in Beijing in 1995 recommended a bold agenda for the improvement of several aspects of reproductive health.^1,2 The implementation of their recommendations requires concerted efforts by government, non-governmental organisations, educational institutions and professional bodies.

Attaining the goal of improved reproductive health services will necessitate major reforms in the training of health professionals through a collaborative effort with multidisciplinary alliances of professional societies. The implementation of these reforms and a detailed understanding of the barriers to change are priority areas for public health in both developed and developing countries. The recent emergence of women's health as a discipline³ has raised much awareness and is undoubtedly an important first step in the advancement of reproductive health as a whole.

While better clinical service provision is a vital ingredient for improving reproductive health, there is a need to develop an accompanying system of education for its promotion. This article considers how emerging principles of reproductive health can be implemented through curriculum reform in medical education. This goal is attainable through an interdisciplinary, problem-based, student-centred, community-oriented, and integrated approach to instruction to overcome barriers to change by implementing selected strategies for integrating reproductive health in undergraduate education. 

Rationale for Reproductive Health Education

Through international collaboration, training institutions in developing countries often have a good track record for carrying out activities recommended in the declarations of international conferences, but their achievement depends largely on the appropriate training of service providers. Long-term capacity building necessitates changes during basic professional training, as compared to continuing professional development that can only help towards short-term changes. Medical education needs innovative curriculum changes for courses in both undergraduate and specialist registrar training.³ Since the current developments in the field of reproductive health will have their greatest impact at the primary care level, implementation of curriculum reforms should begin at the undergraduate level.

Holistic Perspective on Reproductive Health

Current medical curricula are largely fragmented, specialty oriented, disease focused, and fail to recognise the linkages between events at younger ages and consequences at later ages. Various initiatives have sought to promote an integrated approach to women's health through reforming the training of health care providers.⁴ Curriculum reform is specially needed for physicians to meet service needs regarding sexuality, gender, male involvement, life cycle, communication skills, counselling, and the promotion of individual needs in the context of rights-based programming. Further, in reproductive health education, there tends to be a dearth of instruction on the biological and social determinants and consequences of diseases from a gender perspective. Also, the socio-cultural context of the community and its medical schools should be taken into consideration in the implementation of the new curriculum.  

Professional Roles in Educational Curriculum

There is a rising expectation of society in general for higher professional accountability of physicians beyond their medical skills. The public currently expects physicians to possess excellent communication skills, promote their rights, advocate on their behalf, and provide high quality, cost-effective and evidence-based care. Effective reproductive health care can be improved by the inclusion of formal instructions in communication, health policy, management and advocacy in the training of physicians.

The need for addressing professionalism in reproductive health is further confirmed by recent studies suggesting that physicians' personal awareness may be an important means to understanding the attitudes and practices of patients.⁵ If physicians have explored their own behaviour and values, they are likely to better understand why a patient is behaving in a particular way and adjust their own actions to the prevailing circumstances. If medical educators respond to the challenge of instituting and evaluating activities that promote personal awareness, they could have important benefits for patients and physicians.⁶ It is clearly evident that a paradigm shift is needed in the traditional curricula of medical education that have been largely focused on the mere acquisition of a large volume of knowledge. Bringing about real change will require a fundamental shift in medical education to help students acquire appropriate attributes that are in congruence with the increasingly sophisticated needs and expectations of their community.

Implementing Curriculum Reforms

A pragmatic approach to integrating reproductive health in undergraduate medical curriculum necessitates identifying a model that is likely to contribute to action and promote change. The timing of introducing reproductive health in relation to a review of the general curriculum is also important. Any immediate reform of medical curricula is likely to include adjustments to their current structure as compared to drastic changes from a disease and discipline-based approach to principle and concept-based. For years medical educators have adopted an “encyclopaedic” approach to teaching. The focus has recently shifted towards a student-centred approach to learning, emphasising that “less is more”, thereby challenging the traditional approach. The duration and content of undergraduate medical education is undergoing drastic reforms with a general trend towards a shorter duration. This trend provides a unique opportunity for developing countries to reform their overall curricula along similar lines. Besides, it enables interdisciplinary collaboration with the integration of reproductive health content.    

Curricula Designs and Options

Three approaches to designing and implementing reproductive health curricula are used commonly: (1) adding free-standing courses to existing curricula; (2) delegating subject areas of reproductive health to parts of existing curricula; and (3) integrating new interdisciplinary courses into the general curricula. The most common approach consists of the addition of the new interdisciplinary courses to the existing discipline-based curriculum, with attempts to establish integrative horizontal connections among concurrent courses.⁷ The integration, sequencing and correlation of basic science and clinical materials are important to reproductive health education beginning in the early stages of medical education. The integrated model is considered to be most suitable because it maintains continuity in planning, instruction and evaluation across the entire educational program. The integration of many disciplines, from basic to clinical and social sciences, in teaching reproductive health from an early phase of the medical education is important for an effective implementation of this type of curriculum.

A model curriculum for reproductive health will serve as the basis for teaching basic generalist competencies including the requisite knowledge, skills and attitudes needed to master them. It will include a curriculum guide and faculty resource package. It will also include recommended training experiences, schedules and approaches to faculty development, tutoring and student evaluation. Our experience in the development and implementation of a reproductive health module suggests that a multidisciplinary and interdisciplinary learning using a biopsychosocial model promotes the integration of gender and rights-based principles into the medical curriculum.

Mode of Implementation

Over the last century, medical education has evolved from an apprentice type attachment to an academic one with a well structured pattern. Being adults, medical students should use appropriate learning strategies and diverse methods to complement lectures, seminars, small group work, ward rounds and bedside experiences. Opportunity for individual work also enables them to display personal perspectives through involvement in research. As the operationalisation of reproductive health emphasises the primary care approach, it can be expected that departments of primary health care will have a major role to play both for service delivery and training. However, there should be ample room for local circumstances to influence the involvement of other levels of care. A redirection towards preventive measures such as cervical screening and the care of underserved populations must receive greater attention.

The integration of research into medical education presents a major challenge. Specially, it can be anticipated that research-intensive tertiary level care would be crucial for the delivery of certain services. Training in empirical investigation, research methodology and analysis has been associated with improved problem solving and discrimination in the appraisal of the medical literature.  Whereas formal research experience has traditionally taken a back seat to other competing priorities, both undergraduate and postgraduate students' participation in research require emphasis in curriculum changes.

Problem-based experiential learning emphasises the active acquisition of knowledge through the application of available information to solve problems about specific situations.  Self-learning is an approach that promotes the subsequent practice of evidence-based medicine that recognises the dynamic nature of knowledge and the accompanying needs to be up-to-date with the medical literature while recognising their limitations.^8-10 Whereas problem-based learning is often referred to as a teaching method in various curricula, its confusion with problem solving leads to major misconceptions.¹¹ The case-based learning and concept mapping approach offers practical tools for problem-based learning.¹² A dire need exists for more collaboration between clinicians and specialists in educational methodology to promote practical applications of educational techniques for reproductive health.

Constraints and Solution

The most frequently identified barriers to adoption of a new curriculum are a lack of faculty time, insufficient number of tutors and training sites, inadequate faculty development, and the need to meet accreditation standards. Curricula changes for undergraduate training require approval at various levels, from the medical school to national educational bodies. A progressive curriculum with its forward-looking elements might not fit into the straight jacket of prescribed directives governing the accreditation of courses. The solution rests with providing ample justification for new changes to existing curricula. Another approach consists of the involvement of key stakeholders such as various government and professional associations in the planning of curriculum changes, so as to ensure their support for implementing changes. This can be achieved through discussions at national forums such as annual meetings of professional associations. The acceptance of a new curriculum for reproductive health depends on success in building a broad consensus among stakeholders and in working within government health policies for its implementation.

A new interdisciplinary course that is weaved into the general curricula may be difficult to implement as it would entail major restructuring affecting a large number of departments. Therefore, it may be more practicable to adopt an interdepartmental collaboration for adding reproductive health topics to existing curricula. As it is unlikely that additional time would be available, a reduction or elimination of certain curricula items becomes necessary for the introduction of new items in the courses.  Students should be trained in primary care in ambulatory settings¹³ where opportunities exist for exposure to common real life problems. Encouraging interdepartmental collaboration in teaching, research and clinical service should remove traditional departmental boundaries and professional fragmentation. We advocate a role for interdisciplinary units in which sharing of human and material resources would efficiently achieve a common goal of quality education.

Curriculum reform in the discipline of obstetrics and gynaecology¹⁴ must lend itself to the application of epidemiology and community health, with special attention to community perspectives and clinical secondary prevention besides primary prevention targeted at individuals. Furthermore, various other departments would need to be involved for the teaching of certain important aspects of reproductive health, examples being gender issues and communication skills. Organisational infrastructures and support are needed for planning and implementing curriculum changes and for managing logistical, educational and management issues that may emerge over time. Overall, academic leadership by the dean is critical to ensuring collaboration among diverse faculty members and monitor performance.

Regarding constraints with the skills of teachers, we can expect that some individuals would prefer well-entrenched habits rather than adapt to new circumstances.¹⁵ Adequate and appropriate integration of reproductive health into the medical curriculum will necessitate training of faculty members who can address specific student needs. This task will include both the recruitment and retraining of teachers who can provide program leadership for new curricula. For example, teachers must have appropriate skills in teaching communication, gender issues, medical ethics and social sciences.  Faculty development seminars on teaching methodology and retreats facilitated by educational specialists are useful strategies to revamp the technical contents of curricula. The move from obstetrics and gynaecology to reproductive health involves the introduction of subject areas beyond the competence of a few individuals. Collaboration with diverse fields as disparate as psychology, human ecology and comparative biology are crucial to ensure success. Most medical schools are fortunate enough to be located in universities having other schools with departments where they can tap such resources. 

Contrary to expectations, the new curriculum in reproductive health may not entirely adopt a problem-based approach. It may be a hybrid model involving a number of learning methods. The expression of a high degree of autonomy by faculty members in the planning, and a resistance to change among faculty members, may be moderated by less radical changes. This is not necessarily negative; the new model may be a pragmatic synthesis between new and traditional medical education. Individual schools should learn from the best practices used by their outstanding teachers for more widespread application in their own institutions.

CONCLUSION

The challenge of curriculum reform for reproductive health depends on the adoption of the new philosophy of reproductive health and its integration into the curriculum. Restructuring of the curriculum must include (i) reduction in the amount of course contents; (ii) replacement of didactic teaching by active, participatory and self-initiated problem-based learning; (iii) stimulation of student interest in research; and (iv) the inclusion of primary care settings at an early stage of training. Course evaluations, originally designed for traditional lecture-based teacher-centred curricula, provide inadequate input from students to support curriculum planning and improvement. Appropriate changes must be made to existing curricula to help medical educators integrate the principles of reproductive health and the new philosophy of doctor-patient relationship into their clinical supervision and training of students.

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