Journal of Contemporary Medical Education

DOI: ???

www.scopemed.org

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INTRODUCTION

Education and health are thought to be inextricably linked to the learning and literacy contexts, as is the ongoing perspective of interdisciplinary strategies from the Galway Consensus and Inter-American Health Promotion and Health Education [1,2]. In recent times, the practice of teaching was also involved in the implementation of health strategies in schools of different complexities [3].

In addition, health promotion is a learning process that enables people to gain control of the determinants of health, thereby improving not only information on health but also acquiring healthier habits. Thus, health education is an issue that demands more than merely the cognition and dedication of health professionals who are enmeshed with the local reality [4-6].

Literature on the use of games in health education discusses their applicability in various learning situations [7]. In general, it can be said that behind the proposal of educational games are conceptual frameworks or a set of frameworks to better address

the study of a particular problem or situation [8]. Despite the frameworks available, the problematization [9] anchored in the method proposed by Charles Maguerez [10] is closely related to constructivism [11]. A conceptual combination of models depends on the complexity of the pedagogical goals involved [12] and can be considered as an innovative strategy in health education [13].

In this paper, the Charles Maguerez arch method was combined with some aspects of social learning theory to provide access to different perspectives of learning from the reality of the individuals, their lives, experiences, and prior knowledge of the cognitive, critical, reflective and autonomous development of students. This methodology required better pedagogical planning focusing on the emerging paradigm of health services that advocate the alliance between a systemic vision of public health and social approach to teaching health professionals. The pedagogical design presented herein features a broad, critical and reflective view, and construction that met the assumptions of primary care efficiency. For this process to take place, the educational game was a significant and relevant teaching resource.

Health at stake: A playful practice of meaningful learning in a medicine courseMarcelo Fernandes da Silva

Original Research

Department of Biological Sciences, Laboratory of Pharmacology and Molecular Epidemiology, Ilhéus, Bahia, Brazil

Address for correspondence:Address for correspondence: Marcelo Fernandes da Silva, Department of Biological Sciences, Laboratory of Pharmacology and Molecular Epidemiology, BA 415, km 16, zip code: 45662-900, Ilhéus, Bahia, Brazil.Phone: (55) 73 3680-5268.Fax: (55) 73 3680-5200,E-mail: mfsilva@uesc.br

Received: Received: March 06, 2014

Accepted: Accepted: July 29, 2014

Published: Published: ???

ABSTRACTObjective: This paper presents the author’s teaching experience with 1st-year medicine students and community health agents of the family health strategy in the city of Ilhéus, Bahia, Brazil, with primary healthcare as a focus. The practice of teaching and learning in medicine was herein understood as the production of knowledge through daily dialogue with healthcare services dealing with public health demands. Students enrolled in the curricular component, integrated practices of education, service and health, developed a playful feature to achieve two main objectives: (i) Strengthen the bond with agents and (ii) insert theoretical content of planning and management in public health. Method: The methodology of questioning presented by Charles Maguerez’s arch was combined with social constructivism and used to develop the game, “health at stake,” which is composed of a board and dice. The performances of students and health agents were accompanied and measured by the Chi-square or Student’s t-test with 5% of significance. Results: General analysis of the application of the game revealed its efficiency in strengthening bonds between students of medicine and agents. The subjects covered in each edition of the game identified content about which students had no prior information or which agents wanted more comprehensive knowledge. In the case of the topic, “dengue,” there was a review of the agents’ practices concerning the signs and symptoms used to differentiate the classic form from the hemorrhagic form of the disease. Conclusion: The author concluded that the game can be one of multiple strategies for training human resources in the field of health for both permanent and continuing education, as pointed out by the directives of the Brazilian Guidelines for Health Education.

KEY WORDS: Healthcare, health promotion, higher education, medicine, meaningful learning

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The insertion of medicine students in primary care unit is the first step in the learning process focusing on the acquisition of core skills and competences in public health. The community health agents (CHAs) are the most receptive to the needs of new students, but communication between health professionals and students of medicine reveals a gap that compromises the efficiency [14] of a new workforce group.

In this sense, educational games could facilitate the group’s coalition, and they have been improving the study of different aspects of health by using simple or advanced technologies and evidence of their success as learning tools is growing [15-17]. However, popular board games are not indicated as an instructional resource because they reproduce some conflicting aspects of medical practices that are clearly opposite to the Flexnerian legacy [18] of giving credit to the player who first manages the hospital as a profitable system or business rather than as an institution that provides humanitarian and comprehensive care.

Many healthcare educators have been reluctant to embrace gaming as a thoughtful form for the instruction and acquisition of core competences [7]. Medical schools have trailed behind in adopting gaming as a valid technique even as nursing schools have recognized the use of more interactive and playful activities in the learning processes [19]. Educational and theoretical evidence explains how and why such games may not work in medical teaching, when, as rarely disclosed to medicine students, the competitive element of gaming is emphasized more than the knowledge gained from the experience, changes in student’s attitudes or skills acquisition [20-24].

Games can contribute to the retention of anatomical knowledge after the learning period, which is essential for the student to be able to use and rely on a full understanding of that knowledge [25]. Such meaningful learning is usually achieved when knowledge is not restricted to learning a collection of isolated facts and is instead the result of an active learning process and of knowledge being fully understood as an experience of the learner beyond grades or scales [26].

Public health practitioners are key members of the health workforce and have a great influence on the health and wellbeing of individuals, groups, communities and populations. Despite the heterogeneity in demands and in the training of practitioners worldwide [27-29], recent policy developments have been discussing medical service routines, including issues of cost, the need to increase the provision of care to improve access, the availability of doctors, and the skills and expertise of nurses, doctors, technicians and other health professionals. It seems vital that universities equip students with high-level knowledge and skills in order to enable them to play an active role in shaping the practices that impact contemporary health [30].

This paper describes the development and assessment of a simple alternative to increase the intimacy of 1st-year students of medicine and CHAs in south Bahia, Brazil as an educational resource for learning the multiple aspects involved in health and disease processes.

METHODS

Subjects and Ethical Implications

The present paper is based on the professor’s observations of the joint work of medicine students enrolled in the curricular component, integrated practices of education, service and health (IPESH), and CHAs during one regular academic year. Despite having no ethical implications, the study complies with the Helsinki declaration [31] on ethical issues and all participants volunteered after providing informed consent.

Diagnostics of Local Health

The activities started in February 2012 and continued until December 2012 at the subdivision of family health unit in the city of Ilhéus in Bahia, Brazil. The healthcare team was composed of one general practitioner, one nurse, three nurse technicians, one nutritionist, one physiotherapist, one dentist, five CHAs, and one general manager. This arrangement was responsible for 600 families (almost 3500 inhabitants) and focused on primary healthcare. Pre-scheduled consults were limited to 16-20 a day, and more than 300 persons were attended to per week as part of health programs like control of hypertension and diabetes, healthy pregnancy, vaccines, child development, women’s health and others. In this context, 10 students from the 1st year of medical school at the State University of Santa Cruz (UESC) joined the unit under the supervision of a professor. Through direct weekly observation of the living conditions of the community and the contact with residents and the healthcare team, students could perceive reality and the factors involved in the processes of health, disease and care, as well as the structure and organization of the work process in health services at the local level, thus establishing the diagnosis of the local health community.

Problematization

The diagnostics of local health was based on the methodology of questioning presented by Charles Maguerez’s arch method [10], which enables the collective construction of knowledge, starting with the observation of routine situations in a given circumstance in this case, and health service routines. After the students had theorized about the main problems that emerged during one semester, the main objective was to develop a strategy in order to propose alternatives for the intervention and resolution of the issues raised in the following semester.

Pedagogical Design

The educational practice was developed in the course of 10 encounters (each lasting 4 h), structured as follows: First encounter - Presentation of the subjects involved, objectives, contents and the proposed method (i.e., development of board game to fulfill the main objectives of a better intimacy with agents and to recognize their major demands in health service). Second encounter - Article selection for reading and comprehensive discussions. Third encounter - Reviewing

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the contents addressed in the previous encounters through discussion of educational games and production of questions to cover the contents of board game construction. Fourth encounter - Development of the board game, question cards and rehearsals. The sixth to tenth encounters were used to play each session of the game with the CHAs. The methodological strategies for data collection used during the encounters were participative observations, interviews and weekly reports and one final questionnaire to evaluate the educational practice and its methodology.

Development of the Health at Stake Game

Students were encouraged to collaborate with the CHAs to understand their needs, difficulties and the basic aspects of their job routines in a better way. Then, as an alternative to improve intimacy, the students developed a board game involving dice representing the theoretical and practical difficulties experienced and related by the CHAs. The teacher’s directives contained the following characteristics: The game should be easy to play, exciting and time saving. In brief, the game consisted of a plastic board (48 × 35 inches) with 30 numbered squares representing potential questions. The questions were pre-formulated either by students or CHAs under the teacher’s supervision. Each player was to be identified with a colored game piece and a pair of dice. The number of houses was given by dice combinations. The game was used in six sequential meetings with the following themes, such as the history of the family health strategy (FHS) in Brazil, the responsibilities of health workers, territorialization, Brazil’s new policies and legislation on health in 2012, women’s primary healthcare and dengue.

Analysis of the Results

The analysis was based on qualitative data consisting of the interpretation of 75 weekly reports and 10 individual interviews. Data was supplied via an oral presentation by the students under the evaluation of professors, community representatives and the CHAs as well as via one final questionnaire. The Chi-square test was used to evaluate the significance of the report’s results. The expected responses were considered as the equitable apportionment among all the alternatives (χ2

C) compared with the quantity of correct answers observed in the reports (χ2

R). The significant level was 5%. Differences between media and the standard deviation of grades from two or more groups were analyzed by the Student’s t or Tukey’s test respectively with a significant level of 5%. Data were analyzed using Graph Pad Prism 4 (Graphpad Software, La Jolla, CA, USA).

RESULTS

Diagnostics of Local Health

Following the diagnostics of local health and based on what was observed and reported by students regarding the work of the CHAs, the major complaints of the community were raised. Among the major issues are health exclusion (30%),

due to the difficulties to set admissions in healthcare unit, hypertension (27%) and dengue (15%). As the FHS has specific programs to attend to hypertension and dengue, the students decided to focus on the causes of health exclusion in the community. Despite the bureaucratic issues, most of the complainants referred to doctor and CHA absenteeism in their home visit routines as predicted in FHS directives. In order to communicate with the CHAs in a better way, the students developed a game to highlight those themes and create a playful practice of meaningful learning in the training of human resources in healthcare services.

Development of Health at Stake

Through the instrument of this board game, the students strengthened their bonds with the CHAs while checking the scope of their previous knowledge on (1) powers, duties and the causes of absenteeism, (2) the composition of the minimum workforce and the role of FHS, (3) mechanisms of social participation, (4) primary care in hypertension and diabetes, (5) women’s health and pregnancy, and (6) dengue. The game proved to be an effective tool with respect to its two purposes of improving intimacy among students and CHA [Figure 1] and bringing the contents necessary to CHA training. Figure 2 exhibits the evaluation of the students (n = 10) and CHAs (n = 5) in the subsequent six encounters involving game sessions. It is possible to note that both students and CHAs were able to learn more about the content with time.

Analysis of Game Sessions

The purpose of the game was to discuss complaints and introduce the content for the learning process of both students and CHAs. The CHAs notably faced difficulties in recognizing their duties and the causes leading to absenteeism [Figure 2, Game session 1]. The latter was caused mainly by delays in salary payments, infrastructural deficiencies in health service and the lack of resource support, all of which point to the municipality’s

Figure 1: (a) Socialization among students and community health agents (CHAs) before game session. (b) One typical session of health at stake. (c) Interaction among nurses, CHAs (right) and students (left) during an explanation. (d) Awards at the end of health at stake with the theme “diabetes”

dc

ba

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negligence rather than to a lack of personal motivation (not shown). The role of FHS, particularly the new policies published in 2011 and 2012, was not well understood by CHAs (Game session 2). Nonetheless, the role of CHAs in social participation had more than 60 hits [Figure 2, Game session 3]. The theme, “diabetes,” differed from the others because one of the CHAs missed all the questions, which suggested the need for restudy and new evaluation [Figure 2, Game session 4]. Women’s health and healthier pregnancy were better comprehended by both students and CHAs (Game session 5), probably because field practices on healthier pregnancy, child development and vaccination follow-ups were performed during home visits by CHAs accompanied by students as part of the problem-based learning (PBL). The theme, “dengue” (Game session 6), was useful for reviewing the differences between the classic and hemorrhagic forms of the disease (which is important for setting the severity of cases and the medical urgency) and popular knowledge that should be avoided in the conduction of suspicious cases. Students (8.38 ± 0.82) appear to have more hits than CHAs (6.23 ± 1.91; P < 0.01), which can be explained by the fact that the students theorized the themes before game sessions.

Acquisition of Skills and Competences

In order to evaluate the acquisition of skills and competencies of the students in a better way, the professor accompanied the grades through the academic year. Figure 3 makes it possible to verify the students’ performance. It was verified that the grades were consistent with skills in practice since the students were evaluated during the weekly schedules at FHU. The contribution of health at stake was clearly observed in the performance of students during the evaluation of learning in public health since their grades were significantly higher (P < 0.001) when the game´s sessions were more frequent. As part of the methodology of Charles Maguerez’s arch and PBL,

the game results were presented by the students in an oral session comprising professors (n = 4), all students enrolled in IPESH (n = 40), community representatives (n = 12) and CHAs (n = 5). Figure 4 illustrates that the strategy was well-evaluated with respect to the grades attributed by the community representatives, CHAs and the students’ peers. Criticisms were carried out by professors on the technical and scientific aspects as well as during oral presentations, which led to a reduction in the grades.

DISCUSSION

Education on health depends on several aspects, mainly the cultural and social determinants as well as the linkage between services and universities. These are involved in the delivery of capable health resources to reduce illness worldwide [32]. Public health practices require health promotion to be an important objective. Under expert supervision to perform recommended activities that would engage students, it contributes to the development of skills and competences aligned with health promotion by dealing with public health demands. In these conditions, a student’s mission usually includes more than promoting health among inhabitants; often, they experience difficulties in understanding how they can promote health given the challenges presented by social inequality and poverty [33]. Such a scenario generally leads to profound questioning and significant PBL.

Recent updates have been achieved in the Brazilian healthcare system, such as political involvement and support of health promotion projects [34]; local arrangements of social equipment like elementary schools and non-government agencies to implement health-promotion programs [35]; new policies focusing on primary healthcare [36] and the evaluation of 1st-year practitioners with respect to the FHS to increase perceptions of the effectiveness and acceptability of health-promotion programs [37].

Figure 2: Learning improvements on content used in six consecutive sessions of health at stake. The conti nuous line refers to the student’s performance and the dotted line to the community health agents (CHAs’) overall hits in each game session. χ2

C represents the proportional expected answers and χ2

R represents the correct answers observed in the groups (10 students and 5 CHA). Chi-square test with minimal signifi cance of P < 0.05

Figure 3: Impact of the health at stake in the acquisition of skills and competencies of medicine students (n = 10) of public health practices. The thin lines indicate comparison performed by statistical analysis. The arrows represent when the session games started (July) and ended (October). Student’s t-test *P < 0.001

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UESC has been stimulated to contribute to Brazilian education and health policies by offering IPESH regularly within its course on medicine in order to introduce 1st-year students of medicine to the reality of SUS, which is an attempt to establish universal, integral and equitable health access to all inhabitants over the last 25 years [38]. Contrarily, a gap is clearly observed between government efforts and the practices of the healthcare system [39], which is partly caused by health professionals disconnected from the reality of public health. Nonetheless, conservative and elitist universities are not the main source of the problem because the system of health education reflects a model of health services that still prevails in Brazil, uncertainly governed by economic measures and based in medical technology, rather than based on solidarity and humanitarianism [40].

Traditional healthcare and the basic disciplines of medical schools are rarely invited to participate in communitarian educational opportunities. Alternative methodology applied to small groups, such as board games, provide replicable models with the potential to overcome barriers to teamwork and the communication skills of students [41]. In addition, PBL has complicated routines demanding autonomy and self-control of time and the dedication required learning complex topics [42]. An example was presented by Anyanwu (2013) regarding the artless study of anatomy bearing negative factors, such as fear, stress, loss of concentration and interest, and lack of confidence. As a palliative measure, the author created “anatomy adventure,” board game on anatomy to reduce some of these pressures, emphasizing student-centered and collaborative learning styles, and adding fun to the process of learning while promoting understanding and retention of the subject. The students noted in their feedback, in very high proportions that the game was interesting, highly informative, encouraged team work and improved their attitudes to and perceptions of gross anatomy [43]. In addition to lectures and theorization, hands-on activities contributed to a better learning of anatomy by medical students [44].

Recent technological advances have allowed the achievements of virtual games in several disciplines of medical courses. Tubelo et al. (2013) created a game of family health education

in the virtual city of “Santa Fé,” by allowing students to interact with clinical cases, in the perspective of self-learning utilizing an entertainment method and evaluating individual performance [45]. More recently, Schlegel and Selfridge (2014) show an innovative approach to accommodate a large class divided into competing teams furthering collaborative skills in order to provide formative assessments and feedback for students and faculty alike, thereby enhancing learning and teaching processes [46].

In this sense, health at stake was set up as an educational, interactive and entertaining tool to understand strategically how to identify and discuss deficiencies in health promotion. Thus, it symbolizes a didactic resource that enables the contestants to be the quizzer, sponsor and evaluator of their own learning. The aim of the game was reached as a resource for training on health, since in order to cross the finish line it was necessary, rather than having luck in the dice, to have the knowledge to answer a greater number of questions. The involvement of students in the PBL contributed to better understanding beyond the reality of healthcare services and of individuals dealing with unequal social demands in Brazil. The analysis of the results presented herein indicate that health at stake contributed significantly to the learning process of both students and CHAs by using a simple, low-cost, enjoyable, playful practice of meaningful learning in the training of human resources in healthcare services.

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