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The community health program at Ramathibodi Medical School, Mahidol University, Thailand: Its effectiveness and its influences on attitudes

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The community health program at Ramathibodi Medical School, Mahidol University, Thailand: Its effectiveness and its influences on attitudes

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Content THE CO M M UNITY HEALTH P R O G R A M AT RAMATHIBODI MEDICAL SCHOOL,
MAHIDOL UNIVERSITY, THAILAND: ITS EFFECTIVENESS
AN D ITS INFLUENCES O N ATTITUDES
b y
Karaporn Eoaskoon
A Dissertation Presented to the
FACULTY O F THE G R AD U ATE S C H O O L
UNIVERSITY O F S O U TH ER N CALIFORNIA
In Partial F ulfillm ent of the
Requirements fo r the Degree
D O C TO R O F PHILOSOPHY
(Higher Education)
November 1978
UMI Number: DP24639
All rights reserved
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U N IV E R S IT Y O F S O U T H E R N C A L IF O R N IA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90 0 0 7 E o { jL L
o
'Ph. t).
/
71
E u
This dissertation, written by
IS 3
DOCTOR OF PHILOSOPHY
*
Date ......
DISSERTATION COMMITTEE
y Chairman
Waraporn Eoaskoon
under the direction of h../C.^C........... Dissertation
Committee, and approved by all its members, has
been presented to and accepted by the Dean of The
Graduate School, in partial fulfillm ent of the re
quirements for the degree of
ACKNOW LEDGEMENTS
I acknowledge the assistance of two groups of people. In the
United States, I wish to thank Dr. Leslie Wilbur, Dr. Stephen Abraham-
son, Dr. Eli Glogow, Dr. Leonard Evans, and Dr. Flavian Udinsky for
being m y doctoral committee and reviewing the text c r itic a lly . I am
grateful to Dr. Muriel Wolkow fo r her guidance and fo r the detailed
comments. Thanks go to Dr. Kaaren Hoffman fo r a ll of her advice and
assistance with the computer analysis. Dr. Jeffrey Olsen who helped
with the manuscript and Dr. Marla Knutsen who helped with the format
and style, are immensely appreciated. After the car accident, Mrs.
Evelyn Abrahamson was the doctor who nursed m e back to health, thank
you fo r her help and kindness.
The credit fo r any contributions which this work might make, how
ever, must accrue to the Rockefeller Foundation which has supported m e
a ll the way through the PhD degree and the Ramathibodi Medical School
Executive Committee: Dr. Aree Valyasevi, Dr. Rachit B u ri, Dr. Prem
B u ri, Dr. Natth Bhamarapravati, Dr. V ila i Benchakan, Dr. Channivat
Kashemsant, Dr. Uthai Rutnin, Dr. Thavi Boonchote, Dr. Sermsakdi Phen-
j a t i , and Dr. Chirapan Mathayomchantr, who d ire ct m e through the Med
ical Education Program. F in ally, I acknowledge the assistance given to
m e by Dr. Sakorn Dhanamitta fo r data collection in the north east and
the cooperation from Dr. Anuwat Limsuwan and Dr. Siripath Watthana-Ka-
setr.
it
TABLE O F CONTENTS
Page
ACKNO W LEDG EM ENTS........................................................ i i
LIST O F TABLES.............. v
Chapter
I. THE PU R PO SE AND PROBLEM............................................................... 1
General Problem Area............................................................. 1
The Problem............................................................................... 3
The Purpose...................... 8
The Questions to Be Asked................................................... 9
Statement of Hypotheses....................................................... 10
D efinition of Terms............................................................... 13
Delim itations............................ ............................................... 14
Lim itations............................................................................... 14
I I . REVIEW O F RELATED LITERATURE........................ 16
The Program Evaluation Research....................................... 16
The Innovative Programs in Community Health................ 18
Research on Community Health Programs... ............... 28
I I I . R ESEAR C H M ETHO DO LO G Y ................ 39
Selection of Sample.................................................... 39
Instrumentation Used............................................................ 40
R e lia b ility ...................... 41
Collection and Analysis of the Data................................. 42
The Procedure Used in the Structured Interview 44
IV. FINDINGS.......................................................................................... 45
Age................................ 45
Place of B irth ................ 45
Religion........................ 46
Occupation .............. 46
Income .................... 47
Place of Employment ...................................... 47
Professional Practice........................................................... 47
i i i
Chapter Page
Health Development Experience......................................... 53
Health Care Change............................................................... 53
Students' Attitudes Changed Toward the Health
System................................................................................... 59
Changes in the Attitudes of the Community
Toward the Health System.............................................. 59
Improvement of Conditions fo r the Poor......................... 63
Curriculum Reform..................... 65
Education of the School..................................................... 68
Preceptor................................................................................ 68
Hypothesis 1...................................................................... .. 73
Hypothesis 2.............................................................. 77
Hypothesis 3......................................................................... 79
Hypothesis 4......................................................................... 93
Hypothesis 5............................................................ ............ 95
Hypothesis 6......................................................................... 97
Hypothesis 7...................................... 99
Hypothesis 8...................................... 101
Hypothesis 9........................................................................ 103
Hypothesis 10......................................................................... 114
General Comments by Respondents....................................... 116
Hypothesis 11......................................................................... 122
Interview................................................................................. 138
Discussion.............................................................................. 149
V. SUM M ARY, CONCLUSIONS, AN D RECOM M ENDATIONS......................... 161
Summary..................................................................................... 161
Conclusions.................................................................. 163
Recommendations..................................................................... 166
REFERENCES....................................................................................................... 169
APPENDIXES....................................................................................................... 178
A. Questionnaire................................................................................. 179
B. Interview . .......... 197
iv
LIST O F TABLES
Table Page
1. Occupations of Fathers and Mothers of Respondents................... 48-49
2. Monthly Family Income in Bahts fo r Graduates,
Students and Interns, and Faculty............................................... 50
3. D istribution of Graduates by Province............................................ 51
4. P articipation in Health Development Programs
In Rural Areas..................................................................................... 54-56
5. Summary of Problems Occurring at Health Development
Project Cites As Reported by Each Sample Group.............. .. . 57-58
6. Statements of Respondents Regarding Changes of the
Students' Attitudes Toward the Health System........................ 60-62
7. Statements Regarding A ttitude Changes in the
Community............................................................................................... 64
8. Statements Regarding Reasons fo r Participating or
Not Participating in Curriculum Reform..................................... 66-67
9. Statements Regarding Reasons fo r Cooperating With
the Education of the School........................................................... 69
10. Statements Regarding the Roles of the Preceptor
and Other S taff Members................................................................ 71-72
11. Differences in Responses to Statements Concerning
the Program Goals.............................. 74-75
12. Differences in Responses to Statements Concerning
the Program Experiences Meeting the Needs of Students.... 78
13. Differences in Responses to Statements Concerning
the Demographic Survey Course........................ 80-81
14. Differences in Responses to Statements Concerning
the Analysis of Community Health Problems Course................ 84
15. Differences in Responses to Statements Concerning
the Community Health Planning Course................ 86-87
v
Table Page
16. Differences in Responses to Statements Concerning
the Community Health Clerkship Course ............... 89
17. Differences in Responses to Statements Concerning
the Internship in Community Health Course................ 92
18. Differences in Responses Concerning the
Overall Quality of the Five Courses............................... 94
19. Differences in Responses Concerning the
Usefulness of the Courses................................................... 96
20. Differences in Responses Concerning the
Quality of the Teaching Methods....................................... 98
21. Differences in Responses Concerning the
Amount of Time Given to Each Course.............................. 100
22. Differences in Responses Concerning the
Amount of Material Covered in Each Course................... 102
23. Differences in Responses to Statements Concerning
the C H P Learning Experiences............................................. 104
24. Statements of Respondents Regarding Their
Satisfaction With the CHP................................................... 106
25. Statements of Respondents Regarding Their
Dissatisfaction With the CHP............................................. 107-108
26. Statements of Respondents Regarding Changes
Including Adding Courses to the CHP.............. 110-111
27. Statements of Respondents Regarding Knowledge and
S k ills Acquired From Their Fieldwork........................ 112-113
28. Differences in Responses to Statements Concerning
the Impact of C H P on Future Careers. ............ 115
29. Statements of Respondents Regarding Their
General Opinions of the CHP............................................. 117-121
30. Frequency of Total Score Means of Responses................... 124
31. Rank Orders of Item Means of Responses............................. 126
v i
Table Page
32. Differences in Attitudes Expressed Toward
the Professions and the C lin ica l Management.................. 127-129
33. Differences in Attitudes Expressed Toward
the Poor People and the Health System............................. 133
34. Differences in Responses Concerning
Each Hypothesis....................................................................... 135-137
y ii
CHAPTER I
THE PU R PO SE AND PR O BLEM
General Problem Area
During the past twenty years, many countries have expressed an
increased concern fo r the q u a lity of health care delivery and the ac
cess to health education. Consequently, medical schools have been in
volved in external and internal controversy as to when, where, why, and
how to develop an e ffic ie n t system. One suggestion proposed by Lathem
(1977) is that medical schools in developing countries should be organ
ized and oriented on the basis of health problems such as communicable
diseases, n u tritio n , and population rather than disciplines and con
ventional departments. Hansen and Reeb (1970) also challenged the
v a lid ity of the assumption that i f physicians were competently educated
w ithin the various disciplines and subspecialties, an effective health
care delivery system would re su lt.
Presently health care in most countries is fragmented, uncoordi
nated, and expensive. Perhaps one of the greatest hindrances to ade
quate health care in these areas is the shortage of physicians. At any
rate, much of the lite ra tu re seems to support this contention. Mason
(1972) indicated that the problem is not simply one of absolute numbers,
but one of an imbalance in the d is trib u tio n of physicians. The imbal-
1
ance relating to physician density, as well as geographic location and
d is trib u tio n w ithin specialties, has been cited as the main area of
concern and possible focal point around which fu rth e r research must be
directed. Hansen and Reeb (1970) reported the problem may be that
medical schools have placed too high a p rio rity on the s c ie n tific ex
cellence of medical specialties. Ducker (1977) suggested that fear of
professional isolation may be one factor preventing physicians from
s e ttlin g in nonmetropolitan areas. Castleton (1970) believed that
other factors involved include the inadequacy of hospital f a c ilitie s
and equipment and the lack of opportunity fo r continuing education.
Parker and T u xill (1967), Bible (1970), Champion and Olsen (1971),
Taylor, Dickman, and Kane (1973), Heald, Cooper, and Coleman (1974)
found that opportunities fo r continuing education and fo r a v a ila b ility
of c lin ic a l support are important determinants of geographic and
specialty choices. In addition, Harell (1973) pointed out that wives
are not w illin g to liv e in small towns and to raise th e ir children
with the lim ited cultural and educational resources available.
In an attempt to solve the problems of geographic and specialty
imbalance, several alternatives have been proposed which would a ttra c t
physicians to rural areas. Yett and Sloan (1974) found that states
which subsidize th e ir medical students a ll the way through internships
or residency retain more physicians than those who do not subsidize.
Kegel-Flom (.1977) found that certain personality measures, in addition
to place of rural o rig in , should be considered as a part of the admis
sion interview. Pinchoff, In g a ll, and Crage (1977) suggested that,
2
fo r those medical students who are born in urban areas and are unfamil-
a ir with rural li f e and practice, a rural externship program, which
provides living-working experience in a rural setting, encourages them
to enter rural practice.
Knowles (1966) states that "there is one crucial area where I be
lieve both the teaching hospital and medical schools have fa ile d and
that is in the area of planning fo r the health needs of communities"
(p. 931). Medical schools have responded by creating the community
education program intended to strengthen the health system. However,
community health, in contrast to c lin ic a l medicine, is as yet a new
fie ld that needs much more research and evaluation to plan fo r improve
ment.
The Problem
The previously mentioned problems of health care delivery in most
countries, especially the United States, are also specific health
problems in Thailand.
Thailand is situated in Southeast Asia, with Burma on the west,
Laos and Cambodia on the east, Malaysia to the south,and Burma and
Laos to the north. I t has a land area of 518,000 square miles and a
population estimated at 40,000,000. Eighty fiv e percent of the na
tio n 's population liv e in rural areas and the cultural and economic
foundation of the nation is ric e farming (Buri, Khanjanasthiti, Limsu-
wan, Phanchet, Bryant, Stewart, and Wray, 1974). Thailand consists of
71 provinces. Each province is diyided into 8 to 10 amphurs and each
3
amphur into 8 to 10 tambons. One tambon has 8 to 12 villag e s. There
are 84 provincial hospitals, each with 12 to 20 physicians. In each
amphur there is a health center in which a single physician is sup
posed to handle the curative, preventive, and promotive aspects of the
health care system. Furthermore, at only 252 of these centers is there
even one M.D. and, in most cases, the health centers have only a nurse
to handle the health care needs. In each tambon there is only a health
station or a maternity c lin ic supervised by health personnel with
lim ited knowledge, such as midwives and other paramedics. There are
50,000 villages in which there are no government health o ffic ia ls at
a ll. The people in these villages have to rely upon private pharmaceu
tic a l shops, old Thai medicine, quacks or magic (Tungsubutra, 1976).
An "illn e ss behavior" survey conducted by the M inistry of Health, the
Faculty of Public Health, and the World Health Organization (W HO )
showed that when people get sick, 52% buy medicine on th e ir own, 33%
v is it c lin ic s or hospitals, 8% v is it tra d itio n a l healers and quacks,
5% v is it health centers, 3% take treatment but do not answer question
naires (Buri, 1972). I t is no wonder that the q u a lity of medical care
is so poor!
The doctor/population ra tio is 1 to 7,000 in the whole country;
i t is about 1 to 1,000 in Bangkok, about 1 to 20,000 fo r the re st of
the country, and in tru ly rural area i t is less than 1 to 100,000
(Buri et a l., 1974).
I t is generally considered that population growth leads to major
health problems (Wray, 1974). In Thailand the annual population growth
4
rate is 3.3% (Dinning, 1974), which is one of the highest in the world.
The leading causes of death are major health problems such as m alnutri
tio n , venereal diseases, malaria, hemorrhagic fever, trachoma, leprosy, .
and rheumatic heart diseases (Buri et a l., 1974).
In Thailand there are now seven medical schools, including four in
Bangkok, one in the north, one in the south, and one in the east.
There is considerable d iv e rs ity in th e ir educational programs. How
ever, they are sim ilar in one important respect: the educational goal
in each instance has been to produce a hospital-oriented, s c ie n tis t
c lin ic ia n . I t should be no surprise that few graduates of the system
have been attracted to the M inistry of Health (Bryant, 1969).
There can no longer be any question, but that Thailand is faced
with a serious doctor shortage, which is d a ily becoming more severe.
Technical advances, medical therapeutic progress, greater use of aux
ilia r y personnel, and urbanization, have resulted in a marked increase
in physician productivity. Yet, i t is easily perceptible that these
positive factors have been overbalanced by negative factors such as a
population growth that has outdistanced the number of physicians in
private practice. Other negative factors include an "explosion of de
mand" fo r health services due to higher income and education levels in.
Bangkok, the aging of the population with the attendant increase in
chronic diseases, and added demands upon the physician's time because
of highly complex diagnostic and therapeutic procedures that were un
known only two decades ago.
There are three additional problems, which have accentuated the
5
physician shortage in Thailand. F irs t, there are those physicians who
receive training in urban centers such as Bangkok and w ill not work in
rural areas. Secondly, there are those who receive such training and
then find employment in foreign countries. T h ird ly, there are Thai
citize n s, who graduate from American and German medical schools, and do
not return to th e ir homeland. These three problems create what is
called "the brain drain."
The problem of brain drain can be attributed to two factors, one
internal and the other international. F irs t, very often the capable,
well-educated physician chooses to work in the c ity and leaves the poor
areas to less capable professionals. Even students who graduate from
a country college or university compete with each other in order to
liv e in big c itie s . Secondly, graduates from the under-developed
countries are attracted to work in well-developed countries and a large
percentage of physicians from Asian countries such as Korea, Taiwan,
P h ilip p in e s , India, and Thailand seek employment in Europe and the
United States.
The brain drain is a complex problem because i t re fle cts the
p o litic a l and economic system, as well as existing social values. La-
them (1976) points out how d if f ic u lt i t is to solve the problem unless
the p o litic a l system, the economic system, and social values are
changed.
The question of whether there is a national shortage of physicians
or whether the apparent shortage is merely a matter of d is trib u tio n
has been of considerable general interest in recent years. The inade
6
quacy of medical care fo r rural Thailand has received attention both
from medical schools and the M inistry of Health.
In 1972, Thailand passed the compulsory service law under which
most medical school graduates must serve fo r three years. Graduates
are to divide th e ir time between rural health services and hospital
services (Bryant, 1969). O n the basis of th is law the medical school
makes a commitment of its education and research resources to the
health care delivery in rural areas.(Buri et a l ., 1974).
As a re su lt of th is law, the Ramathibodi Medical School offers the
Community Health Program (CHP) consisting of fiv e courses extending
over four years including one year internship, fo r the purpose of pre
paring physicians to work in a rural setting. The school's basic as
sumption and rationale is that health care delivery is a human rig h t,
not a p rivile g e . The curriculum committees and the C H P s ta ff feel
that physicians have a negative a ttitu d e toward practicing in rural
areas due to a lack of information about and experience with health
services in rural communities.
The attitudes and performance of the medical students are very
important and must be measured. The usual examination and te st proce
dures are inadequate fo r th is purpose. As Alibazah 0972) pointed out,
program goals and objectives which have been formulated by fa cu lty spe
cialized in biomedical disciplines should be ca re fu lly debated by stu
dents and practitio n e rs. The C H P has been planned since 1967 and there
are several classes of students who have graduated from the program.
There has been no study of the effectiveness of th is program to provide
7
information fo r alternative future development, nor has follow-up data
been collected on the graduates who now work in various parts of Thai
land.
The Purpose
The purpose of th is research was to study selected aspects of the
instructional programs in C H P at Ramathibodi Medical School. This in
vestigator believed that by s o lic itin g the opinions of fa cu lty and stu
dents who are or have been d ire c tly involved in the program (members of
the curriculum committee, teaching fa c u lty , graduate students, and
undergraduate students) i t would be possible to id e n tify specific
weaknesses in the program and to make appropriate recommendations fo r
its improvement. Pauli (1973) indicated that the problems that beset
curriculum designers today are the questions of educational objectives,
whether they are present and, i f so, whether they are put into opera
tion. Judgement is often d if f ic u lt . The present study focused on
aspects of the learning experiences in terms of the stated goals and
objectives of the program. Five courses in the program were selected
fo r study. They were Demographic Survey, Analysis of Community Health
Problems, Community Health Planning, Clerkship in Community Health,
and Internship in Community Health.
The research study's main intent was to contribute to the develop
ment of an e ffe ctive C H P in Thailand, since this program is the only
one which trains physicians to meet the health care needs of the coun
try . I t was believed that the information obtained would provide a
8
basis fo r p r io rity decisions regarding the improvement of various as
pects of educational programs, and the p ilo t study would lead to needed
changes in the curriculum.
The Questions to Be Asked
The study sought to determine answers to the following questions
from three sample groups: (a) graduates of the CHP, (b) students and
interns, (c) members of the curriculum committee and teaching s ta ff.
1. W as the course content s p e c ific a lly structured to enable stu
dents to accomplish the stated goals?
2. Were students able to accomplish the learning objectives of
the selected courses of the CHP?
3. What was the overall q u a lity of each course of the C H P?
4. What was the usefulness of each course of the CH P?
5. What was the q u a lity of the .teaching methods of each course
of the C H P?
6. How appropriate was the time given to each course of the CH P?
7. How appropriate was the material covered in each course of
the CHP?
8. What were the most successful aspects of the program?
9. What were the least successful aspects of the program?
10. What learning experiences not presently provided should be
added to the program?
11. What were the knowledge or s k ills from fie ld work which were
not taught in the classroom?
9
12. Did the C H P help them practice th e ir future careers?
13. Did they prefer general practice or specialty practice?
14. What were th e ir attitudes toward the professions?
15. What were th e ir attitudes toward the c lin ic a l management?
16. Did they have a positive a ttitu d e toward the poor people?
17. Did they have a positive a ttitu d e toward the health system?
Statement of Hypotheses
The hypotheses of th is study are as follows:
Hypothesis 1. There w ill be no differences among students-and-
interns, graduates, and facu lty groups in opinions expressed
concerning whether the course content enables students to
accomplish the program goals.
Hypothesis 2. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
concerning how experiences provided by the program meet the
needs of the students.
Hypothesis 3. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding students' a b ility to accomplish the learning
objectives of the selected courses.
Subhypothesis 1. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in opin
ions expressed regarding the course, Demographic Survey.
10
Subhypothesis 2. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
opinions expressed regarding the course, Analysis of the
Community Health Problems.
Subhypothesis 3 . There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
opinions expressed regarding the course, Community Health
Planning.
Subhypothesis 4. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
opinions expressed regarding the course, Community Health
Clerkship.
Subhypothesis 5. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
opinions expressed regarding the course, Internship in Com m u
n ity Health.
Hypothesis 4. There w ill be no differences among students-and-
interns, graduates, and faculty groups in opinions expressed
regarding the overall q u ality of each course of the CHP.
Hypothesis 5. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the usefulness of each course of the CHP.
1 1
Hypothesis 6. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the q u a lity of the teaching methods of each course
of the CHP.
Hypothesis 7. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the amount of time given to each course of the CHP.
Hypothesis 8. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the amount of material covered in each course of the
CHP.
Hypothesis 9. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the learning experiences included in the program.
Hypothesis 10. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in opinions expressed
regarding the impact of the C H P on future careers.
Hypothesis 11. There w ill be no differences among students-and-
interns, graduates, and fa cu lty groups in the statements
expressed regarding the a ttitu d in a l factors.
Subhypothesis 1. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
attitudes toward the professions.
12
Subhypothesis 2. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
attitudes toward the c lin ic a l management.
Subhypothesis 3. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
attitudes toward the poor people.
Subhypothesis 4. There w ill be no differences among
students-and-interns, graduates, and fa cu lty groups in
attitudes toward the health system.
D efinitio n of Terms
Community Health—A ll those a c tiv itie s involved in the delivery
of comprehensive and integrated health care to a defined population
by a team of health workers led by a physician in order to improve the
health of the community.
Integrated health care--Health care delivery that includes pre
ventive, promotive, and curative care.
A defined population--A designated area in a remote section and
an urban slum section of Thailand in which a need fo r more health
service has been indicated by the o ffic e of the M inistry of the Public
Health.
A team of health workers—Physicians directed group which includes
nurses, social workers, technicians, health workers, who are respon
sible fo r the to ta l health care of the population in a giyen d is tr ic t.
13
Bang Pa-In, central p la in --A rural d is tr ic t of 50,000 people
which is served by one primary health center with one doctor as the
leader of some 20-25 members of the health team and a number of
s a te llite centers.
Demography--The study of mankind c o lle c tiv e ly , especially of
th e ir geographical d is trib u tio n and physical environment.
Clerkship--A six week practice in the d is t r ic t (Bang Pa-In) in
the fin a l c lin ic a l year.
Delim itations
1. The study was delimited to sixth year medical students who
had already taken the CHP, and interns at the Ramathibodi
Medical School who were completing the la s t part of the pro
gram.
2. The study was delimited to the graduates of the program who
worked in rural areas in various parts of Thailand and/or the
suburbs of Bangkok.
3. The study was delimited to the C H P teachers and the cu rricu
lum committee at the Ramathibodi Medical School.
Lim itations
1. No randomization was used in selecting subjects fo r the study.
Only graduates who worked in rural areas or suburbs of Bang
kok, sixth year students and interns, and curriculum committee
members and teachers of the C H P were included.
14
2. Variables associated with the population sample such as the
personality, age, and the length of experiences were not
control!ed.
3. A ll the variables associated with the teaching methods
(lectures, demonstrations, fie ld trip s , audio-visual tech
niques, and group p a rticip a tio n ) were not controlled.
15
CHAPTER II
REVIEW O F RELATED LITERATURE
The lite ra tu re related to th is study has been arranged under the
following headings: (1) program evaluation research; (2) innovative
programs in community health; and (3) research on community health pro
grams.
The Program Evaluation Research
The importance of evaluating medical education programs has been
emphasized by many sp e cia lists. A study by Udinsky, Keefe, and Housden
(1972) found that schools are slow to change, p a rtic u la rly i f the
change affects many parts of the system. Coggeshall (1965), in a book
e n title d “ Planning fo r Medical Progress Through Education-," indicated
that:
The medical curriculum currently needs reconsideration,
reevaluation, and revision . . . . There is need fo r
reexamination of curriculum to elim inate both d u p li
cation and subject matter not essential to subsequent
education and practice. There is p a rticu la r need to
encourage member in s titu tio n s to give more intensive
attention to curriculum evaluation, (p. 69)
Funkenstein (1975) suggested that
Each change, whether curriculum or noncurricular, should
be assessed in terms of it s possible effects on the
learning and personal development of students. W hen
16
in s titu te d , i t should be made the subject of constant
evaluation so that any unfortunate consequences can be
detected and remedied without delay, (p. 67)
According to Abrahamson (1968), evaluation should be understood as
"a concept and a process. A continuous process, ' based upon c rite ria
cooperatively developed and concerned with status of and changes in
behavior of the learners" (p. 625).
Bellman and Remmers (1968) gave a more specific d e fin itio n of the
process saying "the evaluation process can be applied to three broad
areas of tra in in g : s k ills , knowledge, and attitudes" (p. 29).
In evaluating these areas, the need fo r defining objectives has
often been emphasized. Kelley and Wilbur (1970) stated that
I t is of major importance that the in stru cto r define the
objectives as cle a rly as possible, inasmuch as the
evaluation is based on the achievement of these objec
tive s. The more cle a rly the objectives are defined, the
easier i t is to decide what means of evaluation should
be used. (p. 175)
Roush (1973) suggested that course objectives are perhaps the
best method of evaluating in structio n . I f the students accomplish the
prescribed objectives, the teaching methods can be considered at least
adequate. Also, course objectives can be used to develop evaluative
instruments fo r obtaining student opinion of the teaching they receive
during a clerkship.
Schulberg and Baker (1969) noted that
The most c r itic a l and d if f ic u lt phase in the process of
program evaluation is c la rific a tio n of a program's
objectives. This emphasis stems from a conception of
evaluation as measurement of the degree of success or
fa ilu re encountered by the program in reaching prede
termined objectives, (p. 565)
17
Schulberg and Baker (1969) fu rth e r suggested that program evalu
ation consists of two research models: the goal-attainment model, and
the system model.
These two concepts were described by James (1962) and Etzioni
(1960). James described the goal-attainment evaluation process as
c irc u la r, i t starts with in it ia l goal-setting, proceeds to a determi
nation of the measures of the goal, turns to co llection of data ap
praising the e ffe ct of the goal, and then modifies the in it ia l goal on
the basis of the collected data. Etzioni pointed out that the system
model is concerned with establishing a working model of a social u n it
which is capable of achieving a goal and is a m ultifunctional u n it.
Wilbur (1968) described the evaluation tools to be used by health
personnel to produce change:
Evaluation c rite ria fo r educational programs should always
be in terms of what people have learned. And, to be even
more demanding, in terms of how people use what they have
learned in actual health behavior . . . . Achievement eval
uation shows the success in attaining long-term objec
tives. Progress evaluation of the phases or objectives
fo r each year serves as a guide in making any necessary
changes in the program, (p. 25)
Keairness (1970) stressed the importance of feedback at the na
tional Conference and Workshop on Evaluation, I llin o is , as follows:
W hen used fo r learning or planning, program evaluation
attempts to assist the s ta ff and advisory committees
through a continuous feedback process to improve the
q u a lity of th e ir decisions and actions. This is the
tra d itio n a l planning-action-evaluation cycle, (p. 104)
The Innovative Programs in Community Health
Many authorities have suggested that the education of a physician
18
must include an intim ate knowledge of people and th e ir problems as well
as s c ie n tific know-how. The Operation Guide fo r Rural Centers,
started with the help of the Rockefeller Foundation some 46 years ago,
defined the f i r s t duty of the health s ta ff as "Know your area--Know
your people" (Ramakrishna, 1962, p. 147). James (1967) indicated that
to deal e ffe c tiv e ly with the problems o f today and tomorrow, medical
education must be organized around the patient and his fam ily, must
concern it s e lf with social needs and relationships to society.
Bloom (1973) emphasized that
The purpose of a medical school is not to produce
Nobel Prize winners. I t is rather to provide doctors
fo r the health services who w ill meet the health
needs of the country in which they are trained or of
countries that lack adequate health resources, and
the extent to which th is purpose is f u lf ille d depends
not only on the education they receive but also on
the processes of selection fo r that education, (p. 94)
H illis (1968) suggested that the problem facing medical education
and medical care is "how to unite knowledge and s k ill in education, in
the care of patients, and in continuing education so that our p ra c ti
tioners might practice at the level of maximum s k ill? " (p. 56)
Mechanic and Newton (1975) indicated that medical educators must
go beyond the attempt to teach the medical student lo fty values and
ideals. They must supplement such teaching by promoting the conditions
of practice and patient care that allow lo fty values to be implemented
in practice.
Prywes (1973) suggested that medical students are sometimes eager
to go out into the community to "help people" but are not prepared to
19
do i t as a permanent professional commitment, even in the developing
countries where such service is urgent.
Debr& (1967) stated that
Although the world has become quite small, the communities
have remained quite d iffe re n t. Each of them has d iffe re n t
health problems . . . . Each nation requires doctors of
the highest q u a lity but they must be trained fo r d iffe re n t
tasks, d iffe re n tly practiced in d iffe re n t communities.
(p. 73)
Despite the acknowledged importance of providing community expe
riences to medical students, comparatively few schools have as yet
implemented extensive community health programs. However, several in
novative approaches have been described in the lite ra tu re .
Community Medicine at the University of the Philippines
Campos (1970) described the following program objectives:
1. To tra in medical, paramedical, and public health students
at both undergraduate and graduate levels. In addition,
th is f a c ilit y can be the laboratory fo r sociologists,
health educators, anthropologists, and other academic
specialists of the university.
2. To explore new approaches and new methods fo r the delivery
of public health care, medical care, and other health
services.
3. To present a pattern fo r the country's public health agen
cies, and possibly become a future tra in in g ground of
public health personnel.
4. To experiment with a d iffe re n t approach from to ta l depen
dence on the government fo r bringing the benefits of
medical care to the people.
5. To teach the people of the community how to cooperate with
the health agencies so that they can receive maximum
benefits w ithin the lim ited resources that can be channeled
to them.
6. To study the numerous problems in health which can be better
investigated in such a fie ld laboratory, (p. 35)
Campos (1970) fu rth e r explained the a c tiv itie s of the Comprehen
sive Community Health Program which was c la ssifie d under three headings:
20
(1) the tra ining program with the aim of producing physicians who can
engage in general medicine and surgical practice in the rural areas of
the country, (2) the service program which consists of two aspects:
medical and public health, and (3) the research program with numerous
investigations into health problems.
Community Medicine at the U niversity of V alle, C ali, Colombia
Aguire (1970) described the objectives of the program as follows:
1. To provide the student with formative experiences that w ill
help him develop the proper background, m otivation, and a t t i
tudes to function e ffe c tiv e ly in the community—force the
students to think and act in terms of health and not ju s t of
illn e s s ; force him to think and act in terms of the fam ily and
the community and not ju s t of the individual patient; assist
him to make decisions based on logic and the s c ie n tific
method and stimulate his c re a tiv ity and imagination; lead him
to think in terms of opportunities; convince him that a physi
cian is but one member of a complex in te rd is c ip lin a ry health
team.
2. To organize research a c tiv itie s in the community.
3. To investigate methods and systems fo r delivery of health care
to determine which w ill best meet the needs and ch a ra cte ris-'
tic s of our region, (p. 52)
The student was exposed to the community through academic courses
and fie ld experience in the d iffe re n t community medicine centers during
his e n tire seven years. The cu rricu la r a c tiv itie s consisted of Hu
manities, Tutorial Plan, B io s ta tis tic s , Social Sciences, Human Ecology
and Sociodemography, Family and Community Medicine, Epidemiology and
Communicable Diseases, and Community Medicine.
Community Medicine at Makerere University College, Kampala, Uganda
Lutwama (1970) indicated that the objectives of community medicine
is to bring the whole spectrum of health seryices to a ll segments of
the community. The basic health services consisted of health education
21
maternal and child health--including re h a b ilita tio n and n u tritio n , com
municable disease control, environmental sanitation, home v is itin g ,
fam ily health--including g e ria tric s , demography and v ita l s ta tis tic s ,
and curative service. The program was divided into ten weeks with the
tra ining of Community Health at Kasangati, Ankole D is tric t V is it,
Urban Health, Seminars, Occupational Health, Family Health, S ta tis tic s
and Epidemiology, Communicable Disease, Review of Work Submitted and
Examination.
Community Medicine at the A ll India In s titu te of Medical Sciences
Allen (1970) described the program objectives as follows:
To evolve a pattern of comprehensive health services
considered feasible and adequate fo r Ballabhagarh C D
blocks at a reasonably appropriate date in the fu
ture; and to develop an extramural organization
capable of providing practical experience in a com
prehensive rural health program to undergraduate
medical students, nursing students, and other cate
gories of health science personnel. I t is expected
that the project w ill serve as an example fo r other
medical education and health science tra in in g centers
in India, (p. 81)
Five departments—Medicine, Surgery, Pediatrics, Obstetrics and
Gynaecology, and Preventive and Social Medicine--had the main respon
s i b il it y fo r developing and carrying out the program. Every intern
spent a three-month period in the project, one quarter of the intern
class (about 12 students) being assigned at a time.
Community Medicine at the University of Ibadan, Nigeria
Lucas (1970) said that a program in community medicine was de
signed fo r the tra ining of students in the main aspects of medical care
in rural areas.
22
During the fourth year the medical students were sent to the
Ibarapa Project with an introduction to the environment, some courses
in the behavioral sciences, s ta tis tic s and v is itin g a small community
in Ibadan where they could see some of the problems f i r s t hand; prob
lems in environmental sanitation and epidemiology. In th e ir f i f t h and
fin a l year, students took part in a series of seminars and symposia.
University of Pennsylvania Program
The objective of the University of Pennsylvania program was to
stimulate the students to study a ll those factors in the fam ily which
influenced health or disease. Throughout th e ir four years of tra in in g ,
f i r s t year medical students had frequent contact with individuals in
th e ir homes as the medical advisor. Members of the departments of
medicine, preventive medicine, psychiatry, p ediatrics, surgery, and
social service participated in the program. For teaching, the class
was divided into groups of eight students per teaching group. Each
group was supervised by a fa cu lty of three. There were two c lin ic ia n s ,
one of whom was a p syc h ia tris t, and a social worker (Clark, 1952).
The State University College of Medicine at New York City
Clark ('1952) described how students learn through community agency
p a rticip a tio n .
A lim ited number of first-and-second-year students may elect
assignment to fam ily social agencies, one half-day weekly
fo r eight weeks, and participa te in the solution of short
term problems of selected fam ilies.. Besides learning to
appreciate the role of an organized community agency and the
assistance i t can be to the physician, th is program seeks
to provide experience in the a rt of establishing a profes
sional relationship, (p. 56)
23
Boston University School of Medicine
Weisbuch, French, Rubel, and Manoharan (1973) described the
Teaching Elements of Community and Family Medicine to medical under
graduates with the goals:
To teach the basic principles of community and fam ily
medicine and to provide every student an opportunity
to apply these principles in a community setting.
(p. 953)
The fiv e elements which were taught were p rim a rily prevention;
the principles of comprehensive health care; the relationship of the
physical and occupational environment to health, health care, and
disease; the q u antitative methods used in problem-solving--epidemio-
logy, b io s ta tis tic s ; and decision analysis.
These courses were offered to the students during th e ir f i r s t ,
second, and fourth years.
W AM I (Washington, Alaska, Montana, Idaho) Program
Schwarz (1973) indicated that the W AM I regions have too few
physicians and only the State of Washington has a medical school;
Alaska, Montana, and Idaho have to depend on schools located in other
states to tra in th e ir students.
The students received the f i r s t portion of th e ir medical school
tra ining at selected un ive rsities in the W AM I region. At the con
clusion of the f i r s t two years, the students entered the elective phase
of th e ir education in which they would receive part of th e ir training
at the university of Washington School of Medicine and part of th e ir
c lin ic a l education from physicians in the communities where the physi
24
cians lived and practiced. These la tte r "community c lin ic a l u n its ,"
which would be established fo r a given educational need (such as pedi
a tric s and fam ily medicine), might also be used fo r a portion of the
residency tra in in g in the p a rticu la r d is c ip lin e . To accomplish th is ,
formal educational contracts would be w ritte n with the physicians to
define the re s p o n sib ilitie s of both parties. In addition, the physi
cians would be given fa cu lty status at the University of Washington.
Consequently, the students could move th e ir fam ilies to the community
so that the e ntire fam ily would be involved with community a c tiv itie s
and the people. In th is way, i t was hoped that the fam ily, including
student and resident, would be influenced to return to communities of
th is type to practice.
University of Minnesota Medical School
Verby and Connolly (1972) described the objectives of the program:
1. To contribute to the care of a population of patients in
a community while learning the principles of primary
health care delivery.
2. To provide the student with the opportunity to see and
experience lif e as a physician in nonurban setting and
to c la r ify fo r him a physician's place in society, his
social and c iv ic obligations, and his re s p o n sib ilitie s
to patients.
3. To observe how a llie d health personnel support the d e liv
ery of primary care and how they function in the commu
n ity .
4. To study fam ilies "in depth," and to evaluate the in d i
vidual members and th e ir roles w ithin the fam ily c irc le .
5. To give a student knowledge and experience in the proper
use of consultation and r e fe r r a l.
6. To discover variables that a ffe c t the doctor-patient re la
tionship.
7. To confront medical-legal problems and the importance of
complete history and physical findings and records fo r
court testimony.
8. To become acquainted w ith the treatment of common com-
25
p la in ts that are often seen in a fam ily physician's
o ffic e but seldom seen at the medical school.
9. To be made aware of the roles of the various a llie d
health personnel and services provided fo r the patient
during hospitalization.
10. To be exposed to the roles that sp ecialists provide
fo r the benefit of th e ir patients; th is experience
reveals the importance of good interprofessional
relationships between fam ily p ra c titio n e rs , specialty
colleagues, and other professionals such as dentists
and lawyers.
11. To make a student feel more comfortable, confident,
and p ro fic ie n t in almost a ll phases of health and
disease care delivery.
12. To make a student recognize the d iffic u ltie s and the
stresses faced by the practicing physician and learn
how to cope with them.
13. To make a student begin to experience the delights
and pleasures of applying his new knowledge to patient
care. (p. 907)
Under the program, fourth-year medical students spent one year
with practicing physicians in the rural areas of the state and were
paid $10,000 fo r the year--$5000 from le g is la tiv e funds and $5000 from
the rural physicians who served as extended fa cu lty members of the
Department of Family Practice. The students received two quarters of
academic c re d it fo r the year's experience and returned to the medical
school fo r three elective quarters to strengthen the areas of weak
nesses which the program had helped them to recognize.
Mount Sinai School of Medicine
Stewart, Richstone, Greene, and Lange (.1977) described the commu
n ity medicine clerkship at Mount Sinai School of Medicine. The goals
were to provide students with an opportunity fo r problem d e fin itio n
and problem analysis in community health terms. The program descrip
tio n is as follows:
26
A ll students carry out independent studies during th e ir
community medicine clerkship. The research team at
Elmhurst, including four fu ll-tim e s ta ff members with
backgrounds in operations research, b io s ta tis tic s ,
medical sociology, and health education, provides onside
assistance in project design, data c o lle c tio n , and
analysis. Students are strongly encouraged to choose
project topics which have practical im plications fo r
the delivery of ambulatory care. Most student projects
at Elmhurst can be grouped into one of six topic
areas: q u a lity of care assessment, development of
protocols fo r disease management, analysis of needs fo r
patient education and/or preventive intervention, organ
ization of ambulatory services, systems approaches to
ambulatory care, and epidemiological studies in the
c lin ic s , (p. 145)
Dartmouth Medical School
Johnson and Haugton (1975) described an outreach program fo r
Dartmouth Medical School which u tiliz e d rural communities in the edu
cation and tra in in g of medical students and residents in primary care.
The curriculum was in operation fo r three years. I t included epide
miology, systems of health care, medical sociology, psychiatry (deal
ing with e th ics), personality development, human sexuality, alcoholism,
and introduction to health care (through fie ld trip s , readings, and
seminar discussions and including introductions to community health
f a c ilit ie s , agencies, and physicians and to the issues and problems in
delivery of health care).
England and Scotland Community Medicine
In England and Scotland, the community medicine was offered under
the postgraduate programs which led to the granting of a university
degree or diploma evolving out of the former programs in public health
(Diploma of Public Health) (Yerby, 1976).
27
The program was of 2 to 4 academic years duration with the
follow ing objectives:
The u n ive rsity postgraduate program would emphasize
s ta tis tic s , epidemiology, behavioral sciences, the
development and organization of medical and related
services, and the principles of adm inistration and
management. Included would be a series of discussions
with general p ractitio n e rs and sp e cialists concerning
current problems and future directions in th e ir fie ld s .
The academic program would be followed by at least 1^
years of "community-site teaching." The fin a l year
would be spent in the university to enable the trainee
to focus and c la r ify his experience, complete the
d e ta ils of any project work he was given and perhaps
w rite a thesis fo r a master’ s or doctoral degree.
(p. 36)
Research on Community Health Programs
Only a few research studies haye been done to determine the e ffe c
tiveness of innovations in community health. However, these studies
did not use goals and objectives of the course as the bases fo r th e ir
evaluations. The following research studies haye trie d to measure the
effectiveness of the community health program.
Johnson, Kiyel, and Branhil1 (1967) described the evaluation of
the 1967 C alifornia Student Health Project. One hundred and ten stu^
dents worked in three areas.: Northern C a lifo rn ia , prim arily San Fran
cisco and the Bay area; the San Joquin Valley, Fresno, and six rural
towns; and Southern C alifornia, The overall, o b je c tiy e o f the program
was to provide a learning by working experience with poor people to
improve th e ir attitudes toward poor people. Information collected
from (a) da ily logs (diaries) w ritte n by students, (b) tape-recorded
interview of students, and (c) a ttitu d e and demographic questionnaires
28
were analyzed in the Division of Research in Medical Education, School
of Medicine, U niversity of Southern C a liforn ia . The response of the
participants to the project was favorable. Much new learning was ac
quired, there were s ig n ific a n t changes in student attitudes in a de
sired d irection . There was no s ig n ific a n t change in the students'
attitudes toward the poor during the f i r s t fiv e weeks of the summer.
Classen and Quicker (1968) evaluated 30 students who participated
in the Colorado Student Health Project during the summer 1968. The
project was found to be very successful. The students learned a great
deal about poverty and problems.in the delivery of health care to the
poor. As a group, they also became s ig n ific a n tly more humanitarian in
th e ir attitudes toward poverty.
Lashof (1968) described the Chicago Student Health Project during
the summer of 1968. One hundred and twenty four students were asked
whether they had learned much, some, l i t t l e , or nothing about 16
variables as a re s u lt of th e ir summer experience. More respondents
said they learned "much" or "more" about the quantity (66%), q u a lity
of health care (61%), and housing conditions of the poor (58%), than
any other of the lis te d conditions. In fa c t, only 16, 13, and 15%,
respectively learned " l i t t l e " or "nothing" about these factors.
Snodgrass (1968) attempted to evaluate the Philadelphia Student
Health Organization Project during summer of 1968. A questionnaire
consisting of biographical items and a battery of fiv e a ttitu d in a l
tests containing 185 questions was given to the 74 students on the
f i r s t day of orientation and to 62 students at the conclusion of the
29
orientation. There were no changes in students' attitudes from pre
te st to post-test in terms of le f t opinionation, to ta l opinionation,
lib e ra lism , comprehensive medical care, team approach in medicine, and
medical attitudes in general. The findings revealed a p o s s ib ility that
Philadelphia students became less r ig h tis t in p o litic a l ideology and
more in favor of socialized medicine, but Snodgrass continued that the
indicated changes might be due to random va ria tio n . The two measures
on which there were s ig n ific a n t changes were: more favorable attitudes
toward preventive medicine and toward the poor. W hen data fo r medical
students at Pennsylvania were analyzed separately, the p o s s ib ility of a
more right-leaning p o litic a l stance seemed to e xist at the end of the
summer. Pennsylvania medical students became s ig n ific a n tly less favor
ably inclined toward the poor in the post-test.
Bruce (1970) attempted to analyze two fa cto r groups containing
nine variables in the SAM A Project fo r medical education and community
orientation (MECO) at the U niversity of I llin o is College of Medicine.
Factor 1 was composed of the variables of in sp ira tion fo r fu rth e r
learning, c lin ic a l relevance of the program, instructional process,
learning process, and importance of material in the program. Factor 2
was composed of the variables of exposure to patients and interaction
with patients, relationship with nurses and paramedical personnel, and
with s ta ff and interns. The analysis of the project was conducted
u tiliz in g both open-ended questionnaires which were answered by both
students and physicians and a more objective questionnaire completed
by the students. The questionnaire u tiliz e d the Osgood Semantic D if-
30
fe re n tia l to analyze nine variables. Based upon th is data, the fo llo w
ing conclusions were made: 0 ) the most successful and positive part
of the program was the in sp ira tio n which the students received fo r
fu rth e r learning, (2) the next most successful and positive aspect of
the program was the overall importance of the material in th e ir pro
gram and the c lin ic a l relevance of such m aterial, (3) the next ranking
variables were, in order, the learning process, and then the teaching
process, (4) the lowest ranking variables were the students' exposure
to the patient and th e ir intera ctio n with them.
A study was conducted by Deuschle, Bosch, Banta, and Dana (.1972)
to analyze the effectiveness of a six-week fu ll-tim e clerkship in com
munity medicine during the la s t c lin ic a l year at the Mount Sinai School
of Medicine. The 111 students who had completed the clerkship appear
to f a ll in three groups. The f i r s t group were interested in a career
in community medicine. These students generally had a successful
clerkship. The second group were interested in c lin ic a l medicine but
also attracted to the clerkship in community medicine. These had
usually been able to integrate both approaches in the learning process.
The th ird group were interested only in individual patients and the
disease process. These students had usually learned something useful
about the psychosocial dimensions of disease.
Tanner, Linn, and Carmichael (1972) studied the Uniyersity of
Miami's Department of Family Medicine in the area of in te rd is c ip lin a ry
health teamwork. F o rty -fiv e of the 115 firs t-y e a r medical students
volunteered fo r th is e le ctive , no-credit project. Ten of .these yolun-
31
teers were randomly assigned to an experimental group and 12 to a con
tro l group. A comparison group of 14 students was randomly selected
from the non-volunteers in the class. Control and comparison groups
participated only in pre- and post-project a ttitu d e te stin g . The re
sults revealed that few differences in attitudes were found between
experimental and control groups. Differences were a ll in the direc-
t
tio n of being more positive fo r those who chose the fam ily medicine
e lective. As the project progressed, there were increasing behavioral
evidence that students were considering themselves as a team in d e liv
ering care.
Taylor, Dickman, and Kane 0973] studied approximately 200 medical
students from predominantly rural states and th e ir wives in order to
assess th e ir a ttitu d es toward rural practice. Although the student's
background was p o s itiv e ly correlated with his location plans, the
e ffe ct of his w ife 's background was p a rtic u la rly evident among those
students planning to locate in rural communities. This influence was
not as sa lie n t among those planning on urban practices. There was a
strong relationship between in te re st in fam ily practice and plans fo r
rural practice. The year in medical school and/or a v a ila b ility of a
course in fam ily medicine did not appear to influence the students'
orientations toward rural practice.
Bank and Reynolds Cl973] studied the effectiveness of the commu
n ity health clerkship at University of F lorida, College of Medicine.
A five-week community health clerkship was required of a l1 medical stu
dents as an integral part of its cycle of c lin ic a l ro ta tio n s. During
32
the f i r s t six months of the study, 60 students were debriefed in in te r
view immediately a fte r each program experience. In addition, data were
collected to construct a composite p ro file of students, who were par
tic ip a tin g in the clerkship. Preceptors also were interviewed by te le
phone, at the conclusion of th e ir work with each student. In the la st
six months of the study, questionnaires were substituted fo r in te r
viewing. Questions were designed to ascertain the degree to which stu
dents had gained knowledge in those areas related by specific depart
ment goals. Students reported s ig n ific a n t learning concerning the
influence of social factors on patient health care a ttitu d es. Such
learning experiences were most apparent where the patient population
was seen to be d iffe re n t in sociocultural background from the student
himself. Students were most sensitive to fam ily, economic, and edu
cational factors affecting patient values.
Mattson, Stehr, and K ill (1973) described a program designed to
increase the number of physicians in rural areas of I llin o is . Data
regarding application credentials, performance in medical school, loca
tions of internship and residencies, and locations of present practice
were available fo r study. The data were ayaiTable from the Physicians
Records Section of the American Medical Association. The evaluation
demonstrated tha t, the program had been p a rtic u la rly e ffe c tive fo r
those in d ivid u a ls, who were loan recipients only.
P h illip s and Swanson (1974) have reported on the W AMI (Washington,
Alaska, Montana, and Idaho) program which placed major emphasis on the
training of undergraduate students in fam ily medicine. The physician-
33
preceptors who were ca re fu lly selected into the program excelled at
teaching management of common c lin ic a l problems, doctor-patient in te r
action, use of community resources, perception of the demands made by
a p a tie n t's environment, and practice management. Other factors men-’
tioned as contributing to the success of the program were the policy
of assigning in pairs, the helpfulness of the resident's presence
during the student's ro ta tio n , and the wisdom of a six-week term which
provided the community fa cu lty with a needed time fo r re st. As of
December 1973, s ix ty -fo u r percent of those who took the clerkship in
fam ily medicine in rural settings were pursuing fam ily practice tra in
ing or were in rural general practice. Seventeen percent were in
"other primary care" training (medicine, p ediatrics, emergency care).
Eight percent were in other specialties and 10% were undecided or
th e ir choices were unknown.
Skinner and Rogers (1974) in the Western Pennsylvania Health Pre-
ceptorship Program studied an extra cu rricular summer experience fo r
postfreshman and postsophomore medical students. The program was eval
uated by student p a rticipan ts, preceptors, and others and was judged to
be e ffe ctive in introducing students to the practice of primary care
medicine, the analysis of determinants of health in communities in
Western Pennsylvania and in giving them an understanding of the organ
ization and financing of medical care. The results indicated that
experience in the preceptorship program had an impact on career plans
of seyeral students. Some who were undecided about th e ir career plans
had been stimulated to enter primary care as a re su lt of the program.
34
At least one planned to enter partnership in fam ily practice with his
former preceptor. A few who were interested in fam ily practice had
decided against th is as a re su lt of th e ir summer exposure.
Shropshire, Stone, and Knopke (1975) provided a model fo r a lo n g i
tudinal study of a 10 week summer externship experience in primary
medical care at the U niversity of Wisconsin-Madison. The study re
ported data from a four year study designed to monitor the experiences
of f i r s t year medical students who were exposed to the externship pro
gram. The e ffe ct of these experiences on the students' choices of
internship and residency specialties and type and location of medical
practice were analyzed. The results indicated that students reyealed
a high degree of s a tisfa ctio n with the program. Students electing the
externship experience were not s ig n ific a n tly d iffe re n t from non-
externship students in respect of M C AT scores and th e ir undergraduate
GPA's. Externship and non-externship students did not d iffe r sig
n ific a n tly in respect to academic achievement as measured by internal
examinations and by performance on Part I of the National Boards.
However, they did d iffe r s ig n ific a n tly on Part I I of the National
Boards. Since the two groups of students did not d iffe r s ig n ific a n tly
in respect to M C AT scores and GPA's upon entry into medical school,
i t could be implied that the s ig n ific a n t difference on Part II. of the
National Boards was due to d iffe rin g learning experiences of the
students, one of which was the externship experiences. Externship and
non-externship students did d iffe r s ig n ific a n tly in th e ir pattern of
internship and residency selection. This difference might be due to
35
the fa c t that students who selected the externship experience might
have been oriented toward d iffe re n t specialty in terests. The data
indicated the externship experience contributed to maintaining this:
difference.
Steinwald (1975) analyzed the relationship between medical stu
dent p a rticip a tio n in rural tra ining programs, including preceptor-
ships, and the decision to locate medical practice in rural areas.
Data consisted prim a rily of responses to questionnaires mailed in 1972
to a ll graduates of United States medical schools in 1965. Study
findings indicated that the overall impact of such programs on prac
tic e location decisions was re la tiv e ly s lig h t, but was most pronounced
with respect to urban-reared physicians in nonprimary care sp ecialties.
I t was also found that a large proportion of urban-located physicians
had seriously considered rural practice and that the reluctance of
many physicians to locate in rural areas was linked to fear of profes
sional is o la tio n . The findings suggested that an increased orienta
tio n toward urban-reared students and dissemination of information on
non solo practice opportunities in rural areas were means of increas
ing the effectiveness of preceptorships and other rural tra in in g pro
grams in a ttra ctin g young physicians to underserved areas.
Garrard and Verby (1977) reported the results of the Patient
Encounter Project, which was designed to document a ll c lin ic a l expe
riences of medical students (N = 36). fo r seven months in the Rural Phy
sician Associate Program (RPAP) and to compare these experiences with
those of a control group of third-year students (N - 26) enrolled in
36
the,regular curriculum during the same time period at the University of
Minnesota Medical School, Minneapolis. The results indicated d if f e r
ences between the two groups in the types of c lin ic a l problems reported.
Of the 10 most frequently reported problems recorded by each group,
only two, congestive heart fa ilu re and essential hypertension, were
common to both. R PAP students reported greater re s p o n s ib ility fo r
primary c lin ic a l problems than did the control students, however, the
control subjects reported higher levels of re s p o n s ib ility fo r c lin ic a l
s k ills than did the RPAP subjects. I t seemed lik e ly that the greater
re s p o n s ib ility reported by control students were fo r s k ills that posed
less of a medical ris k to the patients than those reported by R PAP stu
dents. By analogy, many of the primary c lin ic a l problems seen by the
RPAP students appeared to have involved re la tiv e ly less ris k to the
patient than those lis te d by the control students. O verall, the re
sults showed that subjects in both groups reported more encounters
with patients whom they had seen previously, that was, those given
continuing care.
Verby (1977) also reported that of the 163 students who had
completed the RPAP, had continued in medical school and another 27 were
in residency-training programs. Primary care residencies had been
chosen by 68, another 31 had completed th e ir medical education and were
in rural practice. Of the 22 practicing in Minnesota, 21 had returned
to ru ra l communities.
Pittman and Barr (1977) described the Community Health Center Pro
gram at Rockford School of Medicine, U niversity of I llin o is College of
37
Medicine. Students were involved over a two-and-a-half year period in
the delivery of primary care in rural, and semi-rural community health
centers. The program had proven to be eminently worthwhile on the ba
sis of its educational and service merists alone. In addition, patient
acceptance of medical student involvement in ambulatory care had been
excellent. The time taken by the student in performing re la tiv e ly
routine c lin ic a l tasks was viewed by the patient more often as a posi
tiv e rather than a negative feature.
Pinchoff, In g a ll, and Cracje (1977) described the Rural Externship
Program at the Lakes Area Regional Medical Program in conjunction with
the State U niversity of New York at Buffalo and the health profession
als of western New York and northwestern Pennsylvania. This in te r
d is c ip lin a ry program provided health science students with an eight-
week summer living-w orking experience in a rural environment, super
vised by practitioner-preceptors. Of the 61 externs contacted, 55%
indicated that they were in rural practice, and 53% of the la tte r in d i
cated that th e ir experience in the program was an important fa cto r in
th e ir decision to practice in a ru ra l area.
38
CHAPTER I I I
RESEARCH M ETHO D O LO G Y
Following the d e fin itio n of the problem to be studied, purpose,
d e lim ita tion s, lim ita tio n s , and hypotheses were stated and terms were
defined. A review of the lite ra tu re was conducted to determine what
s ig n ific a n t information was available pertinent to the study under
investigation.
This chapter describes the procedures followed In conducting the
study. A description and discussion are given of the follow ing:
(1) Selection of the Sample. (2) Instrumentation used. (3) R e lia b il
ity . (4) Collection and analysis of the data. (5) The procedures used
in the structured interview .
Selection of the Sample
The subjects used in ra tin g scales fo r these questionnaires were
Cl) graduates of the program (including physicians working in the sub
urbs of Bangkok and physicians working in rural areas in other parts
of Thailand], (2) sixth year medical students and interns at the Rama-
thibodi Medical School, (3) members of the Curriculum Committee and
teaching s ta ff associated with the C H P (th is group represents wide d if
ferences in socioeconomic background and career in te re s ts, e .g ., pa-'
39
thology, pe d ia trics, surgery, medicine, ophthalmology, x-ray, obstet
rics and gynaecology, and anaesthesiology).
Instrumentati on Used
A questionnaire consisting of statements concerned with percep
tions of various aspects of the C H P was developed. Items included in
the questionnaire were those which would provide answers to the ques
tions asked in Chapter I. Areas of emphasis were determined by a re
view of lite ra tu re and student reports on the f i r s t course in th e ir
program, Demographic Survey, and student evaluations of the school
curriculum.
An interview was held with the chairman of the program, chairman
of the curriculum committee, and teaching s ta ff to discuss and c la r ify
the goals and objectives of the CHP. A c ritiq u e of the o rig in a l ques
tionnaire items was sought from experts in measurement at the Depart
ment of Medical Education, U niyersity of Southern C alifornia (USC),
the chairman of the in v e stig a to r’ s doctoral committee, a U niversity
professor w ith expertise in curriculum and in s tru c tio n , an expert in
measurement at the W H O Regional Center of Medical Education in Thai
land, and a s p e c ia lis t in evaluation at the Ramathibodi Medical School.
Suggestions were made to c la r ify the grouping of items under a par
tic u la r subheading or category, and also to c la r ify the language.
These changes were incorporated in to the study instrument.
The fixed and open-ended questionnaire consisted of three parts
pertaining to the following aspects of the CHP: Part I consisted of
40
21 items, general statements regarding subjects's background, socio
economic status, age, in te re sts, attitudes toward education and toward
social a c tiv itie s , and goals of the program. Part II consisted of 65
items regarding the objectives of each course. Part I I I consisted of
20 items regarding attitudes toward career practice, c lin ic a l manage
ment, poor people, and health system.
The rating scale used fo r Part I of the questionnaire varied
s lig h tly . A sample of each scale used is included in the Appendix A.
In Part I I , the scale used was excellent, good, adequate, poor, and
very poor. In Part I I I , persons responded to each item by selecting
one of the L ikert-typ e alternatives: strongly agree, agree, disagree,
and strongly disagree. To ensure that an opinion was obtained fo r
each response, the neutral or undecided option was le f t out of the se
lectio n .
For Part I I I , the person's score was the weighted alternatives
endorsed by him or her. High scores indicated a po sitive a ttitu d e
toward the item. Items were positive toward career practice, c lin ic a l
management, poor people, and health system, but weights fo r negative
items have been reversed.
Rel iabi 1 i t.y
Since Parts I and I I of the questionnaire consisted of individual
items based on sp e cific program and course objectives, no summative
measures could be obtained and r e lia b ilit y was assumed therefore fo r
these sections of the study instrument. For Part I I I , the a ttitu d e
41
survey was based on an instrument previously used by the Philadelphia
Student Health Organization, Summer 1968, and the Colorado Student
Health Project, Summer 1968. Internal r e lia b ilit y was v e rifie d
through calculations of Cronbach's alpha c o e ffic ie n t (Cronbach, 1951).
Alpha c o e ffic ie n t fo r Part I I I a ttitu d e survey was .56 (maximum raw
score = 80, X = 58.66, SD = 4.96, percentage X = 73.32, percentage S D =
6.20). This r e lia b ilit y estimate was considered high enough to accept
the findings based on the instrument as in te rn a lly re lia b le .
C ollection and Analysis of the Data
The data was gathered during September and October 1976. A c e r ti
fie d le tte r was sent to each member of the population sample explain
ing the purposes of the study, the research methodology, and a request
fo r his or her p a rticip a tio n in the study. The le tte r also stated
that the Dean, Associate Dean, and Chairman of the C H P of the Ramathi-
bodi Medical School, Mahidol U niversity supported the study. Enclosed
with each le tte r was a le tte r of endoresement fo r the study from Dr.
Aree Valyasevi, Dean, Dr. Rachit Buri, Associate Dean, and Dr. Prem
B u ri, Chairman of the CHP.
Follow-up telephone callsrwere made to confirm that the subjects
were w illin g to p a rticip a te in the study. Individual appointments
were then scheduled with the population sample and adequate numbers of
questionnaires were mailed and/or personally delivered.
The questionnaires were sent to 105 graduates, 95 students and
interns, and 30 curriculum committee and teaching s ta ff members. In
42
a l l, 82 questionnaires were returned by the graduates, 63 by students
and interns, and 28 by the curriculum committee and the teaching s ta ff
members.
A ll questionnaires were coded and data were punched fo r s t a t is t i
cal analysis by computer. A ll cards were validated by the key punch
men at the Division of Research in Medical Education (DRME), U S C
School of Medicine. The s ta tis tic a l analysis was performed through
the use of the S ta tis tic a l Package fo r the Social Sciences (SPSS) (Nie,
H u ll, Jenkins, Steinbreuner, and Bent, 1975).
The data were tabulated by percentage of responses which were in
agreement and disagreement with each statement. Results were cate
gorized by sub-group (graduates of the program, students-and-interns,
and curriculum committee members and teaching s ta ff) to allow fo r
comparisons of responses. Responses to the open-ended statements were
tabulated by frequency of comments.
The crosstabulation method of analysis and chi-square were used
in Part I. In Parts I I and I I I , the F-test and analysis of variance
a p rio ri contrasts (K irk, 1968) were used. The s ta tis tic a l analysis
was conducted to determine i f there were s ig n ific a n t differences among
the three subject groups. The a p rio ri contrasts were carried out to
determine which difference between which two means, was s ig n ific a n t.
The investigator set the hypothesis re je ction point at the .05 level
of significance. The results of the questionnaires were tabulated and
assembled in table form.
43
The Procedures Used in the Structured Interview
Following completion of the questionnaires, personal interviews
were carried out, fo r the purpose of obtaining fu rth e r comments and
c la rific a tio n of the p a rticip a n ts' responses. However, only graduates
participated in th is phase since fa cu lty members, students, and interns
were not able to devote time to the procedure. An interview guide was
developed to ensure uniform ity of the interviews. Responses and com
ments obtained during the interview were summarized and used to supple
ment the information gathered through the use of the questionnaires.
44
CHAPTER IV
FINDINGS
Even though the biographical backgrounds of the subjects were not
a part of the hypothesis statements, the data was collected to fin d out
i f there was any difference in the age, socioeconomic backgrounds, and
interests w ithin the three groups. I t may be possible that varying
points of view in biographical backgrounds could be ascribed to d if f e r
ences in each hypothesis.
Age
According to the crosstabulations, 100% of the students and in
terns were aged between 24 and 29 years of age. Of the graduates,
92.7% were aged between 24 and 29, and 7.3% were aged between 30 and
39 years. The percentage of fa c u lty aged between 24 and 29 was 3.6%,
the percentage between 30 and 39 was 25%, the percentage between 40
and 49 was 46.4%, and 25% were aged 50 years and over. There was a
2
s ig n ific a n t difference among groups Cx = 144, df = 6 , p < .01).
Place of B irth
With regard to place of b irth , i t was found that 48.8% of the
graduates were born in Bangkok, and 51.2% in the provinces. Of the
45
students and interns, 57.1% were born in Bangkok, and 42.9% were in the
provinces. Of the fa c u lty , 56% were born in Bangkok, and 44% in the
provinces. The percentage of graduates born- in the provinces were
higher in th is group than the other two groups. The chi-square fo r
th is variable indicated that there was no s ig n ific a n t difference among
the three groups.
Religion
The tabulations fo r re lig io n indicated that 96.3% of the grad
uates, 95.2% of the students and in te rn s, and 96.4% of the fa c u lty
were Buddhists. The second largest re lig io u s a f f ilia t io n was found
among the fa c u lty group, where 3.6% were Muslims. Of the graduates,
1.2% were Muslims, while the remaining 1.2% were Catholics, and 1.2%
believed in other re lig io n s . Of the students and interns, 4.8% be
lieved in other re lig io n s . As was re ad ily apparent, there was close
agreement between the observed frequencies and the expected frequen-
2
cies. The resulting % was 6.59. In th is case, df - 6, and the c r i t i -
2
cal values of x did not reach a point of significance.
Occupation
Most of the parents of the respondents worked in business. Among
the graduate group, 57% of the fathers, and 41% of the mothers were in
business. Among the student and intern group, 61% of the fathers, and
37% of the mothers were in business. While among the fa c u lty , 36% of
the fathers, and 7% of the mothers were in business. In each group,
the largest percentage of mothers were housewives, with 44% so desig-
46
nated among the graduates, 40% fo r students and interns, and 61% fo r
fa c u lty members ( see Table 1).
Income
D iffe re n t groups reported d iffe re n t fam ily incomes. Among the
graduates, approximately 48.8% earned from 2,000 to 4,999 bahts. Stu
dents and interns whose fam ily earned 10,000 bahts formed 30.2% of the
to ta l group, and 55.6% of the fa cu lty members earned over 10,000 bahts.
Details of d is trib u tio n of income are included in Table 2.
Place of Employment
A ll of the students and interns, and fa c u lty w o rk e d in Bangkok.
The only group who were employed in areas outside of the urban center
were the graduates (see Table 3 and the map on page 52).
Professional Practice
The item on planning to practice in poverty areas revealed sig
n ific a n t differences among the graduate, student and in te rn , and fac^
2
u lty respondents (x = 88.11, df = 2, p < .01). As would be expected,
the greatest differences involved comparisons of fa cu lty responses
with those of the other two sample groups, 90.8% of the graduate r e
spondents have decided to go on practicing in rural areas, and 95.7%
of the student and intern respondents plan to do so, but only 7.4% of
the fa cu lty respondents indicated fu tu re plans to practice in rural
areas. The percentage of respondents who plan to stay in Bangkok were
9.2% of the graduate group, 4.3% of the student and intern group,
92.6% of the fa c u lty group.
47
TABLE 1
OCCUPATIONS OF FATHERS AND MOTHERS OF RESPONDENTS
Occupations Groups
Fathers Mothers
No. % No. %
Accountant Graduates
Students & Interns 2 3
_ _
Faculty - - - -
Business Graduates 47 57 34 41
Students & Interns 38 61 23 37
Faculty 10 36 2 7
Company Graduates 6 7 1 1
Employee Students & Interns 5 8 1 1
Faculty - - - -
Clerk
Graduates 1 1
_
Students & Interns 2 3 2 3
Faculty - - - -
Dentist Graduates 1 1
,
Students & Interns
— — — _
Faculty - - - -
Dressmaker Graduates
_
Students & Interns
— -
1 1
Faculty - - - -
Engineer Graduates 1 1
_
Students & Interns - - — —
Faculty - - - -
Farmer Graduates 3 4 2 3
Students & Interns 1 1 1 1
Faculty - - - -
Government Graduates 7 9 2 3
Officer Students & Interns 3 5 3 5
Faculty 8 29 2 7
Houseman or
Graduates 1 1 36 44
Housewife
Students & Intenns
-
25 40
Faculty
17 61
48
TABLE 1— Continued
Occupations Groups
Fathers Mothers
No. % No. %
Judge Graduates 1' 1
Students & Interns - - - -
Faculty - — — —
Lawyer Graduates
- - - -
Students & Interns 3 5 - -
Faculty - — — —
Manager Graduates 2 3
- —
Students & Interns 3 5 1 1
Faculty - - - -
Physician Graduates 2 3
— —
Students & Interns - - - -
Faculty 2 7 - —
Public Graduates 1 1
— • —
Enterprise Students & Interns - - - -
Employee Faculty — — —
Teacher Graduates 2 3 2 3
Students & Interns 3 5 3 5
Faculty 1 4 1 4
None Graduates 7 9 5 6
(Deceased) Students & Interns 3 5 3 5
Faculty 7 25 5 18
49
TABLE 2
MONTHLY FAMILY INCOME IN BAHTS FOR GRADUATES,
STUDENTS AND INTERNS, AND FACULTY
Range of Income Groups No.
% of
Income
Group
% of
Population
Group
% of
Total
Population
Graduates
_ _
Lower than 999 Students & Interns 3 100 4.8 1.7
Faculty - ■- -
Graduates 1 25.0 1.2 0.6
1,000 - 1,999 Students & Interns 3 75.0 4.8 1.7
Faculty - - - —
Graduates 40 66.7 48.8 23.3
2,000 - 4,999 Students & Interns 17 28.3 27.0 9.9
Faculty 3 5.0 11.1 1.7
Graduates 14 38.9 17.1 8.1
5,000 - 7,999 Students & Interns 17 47.2 27.0 9.9
Faculty 5 13.9 18.5 2.9
Graduates 12 60.0 14.6 7.0
8,000 - 10,000 Students & Interns 4 20.0 6.3 2.3
Faculty 4 20.0 14.8 2.3
Graduates 15 30.6 18.3 8.7
Over 10,000 Students & Interns 19 38.8 30.2 11.0
Faculty 15 30.6 55.6 8.7
Note. 1 U.S. dollar = 20 bahts.
50
TABLE 3
DISTRIBUTION OF GRADUATES BY PROVINCE
Name of Provinces No. of Graduates % of Group
North
Chiengmai 4 5
Nakornsawan 1 1
Phitsanuloke 1 1
Phrae 2 2
Lampang 1 1
Northern East
Kornkaen 10 12
Nakornphanom 1 1
Nakornrachsima 10 12
Srisaket 4 5
Ubon 7 9
East
Chantaburi 3 4
Chonburi 3 4
Rayong 3 4
West
Karnchanabur1 1 1
Hiddie
Nakornnayok 1 1
Nakornpathom 1 1
Bangkok 9 11
Nontaburi 3 4
Prach.inb.uri 2 2
Ay.uthaya 1 1
Uthaithani 1 1
South
Raj bur i 1 1
Phetburi 1 1
Trang 1 1
Naratiwart -2 2
Pattani 2 2
Phang-nga 2 2
Yala 1 1
Songkhla
2 2
Satul
1
1
Total 82 100
51
M AP O F THAILAND SHOW ING THE PROVINCES W H E R E
GRADUATES ARE LOCATED
Chiengmai
BU RM A
LAOS
Nam I
Phrae /
Nakornphanom v,
Phitsanuloke
Nakornsawan
Uthaithani tJbon
Nakorr.rachsima
Srisaket
THAILAND
Kanchanaburi
Nakornnayok
Prachinburi
Ayuthaya
'*^*Nakornpathom
. Bangkok Nontaburl
* Chonburi (
CAMBODIA
Phetbpr: Charjtaburi
GULF O F SIAM
‘ hang-nga
Trang
Songkhla
Satul Pattani
Yala *
MALAYSIA
52
Health Development Experience
As would be expected, fa cu lty members had more experience in
health programs than graduates, students, and interns. However, when
the chi-square was computed between frequencies of the three groups,
no s ig n ific a n t differences were found. I t appeared that 88.9% of the
fa c u lty , 77.8% of students and interns, and 67.9% of graduates had
actual experience^with health development programs in rural areas. The
percentage of respondents who indicated that they had no experience
with health development programs in rural areas were 11.1% of the fac
u lty group, 22.2% of the student and intern group, and 32.1% of the
graduate group. Names and locations o f the projects which the sample
groups reported involvement can be seen in Table 4. Table 5 is a
summary of the major problems which each group indicated they had
experienced during th e ir work a c tiv itie s .
Health Care Change
There were reported differences among fa c u lty , graduate, student
and intern respondents with respect to seeking health care changes as
a re su lt of p a rticip a tio n in the CHP. The analysis indicated a sig-
2
n ific a n t difference among frequencies Cx = 15.54, df = 2, p < .01),
with the fa cu lty respondents indicating more a c tiv ity than graduate,
student and intern respondents. The precentage of the respondents who
were active in seeking health care change were 88.9% of the fa cu lty
group, 49.4% of the graduate group, and 46% of the student and intern
group. The percentage of respondents who indicated that they were not
53
TABLE 4
PARTICIPATION IN HEALTH DEVELOPMENT PROGRAMS
IN RURAL AREA
Proj ect Province
Frequency
Graduates Students
Interns
Faculty
Around Thailand
Health Team of Coun
try Development
Proj ect
Health Team of the
Queen Mother
Training of Public
Health Village
Volunteer
Family Planning
Mobile Health Team
of Ministry of
Public Health
North
Mobile Health
Exhibition
Lampang Project
Trainer for Trainee
Special Health
Service Team of the
King
Mother and Child
Health Project
Preventive Medicine
Proj ect
Rural
area
Rural
area
All
north
Lampang
Lampang
Chiengmai
Chiengmai
Cheingmai
54
TABLE 4'— C ontinued
Frequency
Proj ect Province Graduates Students
Interns
Faculty
Survey of Health
Education and Life of
y111age People Chiengmai 1
Approach Village of
Ministry of Interior Narn - 1
Election of Local
Representative Health
Team Chainart 1
,
Northern East
Helping Development
Camp
Udorn-
thani
—
2
—
Siriraj Hospital &
Country Development
Project
Udorn-
thani
—*
4
Junior Camp Sakorn-
nakorn - 1 -
Research on Problem
of Nutrition Ubon - 2
Local yaccine, RCG?
and DPT Project Srisaket 1 -
East
Mae-Klong River
Proj ect
Kanchana-
buri
-
1 5
West
Mobile Public Health Rayong 2 - -
Public Health Plan
ning Project Rayorig 1 -
Public Health Project
Eor People
Samut-
prakarn 1 -
55
TABLE 4— C ontinued
Frequency
Project Province Graduates * Students
Interns
. Faculty
Mobile Health Team
of Lion Association
Chacherng-
sao
Chantaburi 4
South
Volunteer Physician
of Ministry of
Public Health
N'ar a-
tiwart 1
•M
_
Health Vagabond All south - 9 -
Middle
Training Monk from
North Province in
Basic Knowledge of
Medicine Bangkok 1
JC Project. Bangkok - 1 -
Prapadaeng Slum
Proj ect Bangkok - - 1
Dindaeng Slum
Proj ect Bangkok - 2 -
Klong Toey Slum
Proj ect Bangkok - 1 -
Drug Abuse Project Bangkok - 1 -
Training of Quack
Doctor Ayuthaya 1 -
_
56
TABLE 5
SUMMARY OF PROBLEMS OCCURRING AT HEALTH DEVELOPMENT
AS REPORTED BY EACH SAMPLE GROUP
PROJECT CITES,
Graduates Students Faculty
Items Interns
No. % No % No. %
1. Project problems:
a. The objectives did not meet the
needs of the village people,
too many objectives so some
could not be achieved. 4 7 9 20 4 7
b. Limit choices in selecting
population and location. 1 2 2 4 - -
c. No staff consultation when
needed. 4 7 - - - -
d. Lack of long term evaluation,
no validated data, invalid
statistics. 2 4 — - - -
2. Conflict inside the team about
a. Topic of the project, defini
tion of terms used, and pro
cedures . 1 2 2 4 - -
b. No job description, irrespon
sibility of some members. 3 5 6 13 - -
c. Some members joined because of
trip. 1 2 2 4 -
3. Control and prevention of diseases
were not effective. 1 2 —■ — — —
4. Teachers did not understand the
methods of treatment of patients
which can be applied in rural
areas. — — — 1 5
5. Different concepts from different
lectures, e.g., Ramthibodi em
phasized team working, National
Institute of Development Academy
emphasized individual working. — — — — 1 5
6. Lack of support from government, no
real attention from Ninistry of
Public Health. - - 1 2 1 5
a. Budget 3 5 1 2 -
b. Skilled lab technicians 2 4 2 4 1 5
57
TABLE 5— C ontinued
Graduates Students Faculty
Items Interns
No. % No. % No %
7. Administration problems:
a. Communication gap between
University and Ministry of
Public Health, no cooper
ation. 1 2 - - 7 37
b. Different system on manage
ment, Health Center used
traditional method, Univer
sity used problem solving. - - - - 1 5
c. No cooperation from the gov
ernment officer. 1 2 1 2 - -
d. Lack of public relations. - - 1 2 - -
e. Transportation problem because
people scattered around vil
lages . 7 13 2 4 3 16
8. No guidance in how to approach
government officers. 2 4 2 4
9. Lack of knowledge, skill, and
proper attitude of government
officers who were not prepared to
work in rural areas. 1 2 1 2 2 11
10. Village people:
a. They could not communicate with
village people because of lan
guage dialects. 2 4 2 4 - -
b. Lack of general knowledge, e.g.
»
culture, tradition, beliefs
necessary to solve the problems
of village people. 3 5 1 2 - -
c . Economic status of village
people was low. 2 4 2 4 - -
d. Basic knowledge of village
people was low, they could not
see the importance of distant
problem, kept their own belief
and could not understand the
present treatment of diseases. 12 21 7 16 1 5
58
active in seeking health care change as a re su lt of p a rticip a tio n in
the C H P were 54% of the student and intern group, 50.6% of the grad
uate group, and 11.1% of the fa c u lty group.
Students' A ttitudes Changed Toward the Health System
In response to the question concerning whether, in th e ir opinions,
there were changes in th e ir a ttitu d es toward the health system which
could be a ttrib u te d to th e ir fie ld experiences, 71.4% of graduate
respondents, 41.4% of student and intern respondents, and 79.2% of
fa cu lty respondents thought there were some changes. The respondents
who thought that there were "no" changes included 28.6% of graduates,
58.6% of students and interns, and 20.8% of fa c u lty . From the analysis.
2
i t appeared that the^three groups thought d iffe re n tly fy = 16.31, df =
2, p < .01). See Table 6 fo r a summary of opinions concerning the
effects of the C HP experiences on students' attitu d es toward the health
system. The data indicated the m ajority of respondents believed the
C H P fie ld experiences provided the students with incentives to face
the problems outside the medical school and increased positive a t t i
tudes toward helping poor people.
Changes in the Attitudes of the Community
Toward the Health System
The analysis revealed that there were s ig n ific a n t differences
2
among the three groups C x = 16.73, df = 2, p < .01), w ith 1 respect to
th e ir opinions concerning changes in a ttitu d e s of the people in the
community as a re s u lt of experiences with the health development pro-
59
TABLE 6
STATEMENTS OF RESPONDENTS REGARDING CHANGES OF THE
STUDENTS' ATTITUDES TOWARD THE HEALTH SYSTEM
Graduates Students Faculty
Attitudes Interns____________
___________________________________________No. % No. % No. %
1. The students' impression of the
health care system was directly
affected by the quality of teach
ing methodology and environment. "1 21 4 15 1 6
2. Students revealed both good and
bad attitudes. Bad attitudes re
sulted from communication gaps, as
well as the fact that students
tended to have a narrow view ,of • ’
the whole health system. - - - - 1 6
3. Because the training center was
different from reality, students
were dissatisfied and argued for
improvement. - - - - 1 6
4. The students knew and understood
the system but they gained poor
attitudes toward health personnel. - - - - 1 6
5. The students were disappointed
and afraid because of the "dif fer
ent environment. 1 2 4 15 - -
6. The students felt that the health
system was worse than they ex
pected; some of the people in
control were not capable at their
jobs because they were not knowl
edgeable in the health field, and
government officials were sluggish. 1 2 4 15 - -
7. The students became more aware of
their own interests and their
future. - - 1 3 - -
60
TABLE 6— Continued
Graduates Students Faculty
Attitudes
No. %
Interns
No. % No. %
8. The students wanted to face the
problems outside of the medical
school and gained more positive
attitudes toward helping poor
people. 11 22 7 25 6 37
9. The students understood the real
situation of the country. 7 14 1 3 1 6
10. The students understood the facts
which caused the failure of ru
ral health care including rural
physicians and people. 4 8 - - 2 13
11. In the health system there should
be a good referral system starting
from the village. 1 2 - -
12. The students realized that commu
nity health care was more impor
tant than hospital care. 1 2 1 3 1 6
13. The students knew more about the
country’s public health and real
ized what they taught in medical
school was different from real
public health problems. 9 18 4 14 1 6
14. The students realized that the
Ministry of Public Health was
different from the Medical School. 1 2 - - - -
15. The students knew that a good
health system required team
workers who understood each other
and cooperated well. 1 2 - - -
16. The students in the CHP had more
responsibility in a social con
text than students of other
schools. - - - - 1 6
61
TABLE 6--Continued
Attitudes
Graduates Students
Interns
Faculty
No. % No. % No. %
17. The students realized that
physicians should approach
the patients rather than
let patients come to them. 1 2
18. The students realized that the
major population did not re
ceive services in health
care. 6 12 2 7
19. The students realized that
preventive medicine should
go together with curative
care. 4 8
20. The students realized that
in using knowledge to treat
patients, physicians could not
just follow the text but had-
to adapt treatment to the
existing situation. 1 2 -
-
Total 50 100 28 100 16 100
62
grams in poverty areas. Faculty respondents indicated "yes" by 62.5%,
39.5% of the graduate, and 17.2% of the student and intern respondents
also f e l t that people changed because they worked in health develop
ment programs in poverty areas. The respondents who f e l t that people
did not change at a ll because of experiences, included 12% o f graduate
respondents, 20.7% of student and intern respondents, and 8.3% of
fa c u lty respondents. Summary of reasons can be seen in Table 7. Two
statements were most frequently e lic ite d from respondents in a ll three
groups. These statements were:
- People around the health center revealed good a ttitu d es toward
modern health and an increasing number of people went to the
health center.
- More people were learning to prevent disease by themselves,
e .g ., anaemia from pinworm, good immunization coverage, M C H
(Mother and Child Health).
Improvement o f Conditions fo r the Poor
The analysis of opinions on the improvement of the conditions of
the poor revealed that there were differences among fa c u lty , student
and in te rn , and graduate respondents. The fa cu lty evaluated the CHP's
e ffe c t on improving conditions fo r the poor d iffe re n tly from the ways
in which students and in te rn s, and graduates evaluated th is aspect of
2
the program (x = 25.88, df = 8, p <.01). By crosstabulation, 1.2% of
the graduate group, and 1.6% of the student and intern group indicated
that the program had been extremely e ffe c tive in improving conditions
63
TABLE 7
STATEMENTS REGARDING ATTITUDE CHANGES IN THE COMMUNITY
Statements
Graduates Students
Interns
Faculty
No. % No. % No 7
• /o
Yes
1. People around the health center re
vealed good attitudes toward modern
health and an increasing number of
people went to the health center. 17 63 4 45 10 47
2. More people werfe learning to pre
vent disease by themselves,, e.g. ,
anaemia from pinworm, good immu
nization coverage, MCH. 8 30 3 33 5 24
3. People were more alert to the
importance of Family Planning. 1 4 1 11 1 5
4. Nutritional status had changed, es
pecially in the field program. - - - - 1 5
5. The district was becoming gradually
more urbanized. 1 4 1 11 4 19
No
1. Less people went to the health
center. 1 50
_ _ _
2. People did not see the importance
of good health. 1 50
- - - -
3. People were tired of questions of
student surveys. - - 2 40 - -
4. People were used to student
surveys. - - 2 40 4 100
5. People were less active in help
ing themselves. - - 1 20 - -
64
fo r the poor. In addition, 9.9% of the graduates, 6.3% of students and
interns, and 25% of fa c u lty members indicated th a t the program had
been moderately e ffe ctiv e in improving conditions fo r the poor. O n
the other extreme, 30.9% of graduates, 28.6% of students and interns,
and 45.8% of fa c u lty members indicated th a t the program had been
s lig h tly e ffe c tive in improving conditions fo r the poor. There were
58% of graduates, 63.5% of students and in te rn s, and 20.8% of fa cu lty
members who indicated that the program had no e ffe c t in improving condi
tions fo r the poor. Of fa c u lty respondents 8.3% indicated that the
program had negatively effected the conditions of the poor.
Curriculum Reform
In the fu tu re , 30.5% of the graduates, 31.7% of the students and
interns, and 63% of the fa c u lty members planned to become involved in
curriculum reform at the medical school. On the other extreme, 41.5%
of the graduates, 31.7% o f the students and interns, and 14.8% of the
fa cu lty members did not plan to jo in the curriculum reform. In addi
tio n , 28% of graduates, 36.5% of students and in te rn s, and 22.2% of
fa c u lty members were uncertain as to whether they could become in
volved in curriculum reform. There was a s ig n ific a n t difference among
the fa cu lty group, the student and intern group, and the graduate group
2
(x = 12.37, df = 4, p < .01),. Summary of reasons fo r p a rticip a tin g or
not p a rticip a tin g in the curriculum reform can be seen in Table 8.
65
TABLE 8
STATEMENTS REGARDING REASONS FOR PARTICIPATING OR
NOT PARTICIPATING IN CURRICULUM REFORM
Graduates Students Faculty
Reasons Interns____________
No. % No. % No. %
Yes
1. Some courses in the curriculum were
not appropriate. 1 4 - - - -
2. The curriculum negatively affected
the student and the country. - - - - 1 10
3. The curriculum had to be revised
all the time. 1 4 4 21 1 10
4. At the time we developed the
curriculum we did not have expe
riences, we needed to improve it
after evaluation. - - - - 1 10
5. The three year residency training
program should be revised by
getting training at the Medical
School for 3-6 months, and working
for the remainder of the time in
rural areas. This was another way
to solve the physician^shortage in
some areas. - - 1 5 - -
6. Some courses were unnecessary. - - 2 11 - -
7. After graduating, several students
did not really understand some
courses and they needed additional
time to train in those areas; the
curriculum should further emphasize
them. 1 4 - - - -
8. The learning experiences provided
were not as good as they should be. - - - - 1 10
9. The CHP departments in every uni
versity should cooperate in solving
problems and exchange knowledge and
experiences in this area. 1 4 - - - - -
66
TABLE 8— Continued
Reasons
Graduates Students
Interns
Faculty
No.
%
No. % No %
Yes
10. To increase the school’s chance of
success and to help future stu
dents to have a better education. 3 12 3 53 2 20
11. To train knowledgeable, thoughtful
students who will profit the so
ciety. 4 17
_ _
12. Want the school to emphasize, in
teaching the students, how to give
basic knowledge to the people and
to succeed in establishing good
attitudes among the students. 1 4
13. The school must develop a curric
ulum to help students realize
the real public health situation
in Thailand and methods of solving
public health problems in spite
of the manpower and natural re
source limitation which exist in
the situation. 12 50 9 47 4 60
No
1. No staff really listened to them. 3 15 4 30 - -
2. No relationship with the school. 6 31 4 30 2 25
3. Did not have knowledge and expe
riences in this matter. 6 31 4 30 2 25
4. Did not have ability to accomplish
all they wanted to. - - - - 4 50
5. Did not know the objectives of the
school. 1 5 - - - -
6. The curriculum was well designed. 3 15 1 10 - -
67
Education of the School
With respect to the p o s s ib ility o f future involvement in school
education, the analysis showed s ig n ific a n t differences among the fac-
2
u lty group, the graduate group, and the student and intern group (y =
27.62, df = 4, p < .001). By crosstabulation, 29.3% of the graduates,
28.6% of the students and interns, and 81.5% of the fa c u lty members
indicated that they planned to become involved in the education of the
school. O n the other extreme, 43.9% of the graduates, 39.7% of the stu
dents and interns, and 7.4% of the fa c u lty members did not plan to jo in
in school education projects. There were 26.8% of- the graduates, 31.7%
of the students and in te rn s, and 11.1% of the fa cu lty members who were
uncertain in th is matter. Summary of reasons fo r p a rtic ip a tin g with
the education of the school can be seen in Table 9.
Preceptor
There was a s ig n ific a n t difference among the fa c u lty group, the
2
graduate group, and the student and intern group (y = 137.88, d f = 14,
p < .001) with respect to time spent with the preceptor. This analysis
indicated that 32.1% of the graduates, 20.6% of the students and in
terns, and 3.8% of the fa cu lty members indicated that they had not
been involved in any preceptorship program. There were 12.3% of the
graduates, 14.3% of the students and interns who indicated th a t they
spent " l i t t l e time" with the preceptor. The percentages of the respon
dents who indicated that they spent "1-5 hours" with the preceptor in
cludes 41.3% of the students and in te rn s, and 27.2% of the graduates.
68
TABLE 9
STATEMENTS REGARDING REASONS
THE EDUCATION OF
FOR
THE
COOPERATING
SCHOOL
WITH
Reasons
Graduates Students
Interns
Faculty
No. % No. % No. %
1. To obtain correct information
about rural public health. 5 26 6 66
_
2. Methods and equipment devised
in the health care center and
problems which occurred could
be reported to the school. 1 5 1 11
3. The learning environment should
be improved in order to stimu
late students to solve more
problems. 1 5
4. To teach the students and be
part of the program if the
school extends across the country. 9 47 2 22
_
5. To help the school to find appro
priate teaching methods. 1 5 - - -
6 . To provide a policy of education
at high administrative levels. - - - - 1 6
7. To provide appropriate learning
experiences.
- - ■ - 12
80
8. To train the students to be able
to stay and work in rural areas. - - - - 1 6
9. To develop and maintain complete
records of all students since
year I (starting from School of
Basic Sciences). 1 6
10. To help teach the control of
communicable diseases. 1 5 - - - -
11. To evaluate the courses of the
school. 1 5 - - - -
69
The percentages of the respondents who indicated that they spent "6-10
hours" with the preceptor were 21% of the graduates, and 19% of the
students and interns. The percentages of the respondents who indicated
th a t they spent "11-15 hours" with the preceptor included 7.4% of the
graduates, 1.6% of the students and interns, and 3.8% of the fa cu lty
members. The percentages of the respondents who indicated that they
spent "16-20 hours" with the preceptor were 1.6% of the students and
interns. A d d itio n a lly, i t was found that 1.6% of the students and in
terns, and 7.7% of the fa c u lty members indicated that they were in
volved "21 hours and up" in the preceptorship program; while 73.1% of
the fa cu lty respondents indicated that they were "uncertain" in pre
ceptorship. Summary of statements regarding the roles of the preceptor
and other s ta ff members can be seen in Table 10.
For the purpose of the study, items were grouped w ith in each hy
pothesis and subhypothesis. Each hypothesis and subhypothesis were,
then, tested in d iv id u a lly . For a ll of the follow ing hypotheses and
subhypotheses, means were computed fo r each individual item and fo r the
group of items under each hypothesis statement. F -ratios were computed
to determine which differences between means were s ig n ific a n t. For the
group means, the a p rio ri contrast was used to determine which of the
three differences between the three means was s ig n ific a n t. To perform
the a p r io ri contrast, the te st was carried out on differences between
the fa cu lty group and the combination of graduate group, and student
and intern group. A second a p r io ri contrast was carried out on d if f e r
ences between the graduate group, and the student and intern group.
70
TABLE 10
STATEMENTS REGARDING THE ROLES OF THE PRECEPTOR
AND OTHER STAFF MEMBERS
Influences or suggestions
Graduates Students
Interns
Faculty
No. % No. % No. %
Preceptor
1 . To suggest possible ways of
practicing. 13 48 6 46 2 28
2. To motivate students and point
out mistakes in studies done by
the previous students. 2 7
— _ _ _
3. To plan the work. 5 8 - - -
4. To suggest possible problems in
cluding problems of rural people. 2 7 2 15 - -
5. To see the general problems of
society, not individual problems. 3 11 - - - -
6. To provide theoretical background 1 4 4 30 1 14
7. To realize the responsibility of
physicians toward the community. 1 4 1 7 - -
8. To give knowledge and promote
good attitudes, to get to know
the community including how to
act in the community.
2 28
9. Influence student teaching by
discussing problems on the spot
in fieldwork and by group
discussion.
— — — - 2 28
Other Staff
1 . To run the projects 9 29 2 14 3 50
2. Data gathering and analyzing
the data. 1 3 3 21 2 33
71
TABLE 10— Continued
Graduates Students Faculty
Influences or suggestions Interns
No. % No. % No. %
Other Staff
3. Manual skills 1 3
4. In diagnosing diseases of
which the students were
uncertain. 1 3
5. In solving the immediate problems
which the physicians could cure
in the community without re
ferring to Bangkok hospital. 4 13
6. Psychology. - -
7. Make equipment available and
help with formal correspondence
with other government offices. 7 23
8. Provide academic, dental,'and
sanitary help. 8 25
1 7
1 7
4 3 1 16
43 1 16
72
Hypothesis 1
There w ill be no differences among students-and-interns,
graduates, and fa cu lty groups in opinions expressed
concerning whether the course content enables students
to accomplish the program goals.
The analysis revealed s ig n ific a n t differences at a level s u f f i
cient to re je c t the null hypothesis fo r three out of the seven items
tested. The items which were s ig n ific a n tly d iffe re n t were (see Table
11):
- To what extent, i f any, the C H P experience is helpful to
students in acquiring sp e cific s k ills fo r th e ir profession.
- The students can analyze the health problem of the community
by the s c ie n tific method and decide to select the important
problem with the rig h t method.
- The method which fa m ilia rize s students with the fa c t of public
health and health in general.
The items which were not s ig n ific a n t were:
- The students have found the C H P experience generally sa tis fyin g .
- A learning experience fo r students regarding public health of
the country.
- The method which motivates the in te re s t of the students and
makes them fa m ilia r with the practice o f th e ir profession
in rural areas.
73
TABLE 11
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE PROGRAM GOALS
Items
Groups X SD F Sig.
1.
The students have found the CHP experience
Graduates 1.48 .50
generally satisfying.
Students & Interns 1.60 .49 2.07 NS
Faculty 1.35 .49
2.
To what extent, if any, the CHP experience
Graduates 1.98 .67
is helpful in acquiring specific skills
Students & Interns 2.24 .67 3.81 .05
for the profession of the students.
Faculty 1.87 .70
3. The CHP is successful as a learning
Graduates 2.56 .85
experience for students regarding public
Students & Interns 2.75 .84 1.39 NS
health of the country.
Faculty 2.46 .72
4. The CHP is successful as a method which
Graduates 2.65 .85
familiarizes students with the fact of
Students & Interns 2.89 .97 6.23 .01
public health and health in general.
Faculty
2.13 .90
5.
The CHP is successful as the students can
analyze the health problems of the community
Graduates 2.55 .80
by the scientific method and decide to select
Students & Interns 2.95 .87 5.32 .05
the important problem with the right method.
Faculty 2.42 .97
■ ^ j
The CHP is successful as a method which
motivates the interest of the students
and makes them familiar with the practice
of their profession in rural areas.
Graduates 2.94 .92
Students & Interns 3.19 .99
Faculty 2.68 .98
2.79 NS
The CHP is successful as a method which
helps the medical school coordinate
with the Ministry of Public Health in
terms of serving the patients.
Graduates
Students &
Faculty
Interns
3.35
3.27
2.88
.96
.90
1,05
2.38 NS
C J 1
- The method which helps the medical school coordinate with
the M in istry of Public Health in terms of serving the patients.
On a ll the seven items, the C H P was perceived as more e ffe ctiv e
by fa c u lty members than by the graduates, and the students and interns.
The graduates perceived the program as generally more e ffe c tive in
reacting to its goals than did the students and interns. On one item,
however, the students and interns (X = 3.27) rated the program more
e ffe c tiv e than the graduates (X = 3.35) did. This was:
- The method which helps the medical school coordinate with
the M in istry of Public Health in terms of serving the patients.
W hen the responses to a ll items under hypothesis 1 were grouped,
the differences among the groups were s ig n ific a n t (F = 18.02). The
null hypothesis was rejected at the .001 level of p ro b a b ility . Each
group had d iffe re n t perceptions of whether the course content enabled
students to accomplish the program goals (see Table 34).
A p rio ri contrast between combined groups one and two and group
three was s ig n ific a n t ( t = 4.34, p < .001). The graduates, students
and interns had d iffe re n t perceptions than the fa cu lty members of
whether the course content enabled students to accomplish the program
goals. The contrast between group one and two was s ig n ific a n t ( t =
-1.99, p < .05). The graduate group and the student and intern group
had d iffe re n t perceptions of whether the course content enabled stu
dents to accomplish the program goals.
76
Hypothesis 2
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
concerning how experiences provided by the program
meet the needs of the students.
Individual item analysis indicated s ig n ific a n t mean differences
(see Table 12) on three of the fiv e items.
Faculty respondents considered a ll the items s ig n ific a n tly more
e ffe c tiv e than graduate, student and in te rn respondents did. The
graduate respondents considered fiv e items s ig n ific a n tly more e ffe ctiv e
than the student and intern respondents. One item which the student
and intern respondents (X = 2.90) considered more e ffe c tiv e than the
graduate respondents (X = 3.11) was:
- How well do the learning experiences provided by the In te rn
ship in Community Health meet the needs of the students?
W hen the responses to a ll items under hypothesis 2 were grouped,
the differences among the groups were s ig n ific a n t (F = 53.46). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The
group had d iffe re n t perceptions of whether the experiences proyided by
the program met the needs of the students (see Table 34).
The a p rio ri contrast between combined groups 1 and 2 and group 3
where s ig n ific a n t ( t = 8.38, p < .001). The graduates, students and
interns had d iffe re n t perceptions than the fa c u lty members of whether
77
TABLE 12
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE
PROGRAM EXPERIENCES MEETING THE NEEDS OF STUDENTS
Items
Groups
X SD F
Sig.
1. How well do the learning experiences provided
by the program meet the need of the students?
Graduates
Students & Interns
Faculty
2.78
3.17
2.44
169
.76
.72
6.81 .01
2. How well do the learning experiences provided
by the Demographic Survey enable the students
to accomplish the stated objectives?
Graduates
Students & Interns
Faculty
2.77
2.95
2.50
.80
.76
1.08
1.65 NS
3. How well do the learning experiences provided
by the Analysis of Community Health Problems
enable the students to accomplish the stated
objectives?
Graduates
Students & Interns
Faculty
2.66
2.89
2.33
.79
.78
.87
2.61 NS
4. How well do the learning experiences provided
by the Community Health Planning enable the
students to accomplish the stated objectives?
Graduates
Students & Interns
Faculty
2.75
2.90
2.22
.74
.67
.83
3.74 .05
5. How well do the learning experiences provided
by the Community Health Clerkship enable the
students to accomplish the stated objectives?
Graduates
Students & Interns
Faculty
2.80
2.98
2.56
.68
.63
.73
2.29 NS
6. How well do the learning experiences provided
by the Internship in Community Health enable
the interns to accomplish the stated objec
tives?
00
Graduates
Students & Interns
Faculty
3.11
2.90
2.33
.80
.71
.50
4.19 .01
the course content enabled students to accomplish the program goals.
The contrast between the graduate group and the student and intern
group was not s ig n ific a n t.
Hypothesis 3
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding students' a b ilit y to accomplish the learning
objectives of the selected courses.
For the purpose of testing the hypothesis, the follow ing subhy
potheses were formulated:
Subhypothesis 1.
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the course, Demographic Survey.
The items fo r which s ig n ific a n t differences were obtained Csee
Table 13) were:
- To expose students to the social problems of the people
liv in g in a rural community.
- To expose students to c u ltu ra l characteristics of the
people liv in g in a rural community.
The items fo r which no s ig n ific a n t differences were found were:
- To expose students to health problems and health behavior
79
TABLE 13
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE DEMOGRAPHIC SURVEY COURSE
Items
Groups X SD F Sig.
1. To expose students to the social problems of Graduates 2.57 .97
people liying in a rural community. Students & Interns 2.95 ,94 3.34 .05
Faculty 2.40 .70
2. To expose students to the health problems and Graduates 2.47 .84
health behavior of people living in a rural Students & Interns 2.66 .80 1.77 NS
community. Faculty 2,20 .63
3. To understand the attitudes of the people Graduat es 2.68 .94
living in a rural community. Students & Interns 2.93 .83 2.27 NS
Faculty 2.40 .52
4. To understand the concepts, principles, and Graduates 2,95 .86
techniques of epidemiology. Students & Interns 3,03 .86 ,39 NS
Faculty 2.80 .79
5. To understand the concepts, principles, and Graduates 3.26 ,90
techniques of biostatistics. Students & Interns 3.15 .89 1.76 NS
Faculty 2,70 1.06
6. To understand the concepts, principles, and
Graduates 3.39 ,87
techniques of the social sciences.. Students & Interns 3,40 .83 1.56 NS
Faculty 2,90 .99
00
o
To expose students to cultural characteristics
of the people living in a rural community.
To provide students with an opportunity to
learn the process of community diagnosis
through participation in the planning
and execution of a survey of a rural
population group and to learn that they
can obtain important information using
relatively simple and inexpensive methods.
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
3.12
3.30
2.50
3.04
3.19
2.90
.94
.87
.53
.84
.78
.37
3.57 .05
.75 NS
oo
of the people liv in g in a rural community.
- To understand the a ttitu d e s of the people liv in g in
a rural community.
- To understand the concepts, p rin cip le s, and techniques of
epidemiology.
- To understand the concepts, p rin cip le s, and techniques of
b io s ta tis tic s .
- To understand the concepts, p rin cip le s, and techniques of
social sciences.
- To provide students with an opportunity to learn the process
of community diagnosis through p a rtic ip a tio n in the planning
and execution of a survey of a rural population group and to
learn that they can obtain important information using re la
tiv e ly simple and inexpensive methods.
The fa cu lty respondents indicated a higher rating on a ll items
than did the graduate respondents, who indicated a higher rating on
most items than did the student and in te rn respondents. The item
rated higher by the student and intern respondents (X = 3.15) than by
the graduate respondents (X = 3.26) was:
- To understand the concepts, p rin c ip le s , and techniques
of b io s ta tis tic s .
W hen the responses to a ll items under subhypothesis 1 were
grouped, the differences among the groups were s ig n ific a n t (F = 40.30}.
The null hypothesis was rejected at the .001 level of p ro b a b ility .
Each group had d iffe re n t perceptions of the Demographic Survey Course
82
(see Table 34).
The a p rio ri contrast between combined groups 1 and 2 and group 3
was s ig n ific a n t ( t = 7.20, p < .001). The graduates, students and in
terns had d iffe re n t perceptions from the fa c u lty members of the Demo
graphic Survey Course. The difference between the graduate group and
the student and intern group was not s ig n ific a n t.
Subhypothesis 2
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the course, Analysis of the Community Health
Problems.
According to the analysis, fiv e out of six items indicated s ig
n ific a n t differences among the mean responses (see Table 14). The
item which indicated no s ig n ific a n t difference was:
- To understand, be able to thin k, and consider health and
disease not only in giving service to the people who come
to the ho sp ita l, but also in providing the necessary and
appropriate services in public health and in curing
disease fo r the people in the community.
The fa c u lty respondents gave a higher rating on a ll items than did
the graduates, who gave higher ratings on most items than did the stu
dent and intern respondents.
When the responses to a ll items under subhypothesis 2 were grouped,
83
TABLE 14
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE ANALYSIS OF COMMUNITY HEALTH PROBLEMS COURSE
Items. Groups X SD Sig.
1. To stimulate and to have students explore in
depth community health problems of major
importance in Thailand as a physician.
2. To help students develop the ability to use
a problem-solving approach to specific health
care problems and to relate it to the classic
scientific method.
3. To understand and be able to use the concepts,
principles, and techniques of epidemiology
and biology.
4. To understand and be able to prepare, submit,
and analyze the data of the public health care
problems of the community.
5. To understand and be able to select the impor
tant public health problems of the community.
6. To understand, be able to think, and consider
health and disease, not only in giving serv
ice to the people who come to the hospital,
but also providing necessary and appropriate
services in public health and in curing
disease for the people in the community.
Graduates 2.58 .80
Students & Interns 2.90 .82
Faculty 2.00 .94
Graduates 2.45 ,85
Students & Interns 2.95 .84
Faculty 2.30 .95
Graduates 2.74 .70
Students & Interns 3.08 .80
Faculty 2.50 .97
Graduates 2.74 .77
Students & Interns 3.06 .79
Faculty 2.11 .93
Graduates 2.44 .73
Students & Interns 2.81 .72
Faculty 2.30 .82
Graduates 2.67 .77
Students & Interns 2.76 .76
Faculty 2.40 .70
6.26 .01
6.75
4.71
7.03
5.04
.01
.01
.01
.01
.99 NS
o o
4 >
the differences among the groups were s ig n ific a n t (F = 55.44). The
null hypothesis was rejected at the .001 level of p ro b a b ility . Each
group had d iffe re n t perceptions of the course, Analysis of the Commu
n ity Health Problems (see Table 34).
The a p rio ri contrast between combined groups 1 and 2 and group 3
was s ig n ific a n t ( t = 8.00, p < .001). The graduates, students and in
terns had d iffe re n t perceptions from the fa c u lty members of the course.
The contrast between group 1 and 2 was s ig n ific a n t ( t = -3.30, p <
.001). The graduate group and the student and intern group had d i f
fe re n t perceptions of the course, Analysis of the Community Health
Problems.
Subhypothesis 3
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the course, Community Health Planning.
As indicated in Table 15, fiy e items appeared to have s ig n ific a n t
differences among mean responses of the three groups. The item which
indicated no s ig n ific a n t difference was:
- To. review b rie fly the important health problems of Thailand
and the health care im plications of these problems.
The scores of the three groups of respondents on subhypothesis 3
resulted in a lower mean score fo r the fa c u lty , a higher mean score fo r
the graduate group, and a s t i l l higher mean score fo r ther'student and
85
TABLE 15
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE COMMUNITY HEALTH PLANNING COURSE
Items Groups X SD F Sig
To review briefly the important health problems
of Thailand and the health care implications of
these problems.
Graduates
Students &
Faculty
Interns
2.73
2.84
2.22
.74
.71
.83
2.81 NS
To review basic epidemiologic, statistical, and
demographic concepts required for understanding
these problems.
Graduates
Students &
Faculty
Interns
2.91
3.06
2.33
.77
.79
.87
3.54 .05
To review the application of the problem solving
cycle in the planning of solutions to health
care problems.
Graduates
Students &
Faculty
Interns
2.81
2.98
2.33
.77
.71
.87
3.21 .05
To probe in depth a number of selected issues
involved in planning and implementing programs
for improving health care including the
following: the definition of a "health problem,"
the communityTs own understanding of its health
Graduates
Students & Interns
2.88
3.16
.72
.73 5.01 .01
problems. Faculty 2.44 .88
00
C Tt
TABLE 15— Continued
Items Groups X SD F Sig.
5. To examine the process of designing possible
solutions to health problems, including
(a) defining objectives and how to measure
them; (b) selecting the most appropriate
objectives; (c) planning information systems Graduates 2.83 .76
for monitoring the quality and effectiveness Students & Interns 3.06 .74 5.54 .01
of health care programs. Faculty 2.22 .67
To examine and analyze some existing health Graduates 2.77 .69
programs, such as family planning, malaria Students & Interns 3.05 .76 4.95 .01
eradication, and tuberculosis control. Faculty 2.33 .87
c o
intern group.
W hen the responses to a ll items under subhypothesis 3 were
grouped, the differences among the groups were s ig n ific a n t (F = 56.16).
The null hypothesis was rejected at the .001 level of p ro b a b ility . The
a p rio ri contrast between combined groups 1 and 2 and group 3 was sig
n ific a n t ( t = 8.69, p < .001). The a p rio ri contrast between group 1
and group 2 was s ig n ific a n t ( t = -2.76, p < .01). Data are presented
in Table 34.
The fa c u lty had the most favorable perception of the course, Com
munity Health Planning, of a ll the other respondents. The students and
interns had a more favorable perception of the course than the grad
uates .
Subhypothesis 4
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the course, Community Health Clerkship.
The analysis of variance re sults are reported in Table 16. One
out of fiv e items had a s ta tis tic a l s ig n ific a n t difference among the
means.
- To develop a deeper understanding of the health needs of
the community by p a rtic ip a tin g in v illa g e and home y is it s ,
surveys, and projects outside the health center.
Four items which indicated no s ta tis tic a l differences were;
88
TABLE 16
DIFFERENCES IN RESPONSES TO THE STATEMENTS CONCERNING THE COMMUNITY HEALTH CLERKSHIP COURSE
Items
Groups
X SD F Sig.
1.
To learn from experience the frequency and
seriousness of diseases that bring people
to a rural health center for care.
Graduates
Students &
Faculty
Interns
2.69
2.86
2.67
.75
.75
.71
.94 NS
2.
To develop a deeper understanding of the health
needs of the community by participating in
village and home visits, surveys, and projects
outside the health center.
Graduates
Students &
Faculty
Interns
2.57
2.92
2.38
.79
.90
.92
3.36 .05
3. To continue the process of learning how to
formulate clearly the various health needs of
a defined community, identify target popula
tions for health care programs, design programs
for meeting these needs, and evaluate the
success of such programs.
Graduates
Students &
Faculty
Interns
2.92
3.03
2.78
.69
.79
.67
.69 NS
4. To observe, analyze, and understand the roles
of various members of the existing health
center team.
Graduates
Students &
Faculty
Interns
2.81
2.86
2.56
.73
.73
.53
.72 NS
l _ n
68
To apply under close supervision, at the
health center, clinical skills acquired
in the university hospital.
Graduates
Students &
Faculty
Interns
2.82
3.02
2.67
.80
.83
.71
1.29 NS
- To learn from experience the frequency and seriousness of
diseases that bring people to a rural health center fo r
care.
- To continue the process of learning how to formulate
c le a rly the various health needs of a defined community,
id e n tify target populations fo r health care programs,
design programs fo r meeting these needs, and evaluate
the success of such programs.
- To observe, analyze, and understand the roles of various
members of the existing health center team.,
- To apply under close supervision, at the health center,
c lin ic a l s k ills acquired in the u n ive rsity hospital.
The fa c u lty respondents rated a ll items higher than did the grad
uate respondents, who rated a ll items higher than did the student and
in te rn respondents.
W hen the responses to a ll items under subhypothesis 4 were grouped,
the differences among the groups were s ig n ific a n t (F = 37.89). The
null hypothesis was rejected at the .001 leyel of p ro b a b ility . The a
p rio ri contrast between combined groups 1 and 2 and group 3 was sig
n ific a n t ( t = 7.29, p < .0011. I t was not s ig n ific a n t between group 1
and group 2. The fa c u lty had a more favorable perception o f the
course, Community Health Clerkship, than the other two groups of res
pondents. The results of the analysis are shown in Table 34.
90
Subhypothesis 5
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the course, Internship in Community Health.
The fa c u lty respondents rated a ll the items higher than the stu
dent and intern respondents, who rated a ll items higher than graduate
respondents. The data collected fo r th is subhypothesis are shown in
Table 17. One item which the graduate respondents (X = 3.07] indicated
a higher rating than did the student and intern respondents (X = 3.10)
was:
- To practice the c lin ic a l s k ills essential fo r providing
a high standard of patient care in a rural health center
with lim ite d s ta ff, equipment, and fin a n cia l resources.
W hen the responses to a ll items under subhypothesis 5 were grouped,
the differences among the group were s ig n ific a n t (F = 3.221. The
null hypothesis was rejected at the .05 level of p ro b a b ility . The
a p rio ri contrast between combined groups 1 and 2 and group 3 was s ig
n ific a n t ( t = 2.48, p < .01). I t was not s ig n ific a n t between group 1
and group 2. The fa c u lty had a more favorable perception of the
Internship in Community Health Course than the other two groups of
respondents. The analysis of variance results are reported in Table
34.
91
DIFFERENCES IN RESPONSES TO
TABLE 17
STATEMENTS CONCERNING THE INTERNSHIP IN COMMUNITY HEALTH COURSE
Items Groups X SD F Sig,
To learn the many nonclinical responsibilities pf
a health center physician (that is, his respon
sibilities as administrator, planner, epidem
iologist, teacher, community organizer) as well
as his role in providing direct medical care tp
patients who come for treatment.
To learn, by working in the health care team,
the leadership role of the physician in charge pf
supervising all health care activities in a rural
district as well as in an urban health center.
To understand more clearly the importance pf
integrated curative, preventive, promotive
health care activities.
To learn the administrative structure and
operating policies of Thailand’s Ministry of
Health and its Department of Public Health,
particularly as they affect the daily oper
ation of a rural health center.
To practice the clinical skills essential
for providing a high standard pf patient
care in a rural health center with limited
staff, equipment and financial resources.
Graduates 3,13 1.01
Students & Interns 2,83 .79 1.
Faculty 2,56 ,73
NS
U D
ro
Graduates 3.20 1.01
Students & Interns 2,97 .85 1.07 NS
Faculty 2.78 .67
Graduates 2.93 .91
Students & Interns 2,83 1.00 .17 NS
Faculty 2,78 ,97
Graduates 3.18 ,98
Students & Interns 2,80 ,89 2.53 NS
Faculty 2.56 .73
Graduates 3.07 .89
Students & Interns 3,10 .84 2,29 NS
Faculty 2,44 ,53
Hypothesis 4
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the overall q u a lity of each course of the CHP.
According to the data, individual item analysis on the q u a lity of
each course indicated a s ig n ific a n t difference among means on four of
the fiv e items. Table 18 contains a tabulation of the responses to
the statements under th is hypothesis.
Faculty respondents considered a ll the items s ig n ific a n tly more
e ffe c tiv e than graduate respondents and student and intern respondents
did. The graduate respondents considered four of the fiv e courses
s ig n ific a n tly more e ffe c tiv e than the student and intern respondents.
The q u a lity of the Internship of Community Health was rated higher by
the student and intern respondents (X = 2.93) than by the graduate re
spondents (X = 3.20), although the difference was not s ig n ific a n t.
W hen the responses to a ll items under hypothesis 4 were grouped,
the differences among the groups were s ig n ific a n t (F = 37.28). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The
a p rio ri contrast between combined groups 1 and 2 and group 3 was s ig
n ific a n t ( t = 6.07, p < .001). I t was not s ig n ific a n t between group 1
and group 2. The fa c u lty had a more favorable perception of the
q u a lity of the courses in the Community Health Program. The results of
the analysis are shown in Table 34.
93
TABLE 18
DIFFERENCES IN RESPONSES CONCERNING THE OVERALL QUALITY OF THE FIVE COURSES
Items Groups X SD F
Sig,
1. Demographic Survey Graduates 2.65 ,78
Students & Interns 3,00 ,77 5.92 .01
Faculty 2,31 ,75
2. Analysis of Community Health Problems Graduates. 2,48 .84
Students & Interns 2.81 .81 6.29 .01
Faculty 2.00 .71
3. Community Health Planning Graduates 2.62 .84
Students & Interns 2.95 .69 5.06 .01
Faculty 2.31 .95
4. Clerkship in Community Health Graduates 2.71 .72
Students & Interns 3,03 .79 3.78 .05
Faculty 2.58 .90
5. Internship in Community Health Graduates 3.20 1.03
Students & Interns 2.93 .92 1.84 NS
Faculty 2.67 1.07
Hypothesis 5
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the usefulness of each course of the CHP.
The F-ratios among the three groups on the to ta l scores derived
from the usefulness of each course indicated s ig n ific a n t differences.
Table 19 contains a tabulation of the responses to the statements
under th is hypothesis.
Faculty respondents perceived a ll courses as more useful than did
the graduate, and student and in te rn respondents. Then, the graduate
respondents perceived four of the courses to be more useful than did
the student and intern respondents.* The only course which the student
and intern respondents C X = 2.80) considered more useful than did the
graduate respondents (X - 2.98) was the Internship in Community Health.
W hen the responses to a ll items under hypothesis 5 were grouped,
the differences among the groups were s ig n ific a n t (F = 28.94). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The
graduates, ^students and interns had d iffe re n t perceptions from the fac
u lty members of a ll courses. The a p rio ri contrast between combined
groups 1 and 2 and group 3 was s ig n ific a n t ( t = 6.54, p < .001). I t
was not s ig n ific a n t between group 1 and group 2. The fa cu lty had a
higher opinion of the usefulness of the courses of the CHP. Data are
presented in Table 34.
95
TABLE 19
DIFFERENCES IN RESPONSES CONCERNING THE USEFULNESS OF THE COURSES
Items
Groups X SD
F Sig,
1. Demographic Survey
Graduates 2,91 .96
Students & Interns 2.93 .89 5.10 .01
Faculty 2,07 1.14
2. Analysis of Community Health Problems Graduates 2.48 .98
Students & Interns 2.70 .82 5.04 .01
Faculty 1.86 .86
3. Community Health Planning
Graduates 2.67 . 1.03
Students & Interns 2.77 .86 3.84 .05
Faculty 2.00 .68
4. Clerkship in Community Health
Graduates 2.68 .90
Students & Interns 2,85 .85 5.10 .01
Faculty 2.00 .82
5. Internship in Community Health
Graduates 2,98 1.05
Students & Interns 2.80 .87 3.21 .05
Faculty 2.23 .83
C T >
Hypothesis 6
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the q u a lity of the teaching methods of each
course of the CHP.
According to the data, individual item analysis on the q u a lity of
the teaching methods of each course indicated a s ig n ific a n t difference
among means on three of the fiv e courses.
The courses fo r which s ig n ific a n t differences were indicated (see
Table 20) were:
- Demographic Survey
- Analysis of Community Health Problems
- Community Health Planning
The courses fo r which s ig n ific a n t differences were not indicated were:
- Clerkship in Community Health
- Internship in Community Health
The fa cu lty respondents considered teaching methods in a ll courses
more e ffe c tiv e than the graduates, who considered teaching methods in
a ll courses more e ffe c tiv e than the student and in te rn respondents.
W hen the responses to a ll items under hypothesis 6 were grouped,
the differences among the groups were s ig n ific a n t (F = 43.18). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The a
p rio ri contrast between combined groups 1 and 2 and group 3 was sig-
97
TABLE 20
DIFFERENCES IN RESPONSES CONCERNING THE QUALITY OF THE TEACHING METHODS
Items Groups X SD F
Sig.
1. Demographic Suryey Graduates 2.83 ,77
Students & Interns .3,15 .81 6.09 .01
Faculty 2,30 .82
2. Analysis pf Community Health Problems Graduates 2,48 .85
Students & Interns 3.03 ,81 10.71 ,001
Faculty 2,09 .70
3. Community Health Planning Graduates 2,65 ,77
Students & Interns 3,11 .87 7.52 ,001
Faculty 2.36 .67
4. Clerkship in Community Health
Graduates 2,93 .81
Students & Interns 3.15 *72 2,21
NS
Faculty 2,70 *48
5. Internship in Community Health
Graduates 3,28 .98
Students & Interns 3,17 ,83 2,44 NS
Faculty 2.60 .52
* £ >
o o
n ific a n t ( t = 7.47, p < .001). I t was also s ig n ific a n t between group 1
and group 2 ( t = -2.78, p < .01). The fa c u lty had a higher opinion
than the graduates concerning the q u a lity of the teaching methods in
the C H P courses. The graduates had a higher opinion than the students
of the q u a lity of the teaching methods in the C H P courses. Data are
presented in Table 34.
Hypothesis 7
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the amount of time given to each course of
the CHP.
Although individual item analysis on the amount of time given to
each course of the C H P was not s ig n ific a n t, the student and intern
respondents considered the time allotments fo r three courses more ap
propriate than did the graduate respondents, who considered the time
given to be more appropriate than the fa c u lty . As indicated in Table
21, these courses were the Community Health Planning, the Clerkship in
Community Health, and the Internship in Community Health.
More graduate respondents (X = 1.99) considered the time allo te d
to the Demographic Survey Course to be s u ffic ie n t than the student and
intern respondents (X = 2.02) or fa c u lty respondents (X = 2.20) did.
The time allocated to the Analysis of Community Health Problems
Course was perceived by the fa c u lty respondents (X = 1.91) to be more
s u ffic ie n t than i t was by student and intern respondents (X = 2.10).
99
DIFFERENCES IN RESPONSES
TABLE 21
CONCERNING THE AMOUNT OF TIME GIVEN TO EACH COURSE
Items
Groups X SD F .
Sig.
1. Demographic Survey Graduates 1.99 ,48
Students & Interns 2,02 .64 , 66 NS
Faculty 2.20 ,42
2. Analysis of Community Health Problems
Graduates 2,10 .53
Students & Interns 2.05 • .53 .76 NS
Faculty 1,91 .30
3. Community Health Planning Graduates 2.09 .55
Students & Interns 2.02 .59 1,07 NS
Faculty 2,27 .47
4. Clerkship in Community Health. Graduates 2,09 .52
Students & Interns 1.98 ,59. .74 NS
Faculty 2,10 ,32
5. Internship in Community Health
Graduates 2,02 ,55
Students & Interns 2,00 .54 ,16 NS
Faculty 2,11 .33
_ j
o
o
W hen the responses to a ll items under hypothesis 7 were grouped,
the differences among the groups were s ig n ific a n t (F = 29.63). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The
a p rio ri contrast between combined groups 1 and 2 and group 3 was
rejected ( t = 5.43, p < .001). The fa c u lty had a higher opinion of
the amount of time given to the courses of the C H P (see Table 34).
Hypothesis 8
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the amount of the m aterial covered in each
course of the CHP.
No s ig n ific a n t differences in opinions expressed regarding the
amount of the material covered in each course of the C H P as perceived
by the three groups were noted on a ll items. The analysis of variance
re sults are reported in Table 22.
W hen the responses to a ll items under hypothesis 8 were grouped,
the differences among the three groups were s ig n ific a n t C F = 35.63).
The null hypothesis was rejected at the .001 level of p ro b a b ility . The
a p r io ri contrast between combined groups 1 and 2 and group 3 was sig
n ific a n t ( t = 6.75, p < .001). I t was not s ig n ific a n t between group 1
and group 2. The fa c u lty had a higher opinion of the amount of the
material covered in each course of the CHP. The mean scores, th e ir
differences, and the yalues of the a p rio ri contrast are lis te d in
Table 34.
101
DIFFERENCES IN RESPONSES CONCERNING
TABLE 22
THE AMOUNT OF MATERIAL COVERED IN EACH COURSE
Items
Groups
-
SD F Sig,
1. Demographic Survey Graduates 2,19 .57
Students & Interns 2.30 .53 .95 NS
Faculty 2.10 ,32
2. Analysis of Community Health Problems Graduates 2.20 .52
Students & Interns 2.30 .49 1.76 NS
Faculty 2.00 .00
3. Community Health Planning Graduates 2.23 ,53
Students & Interns 2,33 .51 2.02 NS
Faculty 2,00 .00
4. Clerkship in Community Health Graduates 2,16 .57
Students & Interns 2.20 ;-57 1.21 NS
Faculty 1,90 ,32
5. Internship in Community Health Graduates 2,23 ,64
Students & Interns 2.24 .53 .68 NS
Faculty 2,00 .00
-j
o
ro
Hypothesis 9
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the learning experiences included in the
program.
According to the analysis, one item which indicated s ig n ific a n t
difference:
- In the opinion of each of the three groups, what learning
experiences not presently provided should be added to the
program?
The mean response to the above item was higher fo r the fa cu lty
group (X = 17.81) than the student and in te rn group (X = 10.30) and the
graduate group (_ X = 8.93). Table 23 contains a tabulation of the re
sponses to the statements under th is hypothesis.
When the responses to a ll items under hypothesis 9 were grouped,
the differences among the groups were not s ig n ific a n t C F = 1.06). The
null hypothesis was accepted that there was no difference among the
opinions of the three groups. The a p rio ri contrast between combined
groups 1 and 2 and group 3 was not s ig n ific a n t. I t was also not sig
n ific a n t between group 1 and group 2. The mean scores, th e ir d if f e r
ences, and the value of the a p rio ri contrast are lis te d in Table 34.
In order to help c la r ify each item, the respondents were asked to
respond to open ended questions about several aspects of the program
103
TABLE 23
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE CHP LEARNING EXPERIENCES
Items Groups X SD F Sig,
4.68
3.80 .96 NS
5,08
5,53
6,09. 2.64 NS
2.80
4.80
5.81 16.87 ,01
6,67
.33
,41 1.44 NS
,28
1. In the opinion of the three groups, what part Graduates 8.18
of CHP experiences was most satisfying? Students & Interns 9,30
Faculty 8,36
2. In the opinion of the three groups, what part Graduates 7,83
of CHP experiences, was unsatisfying? Students & Interns 9,02
Faculty 11,75
3. In the opinion of the three groups, what Graduates 8,93
learning experiences not presently proyided Students & Interns 10,30
should be added to the program? Faculty 17,81
4. Did students acquire knowledge or skills Graduates 1.12
from field work which were not taught in Students & Interns
1,21
the classroom? • Faculty 1.08
under general headings lis te d in Table 23. As can be seen in Table
24, there were seventeen sections asking the respondents what part of
the C H P experience was most s a tis fy in g . Four sections e lic ite d large
numbers o f favorable responses from a ll three groups. The f i r s t
largest percentage of student and in te rn respondents (40%), graduate
respondents (32%), and fa c u lty respondents (7%) stated that work in
the v illa g e was sa tisfyin g to them. The second highest number of re
sponses was made to the student project section, with 13% of graduate
and 14% of student and intern respondents giving a favorable response.
The th ird section which e lic ite d a large number of favorable responses
was the opportunity to see the rural country in r e a lity . The th ird
section included 10% of the graduate respondents, 2% of the student
and in tern respondents, and 14% of the fa c u lty respondents. The fourth
section was the problem-solving cycle with 10% of the graduate, 4% of
the student and in te rn , and 21% of the fa c u lty respondents.
As indicated in Table 25, there were twenty one sections in which
respondents were asked questions concerning parts of the C H P experience
which were not sa tisfyin g to them. Four sections e lic ite d large num
bers of unfavorable responses from a ll three groups. These sections
were:
- Lecture method of teaching at Bang Pa-In was not appropriate.
- No teachers to consult at Bang Pa-In. Nothing motivated th e ir
interests because they did not know the purpose of tra in in g .
- Bang Pa-In was not a real community.
- No coordination between school and Bang Pa-In because of d if f e r
ent lin e of control.
105
TABLE 24
STATEMENTS OF RESPONDENTS REGARDING THEIR SATISFACTION WITH THE CHP
Statements
Graduates
No. %
Students
Interns
No. %
Faculty
No. %
1. Objectives of the program, theory,
and discipline. 5 7 1 2 1 7
2. Problem-solving cycle. 7 10 2 4 3 21
3. Community Health Planning. 1 1 - - - -
4. Analysis of Community Health
Problems. 2 3 - - 1 7
5. Preventive Medicine, e.g.,
Epidemiology. 1 1 - - - -
6. Field study, e.g. Malaria. 6 9 6 12 - -
7. Student project. 9 13 7 14 - -
8. Team working 2 3 1 2 - -
9. Village working. 22 32 20 40 1 7
10. Group conference, group discussion. - - 1 2 2 14
11. Teaching method which consisted of
lecture, practice, and use of re
sults of practice as content of
lecture. 2 4 1 7
12. Internship rotation. - - 1 2 - -
13. System of working and working
circumstance.
- - 4 8 3 21
14. Opportunity to see the rural
country in reality. 7 10 1 2 2 14
15. School health for students. 1 1 - - - -
16. Opportunity for students to
observe problems and try to
solve them by themselves. 3 4 1 2
,
17. Have leisure time and trip. 2 3 3 6 - -
106
TABLE 25
STATEMENTS OF RESPONDENTS REGARDING THEIR DISSATISFACTION WITH THE CHP
Statements
Graduates Students
Interns
Faculty
No. % .No. % No. %
1. Demographic Survey: Walking
through villages to collect
data and giving gifts to people
for cooperation. 8 13 1 2
2. Biostatistics: It is important
but too difficult. 3 5 4 7
- -
3. Epidemiology: Repetitious and
some diseases cannot be found in
Thailand, e.g., Typhus. 3 5 1 2
_ _
4. Nutrition program. 1 2 - - - -
5. Method of teaching and class
room demonstration. 18 28 20 34
- -
6. Teachers did not keep schedule
and came late. 1 2 3 5
- -
7. Lecture method of teaching at
Bang Pa-In was not appropriate. 4 6 2 3 2 15
8. No teachers to consult at Bang
Pa-In. Nothing motivated stu
dents’ interests because they
did not know the purpose of
training. 6 9 8 14 2 15
9. No cooperation from other
department teachers. 1 2 3 5
- -
10. Teacher interfered in planning. 2 3 2 3
- -
11. The students did not see the
importance of the program. - - - - 1 8
12. The students had no basic
background for this program. - - - - 2 15
107
TABLE 25— C ontinued
Graduates
Statements
Students Faculty
Interns
No. % No. % No. %
13. The students missed classes
because they had basic science
examinations, so their knowl
edge was disconnected.
14. Bang Pa-In was not a real
community.
15. No coordination between school
and Bang Pa-In because of
different line of control.
16. Teachers taught foreign
Community Health because they
had not lived in a provincial
district before.
17. No motivation or stimulation to
work in rural areas.
18. Examination content was not a
real problem of Thailand.
19. Report was too long and
uneconomical.
20. Iri order to understand the
objectives, the hand-out sheets
should be written in Thai.
21. Too much leisure time.
7 11
2 3
3 5
2 15
1 2 2 15
2 3 2 15
108
However, the largest negative responses were fo r item 5 concerning
the method of teaching and classroom demonstration (graduates 28%,
students and interns 34%).
As noted on Table 26, there were nineteen sections asking
respondents about learning experiences not presently provided that
should be added to the program. Three sections e lic ite d large numbers
of responses from a ll three groups:
- Health system --principle, theory, and new trends including
management of a provincial and d is t r ic t h o sp ita l, or health
center.
- Personnel management.
- Field work location should be real (without modern equipment as
at Bang Pa-In); the students should be exposed to real problems
and should have chances to learn from experienced physicians.
The item which e lic ite d the most fa c u lty responses (25%) was
item 6:
- In cooperation with the M in istry of Public Health, arrange
fie ld areas as real tra in in g places. During year V and VI
there is an e le ctive period of 5-6 weeks in which students can
experience primary hospital care in the provincial hospital.
O n Table 27, twenty one sections are lis te d in which respondents
were asked i f students acquired knowledge or s k ill from f ie ld work
which were not taught in the classroom. Four items e lic ite d the most
responses. These were:
109
TABLE 26
STATEMENTS OF RESPONDENTS REGARDING CHANGES
INCLUDING ADDING COURSES TO THE CHP
Statements
Graduates
No,
Students
Interns
No, %
Faculty
No. %
1. Behavioral science— Human
Relation.
2. Preventive medicine— common
disease, not rare diseases—
including planning for preven
tive medicine.
3. Forensic medicine— postmortem
examination.
4. Basic Law— civil legal aspects,
financial legal aspects, public
health legal aspects.
5. Health system— principle, theory,
and new trends, including manage
ment of a provincial and district
hospital, or health center.
6. Personnel management.
7. Current important problems in
public health.
8. Community Psychology in order to
be able to cooperate with commu
nity leader for using community
resources.
10
15
7
20
10
To familiarize students, through
the use of system analysis and
problem solving alternatives, with
the successes, failures, and
changes of the CHP nationally and
internationally.
New trends in curing community
diseases.
110
TABLE 26— C ontinued
Graduates Students Faculty
Statements Interns____________
No. % No. % No. %
11. Add more teachers at Bang Pa-In. 2 3 3 7 - -
12. Sanitation focusing on elimi
nation of trash. 1 2 - - 2 13
13. Team working. - - - - 1 6
14. Field work location should be
real (without modern equipment
as at Bang Pa-In); the students
should be exposed to real
problems and should have chances
to learn from experienced
physicians. 19 33 11 27 2 13
15. No repetition in teaching and
sequencing of the content. - - 1 2 2 13
16. In cooperation with the Ministry
of Public Health, arrange field
areas as real training places.
During year V and VI, there is
an elective period of 5-6 weeks
in which students can experience
primary hospital care in the
provincial hospital. - - - 4 25
17. Add more time. 2 3 1 2 - -
18. Decrease time by reducing
lecture. - - 2 5 ^ -
19. The program should start from
year I. — - 1 2 1 6
Total 59 100 40 100 16 100
m
TABLE 27
STATEMENTS OF RESPONDENTS REGARDING KNOWLEDGE
AND SKILLS ACQUIRED FROM THEIR FIELDWORK
Graduates Students Faculty
Statements_____________________ Interns____________
No. % No. % No. %
1. Practice in a health center with
limited resources— know the
limitation of resources and how
to adapt the simple equipment
to treat the patients in a
primitive environment. 12 12 7 9 9 25
2. Experiences in outpatient depart
ment with patient screening, con
sulting, and referring the patients
in case of complex problems. Ex
periences in making decisionsiin
diagnosing the patient including
skills of approaching the
patients. 6 6 8 11 4 11
3. To know how to work in a health
team. 3 3 2 3 1 3
4. To learn the methods of health
care delivery in community health
care system. 2 2 3 4 1 3
5. To understand the management of
health centers, e.g., routine
work of the health officer, to
control, and to coordinate. 14 14 16 21 8 22
6. To understand problems, behavior of
health, culture, old values of
health, language, and environment
of people in the community, e.g.,
difficult problems to solve as
when people get sick, but cannot
go to a health center because of
raining and mud slides on the
road. 29 30 13 17 4 16
7. To understand school health and
public health in general, e.g.,
mobile clinic. 1 1 3 4 1 3
112
TABLE 27— C ontinued
Graduates Students Faculty
Statements Interns
No. % No. % No. %
8. To know frequencies of diseases
in community. 1 1 3 4 2 6
9. Home visit. 3 3 3 4 2 6
10. To understand and prepare well
for the limitation in practicing
at health centers after grad
uating . 4 4 4 5 1 3
11. To gather the data and analyze
the problems of public health. 3 3 1 1 1 3
12. To understand how to train the
barefoot doctor (quack, or
magic doctors, and midwives).
_ _
1 1
__ _
13. To learn minor surgery. - - 2 3 - -
14. To work in preventive medicine. - - 2 3 - -
15. To learn common disease and Rx. 2 2 1 1 - -
16. To learn manual skills. 2 2 1 1 ' 2 6
17. To understand the contagious
diseases that spread by
nature. 1 1 2 3
•*-
18. To sympathize with the poor. - - 1 1 - -
19. To know people in different
professions, and learn the
art of talking. 11 11 2 3
_ _ —
20. To learn how to be patient in
working with other health
workers. 3 3
_
•*-
21, Mother and Child Health. 1 1 - - - -
Total 98 100 75 100 36 100
113
- Practice in a health center with lim ite d resources— know
the lim ita tio n of resources and how to adapt the simple
equipment to tre a t the patients in a p rim itiv e environ
ment.
- To understand the management of health centers, e .g .,
routine work of the health o ffic e r, to co n tro l, and to
coordinate.
- To understand problems, behavior of health, c u ltu re , old
values of health, language and environment of people in
the community, e .g ., d i f f i c u l t problems to solve as when
people get sick, but cannot go to a health center because
of raining and mud slides on the road.
- To know people in d iffe re n t professions and learn the a rt
of ta lk in g .
Hypothesis 10
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in opinions expressed
regarding the impact of the C H P on future careers.
S ig n ifica n t differences in the impact of aspects of the C H P as
perceived by the three groups were noted on three items (see Table 28).
No s ig n ific a n t differences were indicated fo r the following":
- The C H P helps students to perform in th e ir future careers.
- The experience from Demographic Survey helps students practicing
114
TABLE 28
DIFFERENCES IN RESPONSES TO STATEMENTS CONCERNING THE IMPACT OF CHP ON FUTURE CAREERS
Items
Groups X SD F Sig.
1. The Community Health Program helps students Graduates 2.01 .82
to perform their future careers.
Students & Interns 2.13 .73 .58 NS
Faculty 1.96 .69
2. The experiences from Demographic Survey Graduates 2.85 .94
help students in practicing their Students & Interns 3.08 .82 1.84 NS
future careers.
Faculty 2.60 .97
3. The experiences from Community Health Graduates 2.58 .85
Problems help students in practicing Students & Interns 2.90 .76 4.32 .01
their future careers. Faculty 2.22 .83
4. The experiences from Community Health Graduates 2.75 .76
Planning help students in practicing Students & Interns 3.03 .68 7.55 .001
their future careers. Faculty 2.11 .60
5. The experiences from Community Health
Graduates 2.65 .71
Clerkship help students in practicing Students & Interns 2.97 .75 3.52 .05
their future careers.
Faculty 2.56 .73
cn
th e ir future career.
The fa c u lty respondents perceived the C H P as a more e ffe c tiv e
preparation fo r the future careers of students than did graduates, who
rated the C H P higher in th is area than the student and in te rn respon
dents.
W hen the responses to a ll items under hypothesis 10 were grouped,
the differences among the groups was s ig n ific a n t (F = 37.90). The
null hypothesis was rejected at the .001 level of p ro b a b ility . The
a p rio ri contrast between combined groups 1 and 2 and group 3 was
s ig n ific a n t ( t = 7.78, p < .001). The graduates, students and interns
rated the C H P lower than the fa c u lty as preparation fo r th e ir future
career. The contrast between group 1 and group 2 was s ig n ific a n t ( t =
-2.80, p < .01). The graduate group rated the C H P higher than the
student and intern group as preparation fo r th e ir fu tu re career. The
mean scores, th e ir differences, and the value of the a p rio ri contrast
are lis te d in Table 34.
General Comments by Respondents
Although no hypothesis was formulated fo r th is purpose, the gen
eral opinions of the three groups toward the program as a whole were
f e l t to be important. As can be seen in Table 29, there were twenty
seven sections in which the C H P was c ritic iz e d by the respondents.
The items which e lic ite d the most graduate responses were 27% fo r
item 3 (a) and 14% fo r item I (e). Item 3 (a) stated "During the C H P
Clerkship Course, the students should be trained at health centers
116
TABLE 29
Graduates Students Faculty
Statements Interns
No. % No. % No. %
STATEMENTS OF THE RESPONDENTS REGARDING
THEIR GENERAL OPINIONS OF THE CHP
1. The CHP Curriculum:
a. The CHP had no relation or coor
dination with other department
staff. That is why the CHP
knowledge was not reinforced in
clinical teaching by every fac
ulty member and newly acquired
attitudes disappeared very fast.
It was suggested that other
teachers should know this cur
riculum and be able to give sug
gestions. 1 2 - - 3 21
b. The students had joined the stu
dent activities since year I and
they learned how to plan and run
the project from senior stu
dents. When they entered year
I.V they began to learn the CHP,
it seemed that they learned how
to walk by themselves before
someone tried to teach them how
to do this. - - - - 1 7
c. The CHP served to sensitize and
crystalize health problems of
Thailand, but if the school
wanted to prepare students to be
self-sufficient, main care and
forensic-medicine should be
added to this program. - - - - 1 7
d. The management of Public Health
during internship should be put
in other courses, because grad
uates who could not get train*-
ing at Ramathibodi had no chance
to study it. 1 2 - - - -
117
TABLE 29— C ontinued
Graduates Students Faculty
Statements_____________________ Interns____________
No. % No. % No. %
e. The curriculum should include
rural culture and tradition, ba
sic economic, national budget,
health budget, and health per
sonnel management. 6 14 1 3
f. The students want to reduce the
clerkship time to 4 weeks. 1 2 5 18
2. Teachers:
a. Every faculty member should get
temporary rural experiences for
at least 2-3 months. - - 1 3
b. Teachers should be really expert
in the CHP and go on field trips
with students all the time. 10 22 6 22
3. Teaching:
a. During the CHP Clerkship Course,
the students should be trained
at health centers around Thai
land under the supervision of
the CHP graduates after the 1-2
week orientation at Bang Pa-In. 12 27 6 22 2 15
b. The setting of objectives and
the learning experience ar
rangements were not related,
e.g., there were expectations
indicated for psychomotor skills
but no materials suggested for
training. - - - - 1 7
c. In order to observe the students
at the health center, the
teacher should assign jnodel pro
cedures, which the students
should be responsible for under
the supervision of the teacher. 1 2 - -■ - -
118
TABLE 29— Continued
Statements
Graduates Students
Interns
Faculty
No. % No. % No. %
d. The teacher should lecture
about the spread of diseases in
the community, e.g., infectious
diseases in clinical environ
ments including epidemiology. 1 2
e. Biostatistics— computer learning
cannot be used in the provinces
— have to work by hand, which was
not taught before. 1 - 2
f. Theory should be emphasized
more than practice, because
practice should be done when
they start (working. 1 3
g-
Health personnel and midwives
should learn basic health care
in order to screen and reduce
the physicians' work load. 1 2
h. The students should learn how to
solve problems, and the school
should take action to solve
problems using some of the infor
mation students had previously
collected, e.g., Bang Pa-In peo
ple health problems. 1 2
4. Project:
a. The students should submit a de
sign procedure and methodology
including analysis and method of
solving problems regarding de
velopments in the community. 3 6
b. The students should be free in
studying public health problems
with teacher guidance, hut not
specific requirements. The proj
ect should be a long term study-
divided into several periods and
119
TABLE 29—-Continued
Graduates Students Faculty
Statements__________________ Interns____________
No. % No. % No. %
students should go out continu
ally to complete the project. 2 4 1 3
c. The assigned project should re
sult in preventive or curative
medicine, e.g., anaemia. 2 4 - -
d. The group should be divided into
smaller groups in order that all
students could participate. - - 6 22 1 7
e. Too many projects were assigned
in the CHP Clerkship during 6
weeks; the best way would be
that the student should select
one and work hard on that in or
der to get the idea of how to
implement it at the health cen
ter. 2 4 - - - -
5. Bang Pa-In:
a. The health team there got the
assigned works from the Ministry
of Health, so they considered
health services as first pri
ority and teaching as second
priority. - - - 1 7
b. The immunization coverage at the
Secondary Health Center prog
ressed well after training, but
if there was support regularly
through field work program from
the Primary Health Center, such
as nutrition in preschool child,
the program would implement
well. - - - 1 7
c. Work schedule and work planning
should be set for the physician,
that how many percent should be
spent in medical care and field
120
TABLE 29— C ontinued
Graduates Students Faculty
Statements . _________Interns____________
No. % No. % No. %
ical care and field program,
e.g., integrated health care at
the training center. In case of
patient load at the training
center, an additional physician
should be requested from provin
cial hospital. - - - - 1 7
d. In order to complete the CHP,
the students should be assigned
to do an exercise with the Sec
ondary Health Center in giving
integrated health caxe serv
ices by accurate target. This
had to be plan of the health
center not the artificial activ
ities done by the teacher for
purpose of instruction. - - - - 1 7
6. Attitude:
a. Some students intended to be
specialists and thought that the
CHP was useless. There must be
sufficient incentive to motivate
them to learn the course mate
rial and finally change their
attitudes. 2 4 1 3 2 15
b. Methods should be devised to
motivate the students to be
eager to work in rural areas. 1 2 - - - -
Total 48 100 28 100 15 100
121
around Thailand under the supervision of the C H P graduates a fte r 1-2
week o rie nta tio n at Bang Pa-Ijn.1 1 Item 1 (e) stated "The curriculum
should include rural culture and tra d itio n , basic economic, national
budget, health budget, and health personnel management.1 1
The item which e lic ite d the most student and intern responses
were 22% fo r items 2 Cb), 3 (a), and 4 (d), and 18% fo r item 1 ( f) .
Item 2 (b} stated "Teachers should be re a lly expert in the C H P and go
on fie ld trip s with students a ll the tim e." Item 3 (a) stated "During
the C H P Clerkship Course, the students should be trained at health cen
ters around Thailand under the supervision of the C H P graduates a fte r
the 1-2 week o rie n ta tio n at Bang Pa-In." Item 4 (d) stated "The group
should be divided in to smaller groups in order th a t a ll students could
p a rtic ip a te ." Item 1 (f ) stated "Students want to reduce the clerkship
time to 4 weeks."
The item which e lic ite d the most fa c u lty response was 21% fo r
item 1 (a). I t stated "The C H P had no re la tio n or coordination with
other department s ta ff. That is why the C H P knowledge was not re in
forced in c lin ic a l teaching by every fa c u lty member and the newly ac
quired a ttitu d e s disappeared .very fa s t. I t was suggested th a t other
teachers should know th is curriculum and be able to give suggestions."
Hypothesis 11
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in the statements expressed
regarding a ttitu d in a l factors.
122
From the s ta tis tic a l analysis of the to ta l items, i t appeared
there was s ig n ific a n t difference at the .01 level of p ro b a b ility or
greater (F = 4.07, df = 2, 160) to re je c t the hypothesis and conclude
that there were s ig n ific a n t differences among the students and in te rns,
the graduates, and the fa cu lty members in a ttitu d e s . In comparison of
means among the three groups, the fa c u lty appeared to have the highest
positive a ttitu d e s (X = 3.03, S D = 5.60), the graduate respondents (X =
2.95, S D = 4.97) showed more positive a ttitu d e than the student and
intern respondents (X = 2.87, S D = 4.42). The a p rio ri contrast be
tween combined groups 1 and 2 and group 3 was s ig n ific a n t ( t = -3.33,
p < .05). The contrast between group 1 and group 2 was not s ig n ific a n t.
The mean scores, th e ir differences, and the value of the a p rio ri con
tra s t are lis te d in Table 34.
As previously noted the maximum raw score mean fo r a ll three
groups was 80 and a calculation of Cronbach!s alpha c o e ffic ie n t in d i
cated a r e lia b ilit y of .56. As can be seen in Table 30, the fa c u lty
respondents indicated the highest po sitive a ttitu d e (..X = 73) and the
graduate respondents indicated the lowest po sitive a ttitu d e (X = 46).
The analysis among the graduate respondents showed the lowest positiye
a ttitu d e to be X = 46, and the highest p o sitive a ttitu d e was X = 71.
Among the student and intern respondents, the least positive a ttitu d e
indicated was X = 48 and the highest was X = 69. Among the fa c u lty ,
the lowest was X = 50 and the highest was X = 73. Most of the respon
dents f e ll w ithin the score interval 55-60 as in Table 30,
I t was f e l t important to report a ll items in rank order to indi-.
123
TABLE 30
FREQUENCY OF TOTAL SCORE MEANS OF RESPONSES
Score Intervals
Graduates Students & Interns Faculty
No. of X % No. of X % No. of X %
45 - 50
a
3
_
3 1
_
51 - 54 10 - 12 - 1 -
55 - 60 38 1 33 1 12 -
61-64 12 4 8 4 5 2
65 - 70 14 20
b
5 21 4 3
71 - 74 1 22 - 19
c
2 7
75 - 80 - 17 - 11 - 7
81 - 84 - 10 - 4
- 4
85 - 90 - 4
- 1 - 1
91 - 94
- - — - — 1
Total 78 78 61 61 25 25
a. 1 out of 3 indicated X = 46
b. 1 out of 5 indicated X = 69
c. 1 out of 2 indicated X = 73
124
cate the re la tiv e degree of importance each respondent group a ttrib u te d
to each item (see Table 31). The results indicated that the item fo r
which the graduate group, the student and intern group, and the fa c u lty
group revealed highest positive a ttitu d e was item 19 (Appendix A):
- I t is important fo r physicians working w ith poor patients to
get to know them well to best serve them.
The item which was ranked the lowest was item 20 (Appendix A):
- The q u a lity of medical care under the system o f private practice
is in fe rio r to that under socialized medicine.
Analysis of the data showed hypothesis 11 to be true in many in
stances although the degree of agreement d iffe re d .
Consequently, the follow ing subhypotheses were formulated to te st
the hypothesis with regard to a ttitu d in a l factors.
Subhypothesis 1
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in a ttitu d e s toward the
professions.
As indicated in Table 32, six items in which the student and in
tern group, the graduate group, and the fa c u lty group revealed sig
n ific a n t differences in a ttitu d e s were:
- Medical tra in in g in the c lin ic a l years should concentrate most
of the student's time on evaluations and treatment of sp e cific
disease process.
125
TABLE 31
RANK ORDERS OF ITEM MEANS OF RESPONSES
Rank Item Item X SD % of Response X
1 19 3.53 .60 88
2 1 3.46 .67 87
3 10 3.41 .59 85
4 18 3.26 .75 81
5 2 3.20 .75 80
6 14 3.10 .65 78
7 12 3.09 .64 77
8 6 2.99 .65 75
9 11 2.97 .75 74
10 7 2.95 .72 74
11 13 2.95 .79 73
12 9 2.87 .80 72
13 5 2.82 .63 71
14 15 2.71 .85 68
15 16 2.70 .83 68
16 8 2.66 .81 66
17 3 2.61 .82 65
18 17 2.53 .91 63
19 4 2.44 .76 61
20 20 2.41 1.04 60
126
TABLE 32
DIFFERENCES IN ATTITUDES EXPRESSED TOWARD THE PROFESSIONS AND THE CLINICAL MANAGEMENT
Items Groups X SD F Sig.
Attitudes Toward the Professions:
1 . In medical practice today there are sufficient
specialists so that a physician in general
practice should not assume long term respon
sibility for his patients.
Graduates
Students &
Faculty
Interns
3.57
3.43
3.50
.53
.50
.72
1.10 NS
2. The medical school should train students for
specialties rather than general practice.
Graduates
Students &
Faculty
Interns
3.23
3.15
3.50
.67
.71
.51
2.40 NS
3. In a general practice there is no reason to
stress good health and promote health care
since the average patient only wants to pay
for the alleviation of his disease.
Graduates
Students &
Faculty
Interns
2.60
2.66
2.67
.71
.81
.05
.12 NS
4. Medical training in the clinical years should
concentrate most of the student’s time on
evaluation and treatment of the specific
disease processes.
Graduates
Students &
Faculty
Interns
2.42
2.36
2.83
.64
.80
.82
3.87 .05
5.
i—*
ro
"vi
Specific knowledge necessary for prevention
of disease is so limited at this state of
development that the time of a practicing
physician is much better spent in curative
medicine.
Graduates
Students &
Faculty
Interns
2.79
2.70
3.20
.64
.59
.58
6.03 .01
TABLE 32— Continued
Items Groups X SD F
Sig.
6. For a well-rounded medical education, work in
radiology and surgery is decidedly more im
portant than work in preventive medicine.
Graduates
Students &
Faculty
Interns
3.01
2.97
3.24
.62
.52
.44
2.18 NS
7. In present day practice the demand for treat
ment of disease is so great that hardly any
time can be spared to concern oneself with
prevention of illness.
Graduates
Students &
Faculty
Interns
3.00
2.72
3.32
.73
.64
.75
7.00 .001
8. Since prevention of disease is directly
related to the properties of disease itself
there is no special reason to teach the
preventive aspects in a separate course.
Graduates
Students &
Faculty
Interns
2.93
2.62
2.55
.53
.64
.80
5.74 .01
9. Prevention of disease as a medical activity
is primarily the responsibility of the CHP
rather than the responsibility of other
departments.
Graduates
Students &
Faculty
Interns
2.80
2.87
3.20
.73
.76
.87
2.57 NS
10. The greatest service a physician can provide
is in following long term treatment and
adjustment of patients and families rather
than in concentrating only on the treatment
of immediate illness complaints of his patients.
Graduates
Students &
Faculty
Interns
3.38
3.38
3.56
.59
.55
.71
1.01 NS
11.
ro
00
As a physician you would prefer to have all
the members of a family as your patients
rather than see patients as individuals.
Graduates
Students &
Faculty
Interns
3.05
2.88
3.29
.59
.67
.62
3.83 .05
TABLE 32— Continued
Items Groups X SD F Sig.
12. The most important function of the physician
is to immediately relieve the suffering of
the patients.
Graduates
Students & Interns
Faculty
3.04
3.05
3.48
.62
.56
.51
5.93 .01
Attitudes Toward the Clinical Management:
1. A medical doctor in a clinical team should
consult with the team members, such as with
nurse, psychologist, social worker, etc.,
before making decisions in the management
of the patients such as discharges, referrals,
or pronounced changes in therapy.
Graduates
Students & Interns
Faculty
3.08
3.13
3.32
.54
.57
.56
1.81 NS
2. In a medical setting, the doctors should
have all personnel involved in the treat
ment of patients participate in case dis
cussion regardless of their professions.
Graduates
Students & Interns
Faculty
2.93
2.92
3.20
.72
.71
.96
1.38 NS
3. In a medical setting, the doctor should
have the patient participating in dis
cussion in the treatment of that patient.
Graduates
Students & Interns
Faculty
2.81
2.83
2.91
.65
.67
.53
.'.19 NS
129
- Specific knowledge necessary fo r prevention of disease is so
lim ite d at th is state of development that the time of a prac
tic in g physician is mich better spent in curative medicine.
- In present day practice the demand fo r treatment o f disease is
so great tha t hardly any time can be spared to concern oneself
with prevention of illn e s s .
- Since prevention of disease is d ire c tly related to the prop
e rtie s of disease it s e l f , there is no special reason to teach
the preventive aspects in separate course.
- As a physician you would prefer to have a ll the members of a
fam ily as your patients rather than see patients as individuals.
- The most important function of the physician is to immediately
re lie ye the suffering of the patients.
A comparison o f the students' and in te rn s ', graduates', and fac
u lty members' a ttitu d e s toward the profession showed that fa cu lty
group valued general practice over spe cia ltie s and considered pre
vention of diseases more important than did the graduate group and the
student and intern group. The graduate respondents regarded these
factors as more important than student and in te rn respondents did. One
sp e cific item which was perceiyed by the student and in te rn respondents
to be more important than the graduate respondents was:
- The most important function of the physician is to immediately
re lie ve the suffering of the patients.
One item was perceived as more important by the graduate respon
dents than by the student and intern respondents, who perceived as more
130
important than by the fa c u lty respondents. This item was:
- Since prevention of disease is d ire c tly related to the prop
e rtie s of disease it s e lf , there is no special reason to teach
the preventive aspects in a separate course.
W hen the responses to a ll items under subhypothesis 1 were grouped,
the differences among the groups were s ig n ific a n t (F = 5.06). The null
hypothesis was rejected at the .01 level of p ro b a b ility . Each group
had d iffe re n t perceptions of the profession. The a p rio ri contrast
between combined groups 1 and 2 and group 3 was s ig n ific a n t ( t = -2.57,
p < .01). The contrast between group 1 and group 2 was not s ig n if
icant. The mean scores, th e ir differences, and the value of the a
p rio ri contrast are lis te d in Table 34.
Subhypothesis 2
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in a ttitu d e s toward
the c lin ic a l management.
No s ig n ific a n t differences in the a ttitu d e s toward the c lin ic a l
management as perceived by the three groups were noted on a ll items.
The analysis of variance results are reported in Table 32'.
When the responses to a ll items under subhypothesis 2 were
grouped, there were no s ig n ific a n t differences among groups. The a
p rio ri contrast between combined groups 1 and 2 and group 3 was not
s ig n ific a n t. The contrast between group 1 and group 2 was also not
131
s ig n ific a n t. The mean scores, th e ir differences, and the values of
the a p rio ri contrast are lis te d in Table 34.
Subhypothesis 3
There w ill be no differences among students-and-interns,
graduates, and fa c u lty groups in a ttitu d e s toward
the poor people.
In th is subset, s ig n ific a n t differences were indicated fo r one
item (see Table 33):
- I t is important fo r a physician working with poor patients
to get to know them well in order to best serve them.
This item was rated more important by the fa c u lty group than by
the graduate group, who perceived i t as more important than the stu
dent and in te rn group.
When the responses to a ll items under subhypothesis 3 were
grouped, the differences among the three groups were not s ig n ific a n t.
The a p rio ri contrast between combined groups 1 and 2 and group 3 was
not s ig n ific a n t. The contrast between group 1 and group 2 was sig
n ific a n t Ct = 2.05, p < .05). There was a s ig n ific a n t difference
between the student and intern group and the graduate group. The grad
uate group had more po sitive a ttitu d e toward the poor than the stu
dent and intern group. The analysis of variance results are reported
in Table 34.
132
DIFFERENCES IN ATTITUDES EXPRESSED
TABLE 33
TOWARD THE POOR PEOPLE AND THE HEALTH SYSTEM
Items Groups X . SD F Sig.
Attitudes Toward the Poor People:
1. Physicians are generally not responsive to the Graduates 2.77 .78
health needs of poor people. Students & Interns 2.68 .73 .23 NS
Faculty 2.76 .93
2. While it is desirable that we help provide Graduates 2.58 .84
health service to the poor, our own personal Students & Interns 2.58 .72 .44 NS
learning comes first. Faculty 2.75 .90
3. Patients from lower income groups are unable Graduates 3.37 .67
to understand the nature of their illness. Students & Interns 3.21 .69 1.23 NS
Faculty 3.16 .85
4. It is important for a physician working with Graduates 3.64 .51
poor patients to get to know them well in Students & Interns 3.38 .55 6.25 .01
order to best serve them. Faculty 3.75 .44
Attitude Toward the Health System:
The quality of medical care under the system Graduates 2.84 .78
of priyate practice is inferior to that Students & Interns 2.60 .70 6.66 .001
under a socialized medicine. Faculty 2.22 .52
CO
CO
Subhypothesis 4
There w ill be no differences among students-and-interns,
graduates, and fa cu lty groups in a ttitu d e s toward
the health system.
From the s ta tis tic a l analysis of the item, i t appeared there was
s ig n ific a n t difference at the .001 level of p ro b a b ility or greater
(F = 6.66, df = 2, 145) to re je c t the subhypothesis and to conclude
that there were differences among the students and interns, the grad
uates, and the fa c u lty members in the a ttitu d e s toward the health
system.
In comparison o f means among the three groups, the graduate re
spondents appeared to have the highest p o sitive a ttitu d e (X = 2.84)
and the student and intern respondents appeared to have a higher pos
itiv e a ttitu d e (X = 2.60) than the fa c u lty members (X = 2.22). The
results of the analysis are shown in Table 33.
134
TABLE 34
DIFFERENCES IN RESPONSES CONCERNING EACH HYPOTHESIS
Contrast 1
Groups X SD
Sig. Group 1+2 & 3
Sig.
Contrast 2
Group 1 & 2
Sig.
Hypothesis 1
Hypothesis 2
Hypothesis 3
Subhypothesis 1
Subhypothesis 2
Subhypothesis 3
Subhypothesis 4
co
cn
Graduates 4.04
Students & Interns 4.37
Faculty 2.93
Graduates 14,46
Students & Interns 15,56
Faculty
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
Graduates
Students &
Faculty
Graduates
Students &
Faculty
Interns
Interns
4 <71
,87
1,07
1.49
4,88
4.01
6,20
21,77 7,98
23.35 7.14
7,43 10.61
14.65 5.15
17 V 29 4.47
4.79 7,08
15.49 5,99
17.87 4.42
4.46 7.08
12.61 4.76
13.67 4.83
4,11 6.20
18.02 .001
53,46 .001
40,30 ,001
55.44 .001
56.16 .001
37.89 .001
4,34 .001
8,38 .001
7,20
8.01
8.69
7.29
,001
.001
.001
.001
-1.99 .05
-1.48 NS
-1,26 NS
’ 3.30 .001
-2.76 .01
-1.32 NS
TABLE 34— Continued
Contrast 1 Contrast 2
Groups X SD F Sig, Group 1+2 & 3 Group 1 & 2
t Sig. t Sig,
Subhypothesis 5 Graduates
Students &
Faculty
Interns
8.51
6.87
4.21
8.34
7.73
6,50
3.22 ,05 2,48 .01 1.22 NS
Hypothesis 4 Graduates
Students &
Faculty
Interns
12.32
13,41
5,32
3.83
3.60
6.37
37,28 .001 6.07 ,001 -1.77 NS
Hypothesis 5 Graduates
Students &
Faculty
Interns
12.38
12.73
4.93
4,73
4.52
5.82
28,94 .001 6,54 ,001 -0.46 NS
Hypothesis 6 Graduates
Students &
Faculty
Interns
12.29
14.30
4.46
4.78
3.97
5,95
43.18 .001 ; 7.47 .001 -2.78 .01
Hypothesis 7 Graduates
Students &
Faculty
Interns
8,93
9.27
3,87
3.07
2.59
4.96
29.63 .001 5.43 ,001 -0.73 NS
Hypothesis 8 Graduates
Students &
Faculty
Interns
9.41
10.32
3.50
3.78
2.91
4.77
35.63 ,001 6.75 ,001 | -1,63 NS
Hypothesis 9
GO
O'*
Graduates
Students &
Faculty
Interns
1.84
2.05
1.93
.76
.77
1.18
1.06 NS .07 NS -1.61 NS
TABLE 34— Continued
Groups X SD
Sig,
Contrast 1
Group 1+2 & 3
Sig,
Contrast 2
Group 1 & 2
Sig.
Hypothesis 10
Hypothesis 11
Subhypothesis 1
Subhypothesis 2
Subhypothesis 3
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
Graduates
Students & Interns
Faculty
2,48 ,91
2,86 .74
1,18 ,94
2.95 4.97
2.87 4.42
3.03 5.60
35,55 3,76
34.59 3.45
37.40 4.27
8.68 1.27
8.74 1.68
9.08 1.68
12.21 1.41
11.72 1.21
12.16 1.68
37,90 ,001
4.07 ,01
5.06 ,01
70 NS
7.78
-3.33
-2.87
.26
2.26 NS -0.65
001
05
01
NS
NS
•2.80
1.75
.13
,81
01
NS
NS
NS
2.05 .05
Interview
Interviews with graduates revealed the follow ing inform ation. Of
the 46 graduates interviewed, 6 worked in the northern, part of Thailand,
6 in the south, 18 in the north east, 7 in the east, 2 in the west, and
7 in central Thailand. There were 40 males and 6 females, h a lf of them
were married. Ages ranged between 23 to 31.
A ll of the graduates had earned M D degrees and two had completed
post doctoral tra in in g a fte r receiving th e ir M D degrees.
The responses to questions regarding work experiences revealed
that 17 had worked at th e ir assigned center fo r six months, 1 fo r ten
months, 15 fo r one year and seven months, 4 fo r two years, 7 fo r three
years, and 2 fo r four years.
In response to the questions concerning job t it l e s , 9 indicated
they were directors of a d is t r ic t h o sp ita l, 1 was in charge of the VD
Control Center and the others were the provincial hospital physicians.
Primary re s p o n s ib ilitie s were as indicated below:
No. of Graduates Primary R esponsibilities
35 Curative care
26 O ut-patient c lin ic s , e .g ., Medicine,
Surgery, P ediatrics, O bstetrics.
9 Surgery including minor surgery,
e .g ., appendix, BC, TR, CV, and
Obstetrics.
1 X-rdi y
1 IUD
138
No. of Graduates Primary R esponsibilities
23 Round in p a tie n t wards, e .g ., Surgery
ward.
17 On duty a fte r the o ffic e hours.
1 Disease co n tro l, e .g ., VD.
17 Preventive medicine, e .g ., well-baby
c lin ic s , anti natal care, B C G serv
ices, movies regarding health.
1 Health promotion.
1 A member of health promotion com-
m ittees.
3 School health, e .g ., health edu
cation, vaccination, in the area or
re s p o n s ib ility which was assigned by
the M in istry of Public Health.
2 Sani tary.
1 Field t r ip fo r planning and super
vising 9 Secondary Health Centers.
9 Home v is its .
6 Mobile health c lin ic s to the remote
v i 11 ages.
1 Emergency room.
12 Adm inistration: planning, personnel
management, finance, o ffic e works,
executive meeting.
1 Director of the hospital a fte r the
o ffic e hours.
1 D irector of the outpatient depart
ment: o ffic e work, s ta tis tic s , and
patient in general.
1 Coordinator among departments.
1 To teach students, in te rn s, and
residents.
139
No. of Graduates Primary R esponsibilities
8 To tra in health personnel, e .g .,
nurses, barefoot doctors.
With respect to the size of the health service f a c ilit ie s , the
graduates indicated that the provincial hospital where they worked had
30-1000 outpatients per day and bed care fo r between 100 and 700 in
patients.
D is tr ic t hospital could provide services fo r 13-80 outpatients
per day and bed care fo r 15-60 inpatients.
The provincial Mother and Child Health Centers could provide
services fo r 200 outpatients per day and bed care fo r 200 patients.
In the opinions of the graduates, the diseases most frequently
seen were infectious diseases, respiratory tra c t, typhoid, m alaria,
g a s tro e n te ritis , pneumonia, cholera, and diarrhoea during the summer,
p a ra sitic in fe s ta tio n , skin diseases--impedigo, scabies—neurosis, hae-
morrhagic fever, and accident--!acerated, minor, and shallow wounds.
In response to questions concerning th e ir future plans, 14 of the
graduates said they planned to be general p ra c titio n e rs , 1 planned to
work fo r a Master Degree in Public Health, another planned to work fo r
a PhD in pharmacology, 2 indicated to specialize in O bstetrics, 6
planned to specialize in Medicine, 8 to become surgeons, 4 to special
ize in P ediatrics, 1 to specialize in Dermatology, with an emphasis on
venereal diseases, and the others were uncertain of th e ir future plans
at the time of the interview .
Of the 46 respondents, 19 were in private practice.
140
In response to questions concerning refresher courses to gain
increased knowledge or s k ills in areas in which they s t i l l lacked some
proficiency, a ll indicated a desire to come back fo r future study.
Persons who indicated sp e cific weak areas f e ll into the follow ing
groups:
No. of Graduates Refresher Courses
2 Obstetrics and Gynaecology
1 Pediatrics
2 Surgery—one indicated Rheumatic
surgery, one indicated hand in ju ry
and hand surgery, both wanted to
learn simple s k ills w ithout sophis
ticated equipments. They also
wanted to practice eye surgery, s i
nus, hemorrhoid surgery.
3 Infectious diseases--Hepatitis be
cause rural people liked in je c tio n .
3 Skin diseases, e .g ., some diseases
could not be diagnosed because they
learned too l i t t l e in th is area.
1 E K G because there were E K G machines
at the hospital and only one spe
c ia lis t in Obstetrics there could
run the machines.
1 Neurosis especially lab te s t about
some enzymes which might help to
diagnose patients who were weak and
had no strength.
1 Preventive medicine.
1 General practice.
2 Public health adm inistration in
cluding hospital adm inistration.
141
In response to questions regarding the ways in which they worked
to increase the health consciousness of th e ir communities, graduates
described several techniques:
No. of Graduates Techniques
25 Individual approach during curative
care, to teach the patients how to
protect themselves from the disease
so they would not have to come back
fo r the same problem again.
10 Stressing the public relations
through newspaper, radio, and te le
vision about self-hygiene.
4 School health education and villa g e
scout health education.
7 Educating the patients by handouts,
pamphets, posters, and movies at
outpatient departments. One respon
dent indicated that he projected
slides about health education at the
in p a tie n t ward during the night be
fore bed-time.
10 Home v is its - - to arrange fo r the mid
wife to v is i t the mother before and
a fte r d elivering a baby in order to
give advice about simple n u tritio n
and in fa n t feeding.
9 Mobile health c lin ic to remote areas
fo r fam ily health care.
5 Family p la n n in g --d istrib u tin g the
free pamphets asking v illa g e people
to jo in fam ily planning, encouraging
the midwife at the Secondary Health
Center to persuade patients to take
advantage of free tubal s t e r i l i
zation.
2 Increasing the amount of para-medical
personnel in order to give services
to every v illa g e in the d is tr ic t.
142
No. of Graduates Techniques
3 Educating nurse assistants, midwives,
para-medical personnels, and old
tra d itio n a l Thai v illa g e medicine
man to work in the villa g e s coop
erating with existing health person
nel, as an immediate measure.
2 Every month educating the leaders of
the villa g e s and d is tr ic ts to under
stand the season's contagious d is
eases—modes, spread of diseases,
how to protect themselves from those
diseases, e .g ., d ip th e ria , rabies,
haemorrhagic fever.
4 Getting in touch with an educated
representative of the v illa g e in or
der to inform the people in that v i l
lage about th e ir health problems.
1 Getting in touch with the d is t r ic t
governor about current contagious
diseases.
3 Informing the provincial public
health department about spread of
any diseases, so that they would in
form the public.
1 Improving the Secondary Health Cen
te r to work more e ffic ie n tly .
5 Establishing a tru stin g relationship
between patient and physician (a d i f
f ic u l t problem at present because of
the language d ia le c t b a rrie r).
1 Convincing people in the v illa g e
that the d is t r ic t hospital or health
center belonged to them.
W i th respect to how the health care system in the graduates' com-
munity is organized, they indicated th a t:
No. of Graduates Health Care System Is Organized
1 A good re fe rra l system existed
143
N o., of Graduates Health Care System Is Organized
between province and d is t r ic t hospi
t a l, but sometimes the provincial
hospital returned the results of
cases too la te .
3 Bad re fe rra l system existed between
provincial and d is t r ic t h o sp ita l, no
feedback of re fe rra l cases from the
provincial hospital. One graduate
indicated that doctors at the pro
v in c ia l hospital were not q u a lifie d .
1 No re fe rra l system between the pro
vin cia l hospital and the VD Con
tr o llin g Center, so that even in com
plicated cases doctors trie d to cure
the patients at the provincial hos
p ita l .
2 There was a re fe rra l sytem between
the provincial hospital and d is t r ic t
hospital or health center but be
cause of preventive and curative
care were separated, management was
not coordinated.
T
One graduate was responsible fo r a
population of 10,000 people around
the health center with the ra tio of
1 personnel to 2500 people. He
could not plan the work because i t
was planned from the top, reducing
his a u th o rity oyer personnel.
1 No planning between d is t r ic t health
center or hospital and d is t r ic t gov
ernor. They discussed and planned
together only when the problems
arose. Because the d is t r ic t area
was too big and the number of people
was too great fo r the health person
nel to handle, curatiye care was
in s u ffic ie n t.
2 Because of overloading of the cura
tiv e seryices, preventive seryices
were not supported.
144
No. of Graduates
1
2
1
1
4
1
Health Care System Is Organized
There was no fixed standards to run
the health ceriter or d is t r ic t hospi
t a l, much depended on the physician.
Only i f the physician was active,
could he build a good hospital or
health center.
I t was stated by one graduate who
was assigned to a d is t r ic t hospital
. that a ll the c re d it was focused on
the d ire c to r. There was no incen
tiv e fo r the graduate and other per
sonnel to be active.
At the Naratiwart (southern p a rt),
there were problems about p o litic a l
robberies. No government o ffic e rs
or health personnel wanted to go to
the v illa g e and give service to the
people.
The health personnel at the Secon
dary Health Center were under the
control of the d is t r ic t governor.
Thus, the physician from the Primary
Health Center could not d ire c t those
from the Secondary Health Center to
improve or change health services
fo r the people.
There was a lack of cooperation in
every level of health management fo r
the whole country.
The physician selected one represen
ta tiv e fo r the community who would
communicate to the v illa g e people.
The respresentative was responsible
fo r bringing patients to the health
centers.
There was ju s t one or two physicians
at the d is t r ic t hospital or health
center. They trained the para-med-
ical personnel, who were graduated
level 6 to handle the patient load.
When the patients had serious prob-
145
No. of Graduates Health Care System Is Organized
lems, they referred these cases to
the provincial hospital. Their serv
ices were not e ffic ie n t. That is
why cases were not referred back
from the provincial hospital.
2 The M in istry of Public Health should
coordinate preventive and curative
services. Cooperation should be on
a basis of equality so that physi
cians at the health center would not
feel in fe rio r to physicians at the
h o s p ita l.
1 There was no accurate plan regarding
preventive medicine, e .g ., super
vis io n , follow -up, and evaluation.
In response to major obstacles to the improvement of d elivery of
health care, these were indicated as:
No. of Graduates Major Obstacles
12 Budget and Personnel.
5 Rural people were uneducated, they
did not believe in modern medicine
especially immunization coverage.
Some believed that i f they died,
they would go to see God. One pa
tie n t who contracted malaria did not
go to the hospital even when the
physician asked him to. In the
southern pa rt, the orthopedic
p a tient would prefer tra d itio n a l
medicine. The patients objected to
the physician putting a cast on his
fractured bone.
3 P o litic s , races, and re lig io u s prob
lems .
16 Inactive health personnel.
2 Transportation.
1 Personal c o n flic t.
146
No. of Graduates Major Obstacle
1 In the southern part of Thailand, V D
could not be controlled because the
disease came from the to u ris ts and
p rostitu te s moved among provinces.
18 Management problems--no p o licy, no
planning, no evaluation, communica
tio n gap between top level and lower
le ve l. The decision making was not
democratic and did not involve people
at lower le v e l, so they tended to
re je c t decisions.
2 Red tape in the bureaucracy, coordi
nation and cooperation had to go
through many steps. Problems arose
would not be solved in time.
1 No support from the M inistry of
Public Health.
In response to questions regarding the extent to which graduates
applied the C H P to th e ir work, 15 indicated a great amount, 15 indicated
l i t t l e , 5 indicated not at a ll, and others said they were uncertain.
With respect to how students related to the people in the commu-‘
n ity , 27 graduates indicated that they f e l t that students had good
re la tion s with the people in the community, 14 indicated an opposite
view and suggested that the reason fo r the bad re la tion sh ip was that
students too often contracted the v illa g e people ju s t fo r data and then
stayed inside the center.
In response to relationships between the graduates and th e ir c o l
leagues, 30 indicated that they had good relationships with th e ir c o l
leagues and 16 claimed to have some c o n flic ts with th e ir colleagues.
Most of the c o n flic ts were not serious, but one graduate indicated that
147
he had reported the d ire cto r of the hospital to the M inistry of Public
Health, because his d ire cto r was corrupt and that d ire cto r was removed.
No. o f Graduates Major Problems of the Internal
Organization of the C H P
1 Transportation problem: Students
had to pay over time to the school
d riv e r, and the d rive r would not
s ta rt his work before 8.30 a.m.
12 No supervision during clerkship.
5 No one was responsible fo r the
schedule of classes. Students them
selves had to take re s p o n s ib ility
fo r making sure that the teachers
came to classes.
1 Class schedules were arranged too
tig h tly .
2 The schedule was not arranged appro
p ria te ly , lecture class was too long
and the assigned project was too
easy.
1 The class was too th e o re tic a l, no
assignment to relate with the v i l
lage people. The students who came
from the top level did not tr y to
approach the v illa g e people.
13 * Teaching was not a ctive , i t did not
focus on the provincial work.
2 No integration among departments.
With respect to the services they provided to the community, 16
indicated that the provided services were not s u ffic ie n t, especially
home v is its and no preventive medicine programs. T h irty graduates in d i
cated there were s u ffic ie n t services with one indicating th a t fam ily
planning was successful because b irth rate was less than 3 % in her pro-
148
ince, and two suggesting that the services were s u ffic ie n t in quantity
but not in q u a lity .
In response to the question regarding alumni services, 20 in d i
cated that they received the academic series from the school, e .g .,
a rtic le s about the current pharmacy and thought the content was very
useful, but they would also lik e to get the report of the school aca
demic conference at the end of each month. Those who had not received
the series indicated that they were anxious to be put on the mailing
l i s t .
Discussion
Analyses of items regarding age, professional practice, health
care.change, student-attitude changes toward health system, changes in
the attitu d es of the community toward health system, improvement of
conditions fo r the poor, curriculum reform, education of the school,
roles of the preceptor showed s ig n ific a n t differences among respondent^
groups. Each group had d iffe re n t perceptions concerning the success of
the program in sp e cific areas. The degrees of differences can be seen
in the responses each group made to sp e cific items. The most important
results of the personal background data are the data concerning the
planned professional practice of the respondents. Most of the grad-:
uates, students and interns responded that they were interested in
staying in the rural community. Thrs implies that the students are
committed to the work they are studying. The data also indicated the
m a jo rity of respondents believed the C H P fie ld experiences provided the
149
students with an awareness of problems outside of the medical school.
However, the m ajority of the respondents indicated that the curriculum
and teaching methods had to be reformed to make students re a lize the
real public health situ a tio n in Thailand.
The hypotheses were developed to determine i f there was any d i f
ference in the opinions concerning the courses of the C H P and the
a ttitu d in a l factors among the groups. According to the re s u lts , the
proposed null hypotheses of s ig n ific a n t differences fo r a ll items con
cerned with the effectiveness o f the program were rejected with the
exception of hypotheses and subhypotheses related to (1) the learning
experiences included in the program, (2) the a ttitu d e s toward the
c lin ic a l management, and (3) the a ttitu d e s toward the poor people. The
d iffe re n t levels of p ro b a b ility reported in the results of the analysis
of variance procedure represent the degree of importance each group
gave to that item as contributing to effectiveness of the program.
Items indica tin g no differences among groups were also important, and
they were reported in the re su lts.
In a ll cases fa cu lty gave the highest ra tin g s, followed by grad
uates, w ith the students and interns giving the lowest ratings. Ex
ceptions to th is w ill be discussed under each hypothesis statement.
Hypothesis 1
There w ill be no differences among the opinions expressed
by the students-and-interns, graduates, and fa cu lty
concerning whether the course content enables students
to accomplish the program goals.
150
This hypothesis was rejected. The more sp e cific questions tended
to have responses that were d iffe re n t among the groups. The more
general questions tended to e l i c i t sim ila r responses fo r a ll groups.
Although the fa c u lty respondents ranked the program the highest, f o l
lowed by the graduates, with the students and interns giving the
lowest ra tin g , these differences were at times s ig n ific a n t, a t other
times not s ig n ific a n t.
Hypothesis 2
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding how experiences provided by the program meet
the needs of the students.
The students and interns ranked the program in general as meeting
th e ir needs between adequate and poor. The item about the learning
experience provided by Internship in Community Health where the grad
uates gave a lower rating than the students and interns. The data
showed enough s ig n ific a n t differences to re je c t the null hypothesis
and to support the conclusion that there were differences among the
three groups in th e ir perceptions of the program to meet the needs of
the students.
Hypothesis 3
There w ill be no differences among students-and-^interns,
graduates, and fa c u lty in the opinions expressed
regarding students1 a b ilit y to accomplish the learning
objectives of the selected courses.
151
This hypothesis was deyeloped to determine which of the objectives
of each course these groups thought were the weak places in the cur
riculum. The respondents' strong a ffe c tiv e responses suggested that
the objectives were not inappropriate. This hypothesis was rejected
that there were differences among the three groups in a ll fiv e courses.
Thirteen out of 30 objectives indicated s ig n ific a n t differences.
Among those 13 objectives, seven objectives were ranked between good
and f a ir by fa c u lty , students and interns, and graduates. There were
six objectives, which the students and interns ranked between f a ir and
poor as follow ing:
1. Demographic Survey
1.1. To expose students to cu ltu ra l characteristics of the
people liv in g in a rural community.
2. Analysis of Community Health Problems
2.1. To understand and be able to use the concepts, p rin c i
ples, and techniques of epidemiology and biology.
2.2. To understand and be able to prepare, submit, and ana
lyze the data of the public health care problems of the
community.
3. Community Health Planning
3.1. To review basic epidemiologic, s ta tis tic a l, and demo
graphic concepts required fo r understanding these prob
lems.
3.2. To probe in depth a number of selected issues involved
in planning and implementing programs fo r improving
152
health care including the follow ing: the d e fin itio n
of a "health problem," the community's own understand
ing of its health problems.
3.3. To examine the process of designing possible solutions
to health problems, including (a) defining objectives
and how to measure them, (b) selecting the most appro
p riate objectives, (c) planning information systems fo r
monitoring the q u a lity and effectiveness of health care
programs.
3.4. To examine and analyze some existing health programs,
such as fam ily planning, malaria eradication, and tu
berculosis control.
Hypothesis 4
There w ill be no differences among students-and-interns,
graduates, and fa cu lty in the opinions expressed
regarding the overall q u a lity of each course of the CHP.
This hypothesis was rejected because analysis of the items in d i
cate s ig n ific a n t differences existed among the opinions of the three
groups concerning each course. Differences among the group respondents
were on the Demographic Survey, Analysis of Community Health Problems,
Community Health Planning, and Community Health Clerkship. The stu
dents and interns ranked the Community Health Clerkship Course between
f a ir and poor, as well as the graduates ranked the Internship in Com
munity Health Course.
153
Hypothesis 5
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the usefulness of each course of the CHP.
The results of the analysis of th is hypothesis somewhat p a ra lle l
those of hypothesis 4. There were differences in degree of importance
assigned to each course regarding usefulness of the program among the
faculty- group, the graduate group, and the student and in te rn group.
The three groups perceiyed each course as good or f a ir . The In te rn
ship in Community Health Course was perceiyed by the student and intern
respondents as more useful than by the graduate respondents.
Hypothesis 6
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the q u a lity of the teaching methods of each
course of the CHP.
This hypothesis was rejected because of the small number of items
that indicated s ig n ific a n t differences among the respondents. A com
parison of the fa c u lty 's , student';s and in te rn 's , and graduate's per
ceptions of the teaching methods of each course indicated th at the fac
u lty group perceiyed the teaching .methods in Demographic Survey, Anal
ysis of Community Health Problems, and Community Health Clerkship as
more e ffe c tiv e than the graduate group and the student and intern
group did. The graduate respondents perceiyed Demographic Suryey?
Analysis of Community Health Prob.lems, and Community Health Clerkship
154
more e ffe c tive than the studentrand intern respondents did. The fac
u lty members and graduates rated the teaching methods between good and
f a ir . The students and interns rated the teaching methods between
f a ir and poor.
Hypothesis 7
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the amount of time given to each course of
the CHP.
The hypothesis was rejected. The fa c u lty group, the student and
intern group, and the graduate group did perceive differences in the
degree of importance of each course of the CHP.
Hypothesis 8
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the material covered in each course of the CHP.
These findings were somewhat sim ila r to hypothesis 7. A compari
son of the fa c u lty 's , student's and in te rn 's , and graduate's percep
tions of the amount of material covered in each course of the C H P
showed s ig n ific a n t differences.
Hypothesis 9
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the learning experiences included in the program.
This hypothesis was accepted as true. Only opinions about the
155
learning experiences that should be added to the program indicated
s ig n ific a n t difference among the fa c u lty group, the student and intern
group, and the graduate group.
In answering the question regarding the most successful aspects of
the program, the m ajority of fa c u lty members, of students and in te rn s,
and of graduates f e l t that working in the v illa g e , the opportunity to ^
see the rural country in r e a lity , and problem solving cycle experiences
provided the most s a tis fa c tio n .
With respect to the least successful aspect of the program, the
m ajority o f students and interns, and graduates were d is s a tis fie d with
the methods of teaching and classroom demonstrations. The m ajority of
fa c u lty members were d is s a tis fie d with Bang Pa-In teaching, with the
poor attendance of students, and with the students' inadequate back
ground in the CHP.
In answering the question regarding the learning experiences not
presently provided that should be added to the program, the largest
number of graduates, and students and interns believed that the fie ld
work location should be real (without modern equipment as at Bang Pa
in ), the students should be exposed to real problems and should have
chances to learn from experienced physicians. A large percentage of
the fa c u lty members believed that in cooperation with the M in istry of
of Public Health, fie ld areas could be arranged as real tra in in g
places. During year VI, there is an e le ctive period of 3-5 weeks
in which students can experience primary hospital care in a provincial
h o s p ita l.
156
In answering the question regarding the knowledge or s k ills gained
in fie ld work which were not taught in the classroom, the highest num
ber of graduate respondents indicated an understanding of the problems,
behavior or health cu ltu re , old values of health, language and environ
ment of people in the community (such problems as what happens when
people get sick, but cannot go to a health center because of heavy rain
and mud slides on the road). The m ajo rity of students and interns
indicated management of health centers, e .g ., routine work of the
health o ffic e r. The largest number of fa c u lty respondents indicated
practicing in a health center with lim ite d resources, getting to know
the lim ita tio n s of resources, and how to adapt simple equipment to
tre a t the patients in a p rim itiv e environment.
Hypothesis 10
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
regarding the impact of the C H P on future careers.
This hypothesis was rejected because three out of fiv e items
regarding the courses, Analysis of Community Health Problems, Community
Health Planning, and Community Health Clerkship indicated s ig n ific a n t
differences among therrespondents. The fa c u lty respondents perceived
the courses, Analysis of Community Health Problems, Community Health
Planning, and Community Health Clerkship as more helpful in preparing
students fo r future career performance than the graduate respondents,
who perceiyed these courses as more useful than the student and intern
respondents did. The three groups perceiyed the courses, Analysis of
157
Community Health Problems, Community Health Clerkship as between good
and f a ir with respect to helpfulness in preparing students fo r per
forming in th e ir future careers. The Community Health Planning was
also rated as between good and f a ir by the fa cu lty group and the grad
uate group, but the student and intern group saw i t as between f a ir
and poor.
General Comments by Respondents
Regarding comments toward the program as a whole, the largest num
ber of the graduates, students and interns indicated th a t during the
course, Community Health Clerkship, the students should be trained at
health centers around Thailand under the supervision of Community
Health graduates, a fte r 1-2 week orie nta tion at Bang Pa-In. A large
number of student and intern respondents indicated th a t teachers
should be expert in Community Health and go on fie ld trip s with stu
dents more often. The classes should be divided into smaller groups in
order that a ll students should be able to p a rtic ip a te . The largest
number o f fa c u lty respondents indicated that the C H P had no re la tio n or
coordination with other department s ta ff and when the C H P knowledge
was not reinforced in c lin ic a l teaching by a ll fa c u lty members, newly
acquired a ttitu d es disappeared very fa s t. I t was suggested th a t other
teachers should get to know th is curriculum and be able to give sugges
tions.
Hypothesis 11
There w ill be no differences among students-and-interns,
graduates, and fa c u lty in the opinions expressed
158
regarding a ttitu d in a l factors.
'This hypothesis was rejected. As indicated there were s ig n if i
cant mean differences among attitu d es expressed by the fa c u lty , the
graduate, and the student and intern respondents. Inspection of the
item results with respect to perceived differences among the fa c u lty ,
the student and in te rn , and the graduate respondents showed fa cu lty
respondents w ith the highest po sitive attitu d es and graduate respon
dents with more p o sitive a ttitu d es than the student and intern respon
dents.
Medical fa cu lty rated preventive medicine as s ig n ific a n tly more
important than curative care or improvement of conditions fo r the poor.
As compared to graduate respondents, student and in te rn respondents,
fa c u lty respondents perceived i t s ig n ific a n tly more important fo r pre
ventive medicine and poor people. The graduate respondents indicated
that preventive medicine and concern fo r poor people were more impor
tant fo r th e ir practice than student and intern respondents did. A
comparison of the three groups' perceptions of the health system showed
that graduate respondents valued socialized medicine over the private
practice system to a s ig n ific a n tly greater degree than did fa c u lty
group and student and intern group. The student and intern respondents
yalued socialized medicine over private practice to a greater degree
than the fa c u lty did.
Interview
The graduates who worked at d is t r ic t hospitals or healthreenters
indicated that they applied the C H P to th e ir work. Those who worked
159
at the provincial hospital or Mother and Child Health Center were
responsible mostly fo r curative care and indicated that they rarely
applied the C H P to th e ir work, but some indicated that they used the
problem-solving cycle sometimes.
In regard to re la tion s with th e ir colleagues, most indicated a
good re la tionsh ip existed. Those expressed the feeling that re la tio n
ships were not good were mostly young, active physicians, who f e l t
that some of th e ir colleagues tended to be too slow in promoting
changes. Personality was considered as an important fa cto r co n trib
uting to good relationships and a warm caring a ttitu d e was mentioned
by the graduate as most important. In his study of effects of health
education methods on appointment breaking, Glogow (1970). also pointed
out the importance of warmth, gentleness, and the a b ilit y to communi
cate with c lie n ts , as essential in establishing the desired c lie n t-
s ta ff re la tion sh ip s.
160
CHAPTER V
SUM M ARY, CONCLUSIONS, AND
RECOM M ENDATIONS
This chapter presents a.summary of the completed study, lis t s the
conclusions th a t can be drawn, and makes some recommendations fo r the
Ramathibodi Medical School. Recommendations are directed especially
to the Community Health Program s ta ff, but also fo r others involved in
th is program, and fo r students who wish to research th is area in the
fu tu re .
Summary
This study is an evaluation of the Community Health Program o f
fered by the Ramathibodi Medical School. The school's basic assumption
and rationale is that health care d e liye ry is a human rig h t and not a
p riv ile g e . The assumption of th is study was th at questionnaire data
obtained from students and interns, graduates, and fa c u lty members
would provide useful data to help decision makers make judgements among
decision a lte rn a tives.
Eleven hypotheses were stated along with subhypotheses. A ques
tionnaire was deyeloped to c o lle c t information from the three groups
161
involved in the Community Health Program: graduates, students and
interns, and fa c u lty members.
A ll the hypotheses and subhypotheses were stated in the null form
and a ll were concerned with differences among these three groups. Of
the 173 responding, 63 were students and in te rn s, 82 were graduates,
and 28 were fa c u lty members. The questionnaires were d istrib u te d
during October and November 1976.
The S ta tis tic a l Package fo r the Social Sciences was used to cross-
tabulate the data and to te s t fo r s ig n ific a n t differences among means
with the use of chi square and analysis of variance procedures. These
s ta tis tic s were used to accept or re je ct the hypotheses, so that con
clusions could be drawn. A p rio ri contrast was computed to fin d d if
ferences among groups.
The f i r s t data tabulated in th is study is the information con
cerning the ch a ra cteristics of the respondents. Information concern
ing age, place of b irth , re lig io n , occupation, income, place of employ
ment, professional practice and location are presented. Personal in
formation concerning the respondents include th e ir health development
experience, amount of a c tiy ity in seeking health care changes, changes
in the a ttitudes of the students and the community toward the health,
system, and th e ir perception of the conditions of the poor.
Professional opinions presented here include the p o s s ib ility of
future involvement in the education of the school, the roles of the
preceptor.
The remaining data were used to support or re je c t the hypotheses
162
and subhypotheses. Of these hypotheses, one was accepted, nine in
cluding a ttitu d in a l factors were rejected, two subhypotheses were ac
cepted, and seven subhypotheses were rejected. The conclusions drawn
from th is data are presented in the next section of the chapter.
Following the questionnaire, personal interviews were held with
the graduates, who were located around the country. Of the 82 grad
uates who responded to the questionnaires, 46 graduates were in te r
viewed.
Information concerning the respondents includes (1) sex, (2) mar
it a l status, (3) age, (4) degree, (5) work experience, (6) job t it le s ,
(7) primary re s p o n s ib ilitie s , (8) size of the health services, (9) d is
eases frequently seen, (10) fu tu re plannings, (11) private practice,
(12) refresher courses, (13) health consciousness of the community,
(14) health care system is organized, (15) major obstacle to the im
provement of d e livery of health care, (16) the C H P a pplication, (17)
relationships between students and community people, (18) re la tio n
ships between graduates and th e ir colleagues, (19) major problems of
the internal organization of the CHP, (20) adequacy of services pro
vided to the community, and (21) alumni services. The conclusions
drawn from th is data are presented in the follow ing section.
Conclusions
A number of conclusions can be drawn from th is study. The gen
eral conclusion is that there were differences among the three groups
regarding th e ir perceptions of the effectiveness of the Community
163
Health Program. The more spe cific conclusions supported by the data
are:
1. The students and interns believe that the program is less
adequate in meeting th e ir needs than do the fa c u lty and the
graduates. The courses which they believe to be least e ffe c
tiv e are Community Health Planning and Analysis of Community
Health Problems.
2. W hen asked s p e c ific a lly about the objectives of the courses,
the Analysis of Community Health Problems and Community Health
Planning, students and interns rated fiv e out of six objec
tives as not effe'ctive fo r each course.
3. W hen asked about the overall general q u a lity of the courses,
the students and interns rated a ll of the courses except In
ternship in Community Health from good to poor. These ratings
were s ig n ific a n tly lower than the ratings of fa c u lty members,
and graduates.
4. A ll courses in the program were perceived as less useful by
the students and interns than by the fa cu lty members and
graduates.
5. Opinions expressed regarding the teaching methods were d if
ferent among the three groups, w ith students giving the
lowest ratings.
6. There were differences among the three groups with the stu
dents gtying the lowest ratings regarding the effectiveness of
the C H P at helping them perform th e ir future careers. The
164
only course which the groups did not have d iffe re n t perceptions
was Demographic Survey.
7. There were differences among the three groups regarding th e ir
a ttitu d in a l fa cto rs, including attitu d es toward the profession
and toward the health system.
8. With respect to general comments, the largest percentage of
the graduates believed that to improve the program, students
needed to be trained at health centers around Thailand. I t
was suggested that th is tra in in g should take place in the
Clerkship in Community Health Course under the supervision of
the C H P graduates a fte r the 1-2 week orientation at Bang Pa-In.
The largest percentage of the students and interns believed
th a t to improye the program students needed to go on fie ld
trip s with teachers who were expert in the CHP. The students
and interns agreed with the graduates concerning tra in in g at
health centers at d iffe re n t locations around Thailand. The
students and interns fu rth e r f e l t that participants should be
divided into smaller groups, so that a ll students could have
opportunities to a ctiv e ly p a rtic ip a te . F in a lly , the fa c u lty
belieyed that to improve the program, teachers in other de
partments should know more about the CHP, so that the C H P con
cepts could be reinforced to c lin ic a l teaching.
9. The graduates who work a t the d is t r ic t hospital or health cen
te r indicated that they did apply the C H P principles in th e ir
work.
165
Recommendations
This study has shown that there were differences among fa c u lty ,
student and in te rn , and graduate respondents' perceptions of the pro
gram. I t is recommended that changes be made in the curriculum, the
content of the courses, the teaching methods, and the research fie ld in
education. The follow ing recommendations f a ll w ithin these categories:
1. I t is recommended that the course content of the follow ing
courses be reassessed and modified so that i t might better
achieve the stated objectives.
1.1. Demographic Survey.
1.2. Analysis of Community Health Problems.
1.3. Community Health Planning.
2. I t is recommended that the content of the follow ing courses
be analyzed to determine how they may be directed more closely
to the future career of the students in the CHP.
2.1. Community Health Planning.
2.2. Clerkship in Community Health.
2.3. Internship in Community Health.
3. I t is recommended that the Community Health Clerkship course
should be changed to include tra in in g at health centers at
d iffe re n t locations around Thailand. The tra in ing should
occur a fte r the 1-2 week o rie nta tio n a t Bang Pa-In.
4. I t is recommended that the f ie ld t r ip should be considered as
166
a useful teaching technique in appropriate courses fo r re le
vant content.
5. I t is recommended that in stru c tio n in preventive medicine
should be included in the curriculum with emphasis on content
relevant to the defined community.
6. I t is recommended that Behavioral Sciences, Basic Law, Manage
ment of the Health System, Personnel Management, Human Rela
tio n s, Personality, Budget, and Community Psychology should
be added to the program.
7. I t is recommended that in s tru ctio n in the C H P should be
closely coordinated with other departments. E fforts should
be made to inyolye s ta ff at a ll departments in the planning
and teaching of the program. This should be accomplished by
giving fa c u lty members in other departments current informa
tio n in the CHP.
8. I t is recommended that the teaching methods in a ll courses
should be analyzed to determine how they may be modified to
encourage student attainment of the stated objectives and im
prove student's attitudes toward the subjects and to the C H P
in general.
9. I t is recommended that individualized study under the direc
tio n of the professor be provided fo r advanced students. This
w ill require that teachers be instructed in e ffe c tiv e s e lf-
study techniques so that they may pass these principles on to
th e ir students. Teachers w ill also have to be instructed in
167
the fundamentals of good test-construction so that student
evaluation may be carried out in an e ffe c tiv e manner.
10. I t is recommended that more research be conducted in the
areas of curriculum development. Future studies based on
the findings of the present study might p ro fita b ly relate
and integrate the C H P to the to ta l curriculum.
11. I t is recommended that more research be conducted in the
areas of in stru ctio n a l effectiveness.
168
169
-REFERENCES
Abrahamson, S. Evaluation in continuing medical education. Journal of
American Medical Association, 1968, 206(3), 625-628.
Aguirre, A. Community medicine at the U niversity of Valle. In W . La-
them (Ed. ) , Community medicine: teaching, research, and health care.
New York: Meredith Corporation, 1970.
Alibazah, P. The teaching of community medicine in undergraduate edu
cation (SEA/Med. Educ./189). World Health Organization Regional
o ffic e fo r South-East Asia, October 1972. (SEA/RC25/13 and C orr.l
on 15 and 16 September 1972)
A llen, L. R. Community medicine at the A ll India In s titu te of Medical
Sciences. In W . Lathem [Ed.), Community medicine: teaching,
research, and health care. New York: Meredith Corporation, 1970.
Banks, S., Reynolds, R. C. The community health clerkship: evaluation
of a program. Journal of Medical Education, 1973, 48, 560-564.
Bellman, H. S., & Remmers, H. H. Evaluating the results of tra in in g .
Journal of American Society of Training D ire cto rs, 1968, 1_2(5), 28-
33.
B ible, B. L. Physicians' views of medical practice in nonmetropolitan
communities. Public Health Reports, 1970, 85, 11-17.
Bloom, S. A working group on the selection of students fo r medical
education. World Health Organization Chronicle, 1973, 27(3), 94-100.
Bruce, G. F. SAM A project fo r medical education and community o rie n
ta tio n . Journal of Medical Education, 1970, 45.
Bryant, J. H. Health and the developing w orld. Ithaca and London:
Cornell U niversity Press, 1969.
B u ri, P. Medical education re s p o n s ib ility and objectives. In W . La
them (Ed. ) 9 Community medicine: teaching, research, and health
care. New York: Meredith Corporation, 1970.
170
B u ri, P. Training in community medicine in undergraduate courses,
Faculty of Medicine, Ramathibodi Hospital. The teaching of commu
n ity medicine in undergraduate education (SEA/Med. Educ./189).
World Health Organization Regional O ffice fo r South-East Asia, Oc
tober, 1972. (SEA/RC25/13 and Corr. 1 on 15 and 16 September 1972)
Buri, P., Buri, R ., K hanjanasthiti, P., Limsuwan, A., Phanchet, S.,
Bryant, J ., Stewart, M., & Wray, J. The Ramathibodi community
health program. Journal of Medical Education, 1974, 49^, 264-277.
Campos, P. C. Community medicine at the U niversity of the Philippines.
In W . Lathem (Ed.), Community medicine: teaching, research, and
health care. New York: Meredith Corporation, 1970.
Castleton, K. B. The present dilemma of rural health sciences. Rocky
Mountain Medical Journal, 1970, 67, 29-34.
Champion, D. G., & Olsen, D. B. Physician behavior in southern Appala
chians: some recruitm ent factors. Journal of Health Social
Behavior, 1971, 1_2, 245-252.
Clark, K. G. Conference of preventive medicine. Chicago: Associate
of American Medical College, 1952.
Classen, A., & Quicker, J. The evaluation. Colorado Student Health
Project Summer 1968 (U.S. Department of Health, Education, and
Welfare,.No. 43-68-1528). .Washington, D.C.: U.S. Government
P rinting O ffice , 1968.
Coggeshall, L. T. Planning fo r medical progress through education.
I llin o is : Association of American Medical Colleges, 1965.
Cronbach, L. J. C oefficient alpha and the internal structure of tests.
Ps.ychometrika, 1951 , 16(3), 297-334.
C ullison, S., Reid, C., & C o lw ill, J. Medical school admissions,
specialty selection and d is trib u tio n of physicians. Journal of
Medical Education, 1976, 235(3), 502-505.
Debr£, R. Correlation between the teaching of medicine and human b io l
ogy. In H. Popper ('Ed.) 9 Trends in new imedical school s. New York:
Grune & S tratton, 1967, 73.
Deuschle, K. W., Bosch, S. J ., Banta, H. D., & Dana, B. The community
medicine clerkship: a learner-centered program. Journal of Medical
Education, 1972, 47(12), 931 -938.
171
Dinning, J. S. University development in Thailand: a program in li f e
sciences. Journal of Medical Education, 1974, 49, 763-769.
Ducker, D. G. The myth of professional iso la tio n among physicians in
nonurban areas. Journal of Medical Education, 1977, 52^ 991-998.
Duval, M. K. A program fo r rural health development. Journal of Med
ical Education, 1972, 221 (2), 168-171.
E tzio n i, A. Two approaches to organizational analysis: a c ritiq u e and
a suggestion. Adm inistration Sciences Q uarterly, 1960, 5 ^, 257-278.
Fenderson, D. Health manpower development and rural services. Journal
of American Medical Education, 1973, 225(13), 1627-1631.
Flahault, D. The tra in in g of rural health personnel. World Health
Organization Chronicle, 1972, 26(6).
Funkenstein, D. B. Learning and personal development of medical stu
dents: reconsidered. In T. Mi 11 on (Ed.), Medical Behavioral Sci
ence. Philadelphia: W . B. Saunders Company, 1975.
Garrard, J ., & Verby, J. E. Comparisons of medical students experiences
in rural and un ive rsity s e ttin g . Journal of Medical Education, 1977,
52, 802-810.
Glogow, E. Effects of health education methods on appointment breaking.
Public Health Reports, 1970, 85, 441-450.
Glodstein, M. S., & Donaldson, P. J. Medical education in Thailand:
an a lte rn a tive perspective. Journal of Medical Education, 1977, 11,
221-230.
Gordon, M., Hadac, R ., & Smith, K. Evaluation of c lin ic a l tra in in g in
the community. Journal of Medical Education, 1977, 52^, 881-895.
H a rre ll, G. Training in a small town fo r rural practice. Journal of
Medical Education, 1973, 225(9), 1103-1105.
Hansen, M. F., & Reeb, K. An educational program fo r primary care.
Journal of Medical Education, 1970, 45(12).
Heald, K. A., Cooper, J. K, & Coleman, S. Choice of location of prac
tic e of medical school graduates: analysis of two surveys. Washing
ton, D. C.: Rand Corporation, 1974.
Holcomb, D. J ., & Garner, A. E. Improving teaching in medical schools.
I llin o is : Charles C. Thomas, 1973.
172
Janies, G. Evaluation in public health practice. American Journal of
Public Health, 1962, 52, 1145-1154.
James, G. Medical education: medical techniques or disease control.
In H. Popper (Ed.), Trends in new medical schools. New York: Grune
and S tratton, 1967.
Johnson, P., K ivel, R ., & B ra n h ill, B. Evaluation of the 1967 C a lifo r
nia student health p roject. In T. M. Bred (Ed.), 1967 C alifornia
student health p ro je c t, U niversity of Southern C a lifo rn ia , 1967.
Johnson, K. G., & Haughton, P. An outreach program in a rural medical
school. Journal of Medical Education, 1975, 50, 38-45.
Kane, R. L. The challenges of community medicine. New York: Springer
Publishing Co., 1974.
Keairness, H. W . Program evaluation workshop in regional medical pro
grams. In H. Margulies (Ed.), National conference and workshop on
evaluation. Chicago, I llin o is , 1970.
Kegel-FIom, P. Predictors of rural practice location. Journal of Med
ica l Education, 1977, 52, 204-209.
Kelley, E ., & W ilbur, L. Teaching in the community ju n io r college.
New York: Appleton-Century^Crofts, 1970.
K irk, E. E. Experimental design: procedures fo r the behavioral Sci
ences . C a lifo rn ia : Brooks/ Cole Publishing Company, 1968.
Knowles, J. H. The teaching h o sp ita l. Cambridge, Massachusetts:
Harvard U niversity Press, 1966.
Knowles, J. H. Views of medical education and medical care. Cambridge,
Massachusetts: Harvard U niversity Press, 1968.
Lashof, J. Chicago student health project summer 1968 (U.S. Department
of Health, Education, and Welfare, No. 43-68-1534). Washington,
D. C.: U. S. Government P rinting O ffice , 1968.
Latem, W . Community medicine: teaching, research, and health care.
New York: Meredith Corporation, 1970.
Lathem, W . Community medicine: success or fa ilu re ? The New England
Journal of Medicine, 1976, 295Cl)» 18-23.
Lathem, W . Medical education reform fo r developing countries. Journal
of Medical Education, 1977, 11(1), 65-70.
173
Leopold, R. Philadelphia student health project summer 1968 (U.S. De
partment of Health, Education, and Welfare, No. 43-68-1533).
Wahington, D.C.: U.S. Government P rinting O ffice , 1968.
Levy, R., & Applegate, W . Student community health projects. How to
win friends without influencing people. Journal of American Medical
Association, 1972, 220.(8), 1113-1115.
Lucas, A. 0. Community medicine at the U niversity of Ibadan. In W .
Lathem (Ed.), Community medicine: teaching, research, and health
care. New York: Meredith Corporation, 1970.
Lutwana, J. S. W . Community medicine at Makarere U niversity College.
In W . Lathem (Ed.), Community medicine: teaching, research, and
health care. New York: Meredith Corporation, 1970.
Mason, H. R. Manpower needs by specialty. Journal of American Medical
Association, 1972, 219, 1621-1626.
Mattson, D. E., Donald, E. S., & W ill, R. E. Evaluation of a program
designed to produce rural physicians. Journal of Medical Education,
1973, 48(4), 323-331.
Mechanic, D., & Newton, M. Social consideration in medical education,
points of convergence between medical and behavioral science.
In T. Mil eon (Ed.), Medical Behavioral Science. Philadelphia: W.B.
Saunders Co., 1975.
Mi 11 is , J. S. The u n ive rsity of president's view of medical education
and medical care. In J. H. Knowles (Ed.), Views of medical educa-
tion and medical care. Massachusetts: Harvard University Press,
1968.
Murphree, A. H. The community health clerkship: p ro file of a program.
Journal of Medical Education, 1972, 47(12), 925-929.
Nie, N ., Hadlai, H., Jenkins, J. G., Steinbrenner, K, & Bent, D. H.
S ta tis tic a l package fo r the social sciences (SPSS). New York:
Mcgraw-Hill Book Company, 1970.
Parker, R. C., & T u x ill, T. G. The a ttitu d e of physicians toward small
community practice. Journal of Medical Education, 1967, 42_, 327-344.
Pauli, H. G. Undergraduate medical education and health care. Journal
of Medical Education, 1973, 48(12), 51-56.
P h illip s , T. J ., & Swanson, A. G. Teaching fam ily medicine in rural
c lin ic a l clerkships. A W AM I progress report. Journal of American
Medical Association, 1974, 22801), 1408-1410.
174
Pinchoff, D. M., In g a ll, J. R. F ., & Crage, W . D. Observations on a
ru ra l health manpower p roject. Journal of Medical Education, 1977,
52, 117-122.
Pittman, J. G., Barr, D. M. Undergraduate education in primary care:
the Rockford experience. Journal of Medical Education, 1977, 52,
982-990.
Popper, H. Trends in new medical schools. New York: Grune and S tra t
ton, 1967.
Prywes, M. Comparative international ch a ra cte ristics. Journal of Med
ical education, 1973, 4 8 0 2 ), 11-25.
Ramakrishna, V. Educational diagnosis and implementation. Interna
tio n al Conference on Health and Health Education, 1962, 2, 147.
R e iff, M. Colorado student health project summer 1968 (U.S. Depart
ment of Health, Education, and Welfare, No. 43-68-1528). Washington,
D.C.: U.S. Government P rinting O ffice , 1968.
Richter, E. D. New problems in community health: im plications fo r
residency and tra in in g program. International Journal of Health
Services, 1973, _3, 189-195.
Roemer, R ., Kramer, C ., & Frink, J. E. Planning urban health services
from jungle to system. New York: Springer Publication Co., 1975.
Roush, R. E. Systematic classroom observation and feedback techniques.
In J. D. Holcomb (Ed.), Improving teaching in medical school.
I llin o is : Charles C. Thomas, 1973.
Schullberg, H. S., & Baker, F. Program evaluation in the health f ie ld s .
New York: Behavioral Publication, 1969.
Schwarz, M. R. WAMI: a concept o f regional medical education.
Journal of Medical Education, 1973, 48(12).
Shropshire, R. W., Stone, H. L ., & Knope, H. Externship: a lo n g i
tudinal study of a learning experience in primary care. Paper
presented at the Fourteenth Annual Conference on Research in Medical
Education, Washington, D.C., 1975.
Skinner, S. R., & Rogers, K. D. A medical student organized and d i
rected primary care preceptorship. Journal of Medical Education,
1974, 49, 1145-1151.
175
Snodgrass, J. An evaluation of the 1968 Philadelphia student health
organization project (U.S. Department of Health, Education, and
Welfare, No. 43-68-1533). Washington, D.C.: U.S. Government
P rinting O ffice , 1968.
Steinwald, C. A c ritiq u e of manpower needs by specialty. Journal of
American Medical Association, 1972, 222(11), 1411-1412.
Steinwald, B ., & Steinwald, C. The e ffe c t of preceptorship and rural
tra in in g programs on physicians' practice location decisions. Med-
ical Care, 1975, 13(3), 219-229.
Stewart, M. M., Richstone, N., Greene, M., & Lange, P. Community med
icine clerkship in an applied se ttin g . Journal of Medical Educa
tio n , 1977, 52, 145-146.
Tanner, L. A ., Linn, M. W., & Carmichael, L. P. An in te rd is c ip lin a ry
student health team project in comprehensive fam ily health care.
Journal of Medical Education, 1972, 47(8), 656-658.
Taylor, M., Dickman, W., & Kane, R. Medical students' a ttitu d es toward
rural practice. Journal of Medical Education, 1973, 48(10), 885-
895.
Tungsubuta, K. Volunteer health workers (Thailand) (Report pursuant
to Grant from the International Development Research Center, Ottawa,
Canada). Khon Kaen, Thailand: Khon Kaen U niversity, 1976.
Udinsky, B. F ., Keefe, J. W., & Housden, J. L. Teacher role change in
the NASSP model schools p ro je c t. Unpublished doctoral d isse rta tio n ,
U niversity of Southern C a lifo rn ia , 1972.
Verby, E. J ., & Connolly, J. P. Rural physician's associate program.
Journal of Medical Education, 1972, 47(11), 907.
Verby, J. E. The Minnesota rural physician re d is trib u tio n plan.
Journal of American Medical Association, 1977, 238(9), 960-964.
Weiner, T. C a lifo rn ia student health project summer 1968 (U.S. Depart
ment of Health, Education, and Welfare, No. 0355-231). Washington,
D.C.: U.S. Government P rinting O ffice, 1968.
Weisbuch, J. B., French, D. M., Rubel, R. A., & Manoharan, T. Teach
ing elements of community and fam ily medicine to medical
undergraduates. Journal of Medical Education, 1973, 48(10), 953-955.
Wilbur, M. B. Educational tools fo r health personnel. New York:
The MacMillan Company, 1968.
176
Wray, J. D. Motivating medical students in the Ramathibodi community
health program. Studies in Family Planning, 1974, 5_(4), 134-139.
Wright, D. D. Recent rural health research. Journal o f Community
Health, 1976, 2.(1).
Yerby, A. S. Community medicine in England and Scotland (U.S. Depart
ment of Health, Education, and Welfare, No. NIH 76-1061). Washing
ton, D.C.: D H E W P ublication, 1976.
Y ett, D. E., & Sloan, F. A. Migration patterns of recent medical school
graduates. In q u iry , 1974, VU 125-142.
Zervanos, N. J ., Benz, E. J ., & Alho, W . Family and community medicine
in a general hospital. Journal of American Medical Association,
1972, 221(1), 54-57.
177
178
APPENDIX A
QUESTIONNAIRE
179
PART I
The questionnaire gives you an opportunity to espress anonymously
your views of this program. Indicate the response closest to your views
by filling out the appropriate box.
1. Age (year)
Place of birth
24-29
30-39
Bangkok
□
c m
cm
40-49
50 and over I J
Province 1 1
Religion
Name of province_
Buddhist
Muslim
cm
cm
Catholic
Christian
Other
□
cm
cm
Family monthly income (baht)
Lower than 999
1.000 to 1,999
2.000 to 4,999
5.000 to 7,999
8.000 to 10,000
Over 10,000
FatherTs occupation_________________________
c m
cm
cm
(Be specific-if retired, list former occupation)
Mother's occupation
Your position______
(Be specific-if retired, list former occupation)
Name of the province where you wo.rk_
Do you presently plan to practice
your profession in a poverty area? Yes m No c m
180
8. Have you previously had actual
experiences with health devel
opment programs in poverty -----
areas such as the CHP? Yes No
If so please list the following:
a. Name of project___________________________ Position_
Location___________________________________Pate_____
b. Name of project___________________________ Position_
Location___________________________________Date_____
c. Name of project___________________________ Position_
Location___________________________________Date_____
Describe what you presently feel
is the biggest problem you face
in carrying out your work activ
ities in this program.__________________________________
Have you become active in any
group seeking health care
change as a result of your
participation in the CHP? Yes No
10. Have students* attitudes to
ward the health system changed
as a result of their field
experiences? Yes No
If yes, how?
11. Have your feelings about
people changed since you have i 1
worked here? Yes 1 — : — I No
Please describe these changes: ______________________
181
12. How effective do you think the
CHP has been in improving the
conditions of the poor? Extremely
effective
No effect
Moderately
effective
Negatively
effective
13
14,
In the future do you plan to
become involved in curriculum
reform at your school? Yes
In the future do you plan to
become involved in education
of the school? Yes
Slightly
effective
No
No
15. How much time do students
spend with their preceptor-
during a typical work?
a.
None
6-10
11-15
16-20
21 and up
In what ways, if any, has
the preceptor influenced
students’ thinking?
b. What kind of help, if any
are students getting
from other staff?
16. Have the students found the
CHP experience generally
satisfying? Yes
17. To what extent, if any, is the
CHP experience helpful in ac
quiring specific skills for the
profession of the students? Very
helpful
No
Slightly
helpful
Moderately
helpful
Not helpful
at all
182
18. As a member of the faculty cur
riculum committee, or as an
instructor, or as a graduate of
the program, or as a student,
do you think that the CHP is
successful as follows:
A learning experience for
students regarding public
health of the country. Very well
Good
Moderately
Very little
Not. at all
The students can analyze the
health problems of the commu
nity by the scientific
method and decide to select
the important problem with
the right method. Very well
Good
Method which familiarizes
students with the fact of
public health and health
in general. Very well
Good
Moderately
Very little
Not at all
Moderately
Very little
Not at all
Method which motivates the
interest of the students
and makes them familiar with
the practice of their
professions in rural areas. Very well
Good
Moderately
Very little
Method which helps the med
ical school coordinate with
the Ministry of Public Health
in terms of serving the
Not at all
patients. Very well Moderately
Good Very little
Not at all
183
19. What part of your CHP experience
was most satisfying?
20. What part of your CHP experience
was most unsatisfying?
21. What learning experience not
presently provided should be
added to the program?
22. Did students acquire knowledge
or skills from field work which
were not taught in the class- . ---- ■
room? Yes________1 ____ I No
What were they? ___________________
23. To what degree do you think
that the CHP experience helps
students to perform their
future careers? A great
deal
Moderately
Very
little
Not at
all
24. What other comments would you
care to make regarding your
experiences in the program?
184
PART II
For each item mark an X in the appropriate box to indicate your
choice according to the following scale:
1. Excellent
2. Good
3. Adequate or fair
4. Poor
5. Very poor
1. How well do the learning experi
ences provided by the program
meet the students1 needfe?
2. How would you rate each of the
courses below with regard to
overall quality?
Demographic Survey
Analysis of Community Health
Problems
Community Health Planning
Clerkship in Community Health
Internship in Community Health
3. How useful is each course?
Demographic Survey
Analysis of Community Health
Problems
Community Health Planning
Clerkship in Community Health
Internship in Community Health
185
il, 1 d 1 3 3 H IJ a L hi 1
i L ..J 2C Z J 3 C hi 3 5 C 1
il
hi ■hi 1 4 I m 5 c 1
il
1 1 2 C hi hi 1 h }
il
hi
hi hi hi 1
il J 2L 1 3 1 _UL hi 1
il hi hi hl 1 3 5 C 1
t I 1 3 2 in hi — 1 4 1 — hi 1
i 1
1 3 2 C
1 3 3 1 _
h 1
hi 1
1 1 , hi J 3 L _ Ul hi 1
1 1 . .. hi
hl hi h 1 1
4. How good are the teaching methods
in each subject?
Demographic Survey
Analysis of Community Health
Problems
Community Health Planning
Clerkship in Community Health
Internship in Community Health
Scale: 1. Too much
2. Adequate
3. Inadequate
5. Describe'the amount of time
given to each course.
Demographic Survey
Analysis of Community Health
Problems
Community Health Planning
Clerkship in Community Health
Internship in Community Health
6. Describe the amount of material
covered in each course.
Demographic Survey
Analysis of Community Health
Problems
Community Health Planning
Clerkship in Community Health
Internship in Community Health
____J? L_—3 3 I— h i □ 5 L . ,1
1s ( I , 1 — 15 I—
1
1 I d . . . J 3 1 __ 1/, 1 Is 1 1
i u r _J 3 L_ U l Isl
1
... __1 3 L - 1 4 1 3 5 L 1
l l i d h i
J
l l
Id isl 1
d . J? L___3 C 1
d U si 1
i L _ZI 2 L .... J 3 L 1
i l
I I _J 3 L
1
i l I d h i 1
1 1 I d _ h L 1
i l I d —] 3 L i
l l _ l 2 1 ..... — h i —
- 1
186
The following questions refer to each objective in each course of
the CHP. For each item mark an X in the appropriate box to indicate
your choice according to the following scale.
Scale: 1. Excellent
2. Good
3. Adequate or fair
4. Poor
5. Very poor
A. Demographic Survey
How well do the learning experi
ences provided by the course
enable the students to accom- , . -___ -... .. -
plish the stated objective? 1 [ J 2 j —„— J 3 I —.... J 4 I J 5 I... J
8. To what extent does this course
increase studentsT understanding
of the following:
a. To expose students to the so
cial problems of people liv- . . . __. ____ { -__. ____
ing in a rural community. 1 1 ___J 2 I_____-J 3 I ----1 41--J 5 I ---
b. To expose students to the
health problems and health
behavior of people living in ^ p----. . p .
a rural community. 1 I * 2 1 ____| 3 1 ---- j 41 1 5 L
c. To understand the attitudes
of the people living in a p .. •......... *----. p. ..■ >
rural community. 1 » , 1 2 j J 3 t-----J 4 I J 5 L--- 1
d. To understand the concepts,
principles, and techniques p.-... . p . . . . . ...... p . , , . .
of epidemiology. 1 1 1 2 f____ j 3 1 1 4 i j5l---1
e. To understand the concepts,
principles, and techniques * — . |.... . ..... p . . p p
of biostatistics . 1 1 I 2 1 J 3 1 J 4 1 — J5 . . 1
f. To understand the concepts,
principles, and, techniques p p> .... j * --- -
of the social sciences. 1 1 ____J 2 1 . 1 3 I ---1 4 L— ..1 5 I ---1
187
g-
To expose students to cul
tural characteristics of the
people living in a rural
community. IL 2 L 3 L
h. To provide students with an
opportunity to learn the
process of community diag
nosis through partici
pation in the planning and
execution of a survey of a
rural population group and
to learn that they can ob
tain important information
using relatively simple and
inexpensive methods. 2 L 3 C 4 C
Do you think that the experience
from this course helps students in
practicing their future careers?!
2 c u m
5[
B. Analysis of Community Health Problems
10. How well do the learning experi
ences provided by the course
enable students to accomplish
the stated objectives? 1
11. To what extent does this course
increase students’ understanding
of the following:
a. To stimulate and to have
students explore in depth
community health problems of
major importance in Thailand
as a physician. 1
b. To help students develop the
ability to use a problem
solving approach to specific
health care problems and to
relate it to the classic
scientific method. 1
H 2 3 L
3 I U t -J 5 1 ----1
c. To understand and be able to
use the concepts, principles,
and techniques of epidemiol
ogy and biology. 1 2 [ l4
188
12.
d. To understand, be able to
prepare, submit, and ana
lyze the data of the public
health care problems of the
community. 1
e. To understand and be able to
select the important public
health problems of the com
munity . 1
f. To understand, be able to
think, and consider health
and disease not only in
giving service to the
people who come to the hos
pital, but also in providing
necessary and appropriate
service in public health
and in curing disease
for the people in the com
munity . 1
Do you think that the experience
from this course helps students in
practicing their future careers?!
□
3 [
□
1 1 2 1 I 3 I - I 4 I 1 5 I I
C. Community Health Planning
13.
14.
How well do the learning experi
ences provided by the course
enable the students to accom
plish the stated objectives? 1
To what extent does this course
increase students’ understanding
of the following:
a. To review briefly the impor
tant health problems of Thai
land and the health care
implications of these prob
lems . 1
b. To review basic epidemiol
ogic, statistical, and
demographic concepts re
quired for understanding
these problems. 1
□ 3 5 - C
□ sC Z]
189
To review the application of
the problem-solving cycle in
the planning of solutions
to health care problems. lL
To probe in depth a number
of selected issues involved
in planning and implementing
programs for improving
health care including the
following: the definition
of a "health problem," the
community’s own understand
ing of its health problem. lL
To examine the process of
designing possible solutions
to health problems, in
cluding (a) defining objec
tives and how to measure
them, (b) selecting the most
appropriate objectives, (c)
planning information systems
for monitoring the quality
and effectiveness of the
health care system. IL
To examine and analyze some
existing health programs
such as family planning, ma
laria eradication, and tu
berculosis control. 1
1 — 1 4 I____1 5 1 ■ ---1
3 C 41 151 1
1 i 2 [ 41— J 5C
15.
16.
17.
Do you think that the experience
from this course helps students in
practicing their future careers?!
] 2 3 C ] 4 r~~i 5i 1
D. Community Health Clerkship
How well do the learning experi
ences provided by the course
enable the students to accom
plish the stated objectives? 1
To what extent does this course
increase students’ understanding
of the following:
l l 2 H Z Z Z 3 3 E Z Z Z 3 41 — 1 si 1
190
a. To learn from experience the
frequency and seriousness of
diseases that bring people
to a rural health center for
care. 1
b. To develop a deeper under
standing of the health needs
of the community by partic
ipating in village and home
visits, surveys, and proj
ects outside the health
center. 1 CZhC
To continue the process of
learning how to formulate
clearly the various health
needs of a defined commu
nity, identify target popu
lations for health care
programs, design programs
for meeting these needs,
and evaluate the success of
such programs. 1 L . 1 2 I I
To observe, analyze, and
understand the roles of var
ious members of the existing r
health center team. 1 L
]4 I J 5 L - ]
L
18
e. To apply under close super
vision, at the health center,
clinical skills acquired in
the university hospital. 1
Do you think that the experience
from this course helps students in
practicing their future careers?!
E. Internship in Community Health
19.
20,
How well do the learning experi
ences provided by the course
enable the interns to accomplish
the stated objectives? 1
To what extent does this course
increase internsT understanding
of the following:
191
To learn the many nonclini-
cal responsibilities of a
health center physician
(that is, his responsibil
ities as an administrator,
planner, community organ
izer) , as well as his role
in providing direct medical
care to patients who come
for treatment. 3 L J 4 L _ J 5
To learn by working in the
health care team the leader
ship role of the physician
in charge of supervising all
health care activities in a
rural district, as well as
in an urban health center. 1 ] 3 L .... J 4 tZZZZlb C
To understand more clearly
the importance of integrated
curative, preventive, promo
tive health care activities.! I aC Z I
To learn the administrative
structure and operating pol
icies of ThailandTs Ministry
of Health: arid its Department
of Public Health, particu
larly as they affect the
daily operation of a rural
health center. ‘ 2 1 J 3'1 J 4 l |5 [
To practice the clinical
skills essential for pro
viding a high standard of
patient care in a rural
health center with limited
staff, equipment, and fi
nancial resources. czuczb cm
192
PART III
Please read the following statements and for each item mark an X
in the appropriate box to indicate your choice according to the
following scale.
Strongly
Agree Agree Disagree
Strongly
Disagree
1. In medical'practice today
there are sufficient spe
cialists so that a physician
in general practice should
not assume long term respon
sibility for his patients.
I
i
i
2. The medical school should
train students for special
ties rather than general
practice.
3. In a general practice there
is no reason to stress good
health and promote health
care since the average pa
tient only wants to pay for
the alleviation of his dis
ease.
4. Medical training in the
clinical years should con
centrate most of the stu
dent’s time on evaluation
and treatment of the spe
cific disease processes.
5. Specific knowledge neces
sary for prevention of dis
ease is sollimited at this
state of development that
the time of a practicing
physician is much better
spent in curative medicine.
193
Strongly
Agree Agree ,Disagree
Strongly
.Disagree
6. For a well-rounded medical
education, work in radiology
and surgery is decidedly
more important than work in
preventive medicine.
7. In present day practice the
demand for treatment of dis
ease is so great that hardly
any time can be spared to
concern oneself with pre
vention of illness.
8. Since prevention of disease
is directly related to the
properties of disease itself
there is no special reason
to teach the preventive as
pect in a separate course.
9. Prevention of disease as a
medical activity is primarily
the responsibility of the CHP
rather than the responsibility
of other departments.
10. The greatest service a phy
sician can provide is in fol
lowing long term treatment
and adjustment of patient and
families rather than in con
centrating only on the treat
ment of immediate illness
complaints of his patients.
11. As a physician you would pre
fer to have all the members
of a family as your patients
rather than see patients as
individuals.
12. The most important function
of the physician is to im
mediately relieve the suf
fering of the patients.
194
Strongly
Agree Agree , Disagree
Strongly
Disagree
13. A medical doctor in a clin
ical team should consult with
the team member, such as the
nurse, psychologist, social
worker, etc., before making
decisions in the management
of the patients such as dis
charges, referrals, or pro
nounced changes in therapy.
14. In a medical setting, the
doctor should have all
personnel involved in the
treatment of patients,
participate in case dis
cussion regardless of
their professions.
15. In a medical setting, the
doctor should have the
patient participating
in discussion in the
treatment of the patient.
16. Physicians are generally
not responsive to the
health needs of poor
people.
17. While it is desirable that
we help provide health
service to the poor, our
own personal learning
comes first.
18. Patients from lower income
groups are unable to un
derstand the nature of
their illness.
19. It is important for a phy
sician working with poor
patients to get to know
them well in order to best
serve them.
195
Strongly
Agree Agree Disagree
Strongly
Disagree
20. The quality of medical care
under the system of private
practice is inferior to
that under a socialized
medicine.
196
APPENDIX B
INTERVIEW
197
INTERVIEW
1. Place of interview_______________________________________________
2. Sex: Male f 1 Female f 1
3. Degree:
1 — I MD
1...1 MD and Diploma
r ' 1 MD and Board
f I Other
4. Are you: I 1 Single 1 j Married 1 4 Divorced f 1 Widow
5. What is your age at your last birthday? __________ _____________
6. What is your official job title? _______________________________
7. About how long have you worked at this job? ___________________
8. Describe your primary responsibilities.
9. What is the size of the health service facilities?
Outpatient__________________
Inpatient __________________
10. What are the diseases frequently seen at the hospital or health
center?
198
11 What are your plans for the future?
General practitioner
Specialist Type of specialty_
Uncertain
12
13
Do you practice after office hours?
No
Yes
Would you like to come back to refresh some knowledges or skills
which were relevant to your work?
Yes No
If yes, what are they?
14. In what ways do you feel that your work increased the health
consciousness of your community?
15. How is the health care system in your community organized?
16. Major obstacles to the improvement of the delivery of health care:
199
17. To what extent do you apply the CHP to your work?
f , 1 A great amount f .. . ■ . . . . . J Little
Uncertain
18. Do you think students relate well to the community?
Yes [-----J No
Reason:
19. Relationships between you and your colleagues?
20. What major problem, if any, do you see with the internal organ
ization of the CHP (comments, criticism, observations,
suggestions)?T
21. What services are provided to your community and how adequate
are those services?
22. Do you receive an alumni service from theeschool?
1 I Yes f I No
Comments:
200

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Asset Metadata

Creator Eoaskoon, Waraporn (author)

Core Title The community health program at Ramathibodi Medical School, Mahidol University, Thailand: Its effectiveness and its influences on attitudes

Contributor Digitized by ProQuest (provenance)

Degree Doctor of Philosophy

Degree Program Higher Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health Sciences, Public Health Education,OAI-PMH Harvest

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c26-475283

Unique identifier UC11246140

Identifier usctheses-c26-475283 (legacy record id)

Legacy Identifier DP24639.pdf

Dmrecord 475283

Document Type Dissertation

Rights Eoaskoon, Waraporn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA