Evaluation of Knowledge, Attitudes, and Practice in an Online Faculty Development Course for Anesthesia Educators in East Africa

Abstract

Introduction:

Faculty in low-resourced communities often have limited training on teaching and learning. An innovative, online, 13-week course using a flipped classroom model was developed for junior faculty anesthesiologists at teaching hospitals in East Africa and piloted in Ethiopia and Tanzania.

Methods:

Quantitative and qualitative data were collected and analyzed to evaluate potential change in participants’ knowledge, skills, and attitudes as well as the feasibility of e-learning in the region.

Results:

Analysis of data revealed that top areas of change in participants’ knowledge were in the flipped classroom approach (increased by 79%), effective mentoring practices (67%), and elements of effective course goals and objectives (58%). Leading areas of change in skills were in developing goals and objectives (72%), using case-based learning (67%), and engaging learners through PowerPoint (64%). Change in attitudes was largest in the areas of effective mentoring and strong leadership (27%), using course and lecture learning objectives (26%), and student-centered learning theory (26%). Qualitative data revealed that participants were satisfied with the course; found the structure, presentations, and delivery methods to be effective; and appreciated the flexibility of being online but experienced challenges, particularly in connectivity.

Discussion:

This evaluation demonstrated the efficacy of using e-learning in East Africa and highlights the innovation of online faculty development in a region where it has not been done before. By using participants as future instructors, this course is scalable in the region and worldwide, and it can help address limited access to training by providing a critical mass of trainers competent in teaching, mentoring, and leading.

The evolution of medical education over the past few decades has highlighted the need for well-trained faculty in pedagogy and instructional methodologies. Faculty development, a field that has grown substantially over the past few years, is the process by which teachers improve their teaching and educational competencies as well as leadership and research skills.¹ Faculty development requires institutional commitment, adequate resources, and an awareness of the importance of well-trained teachers with the requisite teaching skills.² In a recent meta-analysis of 23 faculty development programs across Asia, Europe, and the United States, Ilie et al³ found that instructional development programs had a positive impact at all levels and recommended that such training be an essential part of medical education.

Although the benefits of faculty development programs have been described in the literature globally, there are unique challenges for medical school institutions in low-income and middle-income countries (LMICs), particularly in sub-Saharan Africa. Some of the barriers for these medical schools include limited faculty due to brain drain, insufficient training in the field of medical education, lack of consistent curriculum review, inadequate infrastructure, and lack of faculty development programs.^4–6 Faculty development often requires many steps and a systematic approach for good outcomes.

E-learning offers an innovative platform for training and can address some of the challenges faced by academic institutions in LMICs. This learning tool has become increasingly popular in large part due to increasingly widespread technological advancements. E-learning is commonly known by many terms including web-based learning, online learning, distributed learning, computer-assisted instruction, or Internet-based learning.⁷ We adopted the definition of e-learning as the delivery of knowledge through an Internet network and a range of other knowledge collection and distribution technologies.⁸ E-learning has been shown to enhance tools for both the quantity and quality of medical education programs, and in LMICs, it has dramatically improved access to education.⁹ More recently, the challenges of in-person training as a result of the COVID-19 pandemic have resulted in an even larger transition to e-learning globally.¹⁰

However, the rapid adoption of these virtual platforms has brought attention to the limitations of e-learning. These can be categorized as mechanical, personal, or access-related issues, especially when compared with traditional learning experiences on campus.¹¹ Mechanical issues often include a lack of basic elements needed for e-learning, such as a computer. Personal issues mainly include understanding of the fundamental differences between traditional and online learning. The literature suggests that individuals who are not familiar with e-learning are more likely to be challenged by a model that requires greater independence by the learner. When compared with traditional campus experiences, there is a significant lack of physical interaction with other students, professors, and staff that online learners do not experience. In some cases, this lack has been shown to affect an individual’s likelihood of completing a program.¹² Other limitations include inadequately trained instructors, lack of understanding of pedagogy, and poor curriculum design. These limitations are exacerbated in places, including LMICs, where e-learning programs are piloted but not sustained through a systems-wide approach¹³ and where electricity and Internet access may be erratic.¹⁴ Although there is a growing body of literature on e-learning in LMICs, there is limited research on e-learning for faculty development programs and its impact on knowledge, attitudes, and practice.

To address this research gap, we examined the role of an innovative e-learning faculty development course on knowledge, attitudes, and practice (KAP) in of medical faculty in two LMICs. We evaluated a 13-week course in Ethiopia and Tanzania that was taught remotely using online platforms, in partnership with multiple medical institutions in Ethiopia and Tanzania and with an academic institution in the United States. We aimed to answer two questions: (1) Is there change in KAP of faculty after participating in a course on teaching, mentoring, and leadership; and (2) How can online learning be optimized for future courses in East Africa or other similar settings?

METHODS

We developed an 11-module course covering topics related to teaching, leadership, and mentorship in academic medicine (Table 1). The course was taught twice to different groups of faculty over 13 weeks using Zoom and Telegram online platforms. Participants in the first rotation included Ethiopian anesthesiologist educators (n = 14) and the second rotation included anesthesiologist professionals from Tanzania (n = 15) with Ethiopian alumni from the first rotation assisting in the second rotation training. The selected participants were either fully engaged in teaching postgraduate anesthesiology residents or planning to open a postgraduate residency program in their institute.

TABLE 1.

Course Module Topics

Course Area	Module Topic
Teaching	Introduction to teaching
	Course planning
	Learning theory
	Assessment
	Instructional methodology I: effective PowerPoint presentations
	Instructional methodology II: project-based learning and case-based discussion
	Instructional methodology III: flipped classroom
Mentoring	Effective mentorship practices
Leading	Time management
	Leadership practice I: social and emotional intelligences
	Leadership practice II: contemporary leadership theories

For each module, participants viewed short instructional videos and read articles before class. In small and large groups during class, participants were led by facilitators in discussions about preclass materials and engaged in exercises and case studies that were designed to enhance learning about the course content. Classes were held in 90-minute sessions through Zoom.

We administered pre-, mid-, and postcourse evaluations to query all participants on their perceived KAP related to the program’s competencies in teaching, mentorship, and leadership as well as on their perception of the course delivery methods and materials. Pre- and postcourse evaluations had identical matrices on KAP fields in which participants marked responses on a scale of 1 to 5 (1 = very low, 5 = very high). The mid- and postprogram surveys included questions to assess the participants’ impressions of the course, which will be used for quality improvement in future program development. For each question, participants marked responses on a numerical scale of 0 to 10 (0 = strongly disagree, 10 = strongly agree). Those surveys also included open-response questions to gather feedback about course structure, materials, and delivery methods.

Statistical analysis of quantitative data from pre-, mid-, and postcourse evaluations primarily consisted of descriptive analyses due to the small number of participants. For questions related to participants’ impressions of the course and their KAPs, we calculated means of each question response. To calculate the percent change between pre- and postcourse KAPs, we divided the difference of pre- and postcourse means by the precourse mean to find the percent change. In analyzing qualitative data, we used a content analysis approach¹⁵ to organize and group responses. We reviewed all written comments, noted how they converged and diverged, and grouped data based on the overarching themes that emerged. From those groupings, we determined salient themes that summarized participants’ words. Microsoft Excel was used for both quantitative and qualitative analyses.

Ethics approval was received from institutions leading the study in Ethiopia and United States. Participants agreed to participate and were assured of confidentiality in their responses.

RESULTS

Descriptive Statistics

Twenty-eight anesthesia providers, 14 each from Ethiopia and Tanzania, responded to the precourse survey, and 26 (10 Ethiopians and 16 Tanzanians) responded to the postcourse survey (93% response rate). Eighty-nine percent were physicians, and 11% were nurse anesthetists (Table 2). More than half (53%) of the participants had more than 3 years of medical experience, whereas almost one-third (32%) had less than a year of experience. Less than half of participants had previous training in teaching pedagogy (36%), leadership (29%), or mentorship (14%).

TABLE 2.

Participant Demographics

Demographic Attributes	Count (Percent)
Type of provider
Physician	25 (89.3)
Nurse	3 (10.7)
Years of experience providing anesthesia
Less than 1 y	9 (32.1)
1–3 y	4 (14.3)
More than 3 y	15 (53.6)
Prior formal training
Teaching pedagogy	10 (35.7)
Mentorship	4 (14.3)
Leadership	8 (28.6)

Changes in Knowledge, Practice, and Attitudes

The mean precourse ratings in each of the 13 knowledge fields ranged from 2.46 to 3.29, whereas postcourse ratings ranged from 4.00 to 4.62 (Table 3; see Table 1, Supplemental Digital Content, http://links.lww.com/JCEHP/A217). Analysis of these data revealed that top areas of positive change in participants’ knowledge were in the flipped classroom approach (increased by 79%), effective mentoring practices (67%), elements of effective course goals and objectives (58%), and effective leadership practices (57%). The mean precourse ratings in each of the 13 practice fields ranged from 2.50 to 3.25, whereas postcourse ratings ranged from 3.96 to 4.62. Top areas of change in practice were in developing goals and objectives (72%), using case-based learning (67%), and using PowerPoint to engage learners (64%).

TABLE 3.

Participant Reported Knowledge, Practice, and Attitudes at the Beginning and End of Course

	Precourse Means (n = 28)	Postcourse Means (n=26)	Difference (Post – Pre)	% Change (Diff/Pre)
Knowledge fields
Mean for knowledge fields	2.87	4.36	1.49	53%
Practice fields
Mean for practice fields	2.82	4.32	1.49	53%
Attitude fields
Mean for attitude fields	3.70	4.55	0.85	23%

Please see Supplemental Digital Content (see Table, http://links.lww.com/JCEHP/A217) for detailed list of questions for each field.

In comparison to knowledge and practice fields, participants had higher baseline ratings of their attitudes. The mean pre-course ratings in each of the 9 attitude fields ranged from 3.57 to 3.86. However, postcourse ratings were more similar to the ratings in the other 2 categories and ranged from 4.50 to 4.65. Thus, the magnitude of change was smaller in the attitude fields. Top areas of change in attitudes were in the importance of effective mentoring and strong leadership (27%), using course and lecture learning objectives (26%), and using student-centered learning theory (26%).

Impressions of Online Learning

Participants reported being very satisfied with the course. They strongly agreed that the course met their expectations, they would recommend the course to a colleague, information was presented clearly, and they were very comfortable with pedagogical techniques and approaches covered in the training (9.8, 9.8, 9.5, 9.4, respectively [scale 1–10]). Participants agreed (8.4) that sufficient time was allocated for each training session. They strongly agreed that the course provided information they intend to use in teaching, mentoring, and leading. By contrast, participants only somewhat agreed that the course provided information they already use in teaching, mentoring, and leading.

Participants’ open-ended responses reflected the quantitative data but provided greater insight into issues and areas for improvement of future courses. Salient themes included appreciating course structure and flexibility, challenge of Internet connectivity and online platform, desiring more time, and wanting more hands-on activities. Both Ethiopian and Tanzanian participants found the structure of the course, including PowerPoint presentations and the delivery of the content, to be effective and enjoyed the mentorship and leadership–focused themes. All participants commented on the flexibility of the course delivery method but described challenges with the nature of online course training.

Ethiopian participants noted that they experienced connectivity issues and identified needing more time to complete the training. These participants also wanted more interactive, practical, and face-to-face sessions. The Tanzanian cohort wanted more hands-on experiences and interactive assignments. Although both cohorts discussed the need for longer sessions, it was especially evident among the Tanzanian cohort who often recommended “increasing more time per session.” Finally, the Tanzanian cohort also suggested uploading the course videos on more accessible platforms, such as YouTube, to offset the connectivity issues experienced when accessing the learning management system.

DISCUSSION

This innovative study focused on the feasibility of using an online educational intervention to improve KAP related to teaching pedagogy, leadership, and mentorship of early career in anesthesia faculty working in Ethiopian and Tanzanian teaching hospitals. Before the course, less than half of the participants had previous training in teaching pedagogy, leadership, or mentorship, emphasizing the importance of improving the educational content at universities and holding continuing education for faculty. Most participants in this course agreed that teaching pedagogy, leadership, and mentorship training could assist them with their academic teaching and learning needs.

Participants showed positive change in their knowledge, especially in the flipped classroom approach, effective mentoring practices, elements of effective course goals and objectives, and effective leadership practices, all of which increased by at least 57%. These knowledge areas were key concepts of the course, potentially demonstrating the efficacy of this course. Our results are similar to the systematic review of 111 faculty development studies, which showed an improvement in self-reported knowledge and skills after the intervention.¹ There was a similar finding in a survey conducted in 2015 at the University of Zimbabwe on the role of faculty development programs in medical education. The study showed that participants had improvement in their practice after the training.⁴ Our participants had top areas of change in three domains of practice, including developing goals and objectives, using case-based learning, and using PowerPoint to engage learners. We found the same mean change for both knowledge and practice, suggesting that knowledge was transferred to practice for these participants.

There was also growth in participants’ ratings of their attitudes related to course concepts, although the change was much smaller than in knowledge and practice. However, it is important to note that the data showed that participants had higher baseline ratings of their attitudes in comparison to knowledge and practice (mean: 3.70 versus 2.87 and 2.82, respectively). Thus, with higher baselines, there was not as much room for growth. Of the attitude field domains, the top areas of change were in the importance of effective mentoring, using course and lecture objectives and using student-centered learning theory, which were increased by at least 26% post training. Although the interaction between knowledge, attitudes, and behaviors has been debated by cognitive psychologists and education researchers,¹⁶ we surmise that participants’ underlying high level of positive attitudes towards the concepts taught in this course provided intrinsic motivation for learning materials and modifying behaviors.

Limited travel due to the COVID-19 pandemic necessitated online adaptation of this faculty development course, and the results suggest that online learning can be implemented successfully in low-resource settings, even with some limitations in Internet connectivity. This study provided insight into the advantages and limitations of e-learning for anesthesia faculties, particularly in LMICs. Participants noted that they enjoyed the course and would recommend it to others, demonstrating overall success in course delivery. The popularity of the leadership and mentorship themes by the learners, coupled with high improvement of knowledge in mentorship and leadership, suggests that these topics are important content for faculty development programs.

One of the main challenges that participants described was unstable Internet connection. Although this challenge has been widely reported in the literature by other online training programs, few offered solutions.^17–19 However, our Tanzanian participants recommended that course videos be put on more accessible platforms that require lower bandwidth. Other programs have provided reading materials that can be downloaded in advance and used offline²⁰ or purchased fiber optic cable to improve video quality.²¹ We are optimistic as Internet connectivity is rapidly expanding worldwide and new undersea cables are projected to increase bandwidth and reduce costs in East Africa by several hundred fold.²²

According to our study, the need for continuous education of faculty members after graduation from professional training is evident in the areas of teaching, leadership, and mentorship. Establishing effective faculty development courses requires institutional leadership, appropriate resource allocation, and recognition for teaching excellence² as well as a sustainability plan, quality mentorship, and evaluation and feedback for program continuity.²³

Remote learning features of this training facilitated cross-institutional and cross-national collaboration with participants and instructors from 11 hospitals across 3 countries engaging in the program. This supports other findings, including a systematic review of 20 studies on online learning for faculty development (in the United States and Canada), which found that online learning increases collaboration across disciplines and distance.²⁴ Other research has found that an integrated approach using in-person teaching supplemented with e-learning provides better outcomes in medical education.²⁵ That research aligns with qualitative feedback on our training course, in which participants improved their KAPs but recommended more in-person training with hands-on training opportunities.

Limitations

To our knowledge, this study and course are the first of its kind in anesthesia education training in Ethiopia and Tanzania. This pilot course and study had a small number of participants. As such, it is difficult to generalize the results. A larger study with multiple institutions and countries should be conducted to further confirm findings from this study. The use of self-evaluation data is also a limitation of this study. Direct observation coupled with self-evaluation could provide more comprehensive data about changes, especially in practice.

Future Directions

The results of our study suggest that faculty development training can enhance knowledge, attitudes, and practice in pedagogy, leadership, and mentorship in low-resourced settings. Recognizing the realities of limited resources, it could be beneficial for professional societies and academic institutions to partner with local governments and hospitals in LMICs to provide training through educational workshops. E-learning is a novel concept that uses online platforms to connect participants and instructors from different locations and can help alleviate time and budget limitations that would have otherwise made it difficult to maintain the integrity and quality of training programs. Although this course was effective for these cadres of trainees, before implementing the course with other groups, we recommend performing a needs assessment to determine the interest, applicability, and feasibility of such a course. Local need for such trainings and Internet connectivity should be considered in determining if this course would be effective with other groups.

CONCLUSION

In conclusion, delivery of anesthesia is crucial to realizing the goal of improving global surgical services. With the dearth of anesthesia providers in LMICs, as well as those with appropriate pedagogical skills, implementation of training courses such as this one that builds providers’ skills as educators, mentors, and leaders for the next generation of anesthesiologists is crucial. This evaluation demonstrated the efficacy of using e-learning in East Africa and the innovation of online faculty development in a region where it has not been done before. These methods facilitate collaborative remote administration of training programs through university partnerships. Using e-learning with participants as future instructors, this course is scalable in the region and worldwide. This course can help address limited access to training by providing a critical mass of trainers competent in teaching, mentoring, and leading. We believe that such capacity strengthening building partnerships can serve as a model in other low-resource settings.

Supplementary Material

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcehp.org).

Lessons for Practice.

• Online faculty development collaboration between institutions in low-income and high-resource settings can be effective.

• E-learning can be used in East Africa to teach faculty development programs in teaching pedagogy, mentorship, and leadership.

• Participants’ levels of knowledge, attitudes, and practice (skills) before and after training can be used as an outcome measure.