Improving medical education in Kenya: an international collaboration^,

Abstract

This paper describes a partnership between the University of Nairobi College of Health Sciences (CHS) Library and the University of Maryland Health Sciences and Human Services Library (HS/HSL). The libraries are collaborating to develop best practices for the CHS Library as it meets the challenge of changing medical education information needs in a digital environment. The collaboration is part of a Medical Education Partnership Initiative. The library project has several components: an assessment of the CHS Library, learning visits in the United States and Kenya, development of recommendations to enhance the CHS Library, and ongoing evaluation of the program's progress. Development of new services and expertise at the CHS Library is critical to the project's success. A productive collaboration between the HS/HSL and CHS Library is ongoing. A successful program to improve the quality of medical education will have a beneficial impact on health outcomes in Kenya.

INTRODUCTION

The World Health Organization's 2006 World Health Report drew attention to the shortage in health care workers in resource-poor countries, particularly in Africa, in which 24% of the global burden of disease is managed by only 3% of the global health workforce 1. The report outlined a plan of action in which these countries, using a variety of strategies, would build their health care workforces with the support of global partners. In 2010, the US President's Emergency Plan for AIDS Relief (PEPFAR) committed $130 million over 5 years to advance the education and training of health care workers in Sub-Saharan African countries that receive PEPFAR support. The program, Medical Education Partnership Initiative (MEPI), supports global partnerships to expand and enhance models of medical education, thereby strengthening medical education systems, increasing the number of new health care workers, and building clinical and research capacity in Africa 2. The US National Institutes of Health joined PEPFAR in funding MEPI, which is administered by the John E. Fogarty International Center and the HIV/AIDS Bureau of the Health Resources and Services Administration.

MEPI has funded medical education in African institutions in twelve countries, forming a network of regional partners and more than twenty US and foreign collaborators 3. These global partnerships employ a variety of educational and research initiatives, such as enhanced electronic learning, research training, skills lab creation, and research infrastructure improvement 4. Investing in a quality medical education infrastructure, such as the information infrastructure that libraries provide, is recommended for these approaches to be successful 5. Although providing digital resources is a critical first step, quality medical education requires that students learn how to evaluate, synthesize, and apply information to clinical settings, with an emphasis on building skills and knowledge that prepare them for lifelong learning 6. Librarians and library staff have an important role to play in developing the information infrastructure to advance quality medical education.

In 2010, the University of Nairobi's College of Health Sciences (CHS), a recipient of MEPI funds, formed the Partnership for Innovative Medical Education–Kenya (PRIME-K), partnering with the University of Maryland School of Medicine and University of Washington Department of Global Health. The goal of the PRIME-K collaboration is to strengthen and build clinical and research capacity in the University of Nairobi's CHS for HIV and HIV-related conditions. The program has the following aims: (1) to improve the quality of medical education; (2) to extend the reach of medical training outside Nairobi, Kenya; (3) to increase the retention of University of Nairobi faculty by providing opportunities for University of Nairobi postgraduates and faculty to pursue clinical or applied research; and (4) to streamline the process for conducting research at the University of Nairobi. As University of Nairobi's CHS is the largest medical school in Kenya and in East Africa, the PRIME-K program is positioned to have a major long-term impact on health and health outcomes in Kenya 7. Health Sciences and Human Services Library (HS/HSL) staff are collaborating with University of Maryland School of Medicine and University of Nairobi's CHS program staff and library staff on the first of these aims: to improve the quality of medical education in Kenya. The development of new services and skills at the CHS Library is critical to the success of the PRIME-K program.

The University of Nairobi's CHS is the leading tertiary health care training center in Kenya and the East Africa region. It comprises the Schools of Medicine, Pharmacy, Dental Sciences, Nursing Sciences, and Public Health. In 2012, CHS had a student enrollment of over 1,200, with about 900 students in bachelor's degree programs and 300 in master's degree programs 8. The college has over 300 faculty and annually graduates 280 doctors—more than half of all Kenyan doctors introduced into the workforce each year—and 61 pharmacists, 30 dentists, and 38 nurses. The college also graduates more than 145 postgraduates from these disciplines every year 9.

The CHS Library, 1 of 12 libraries in the University of Nairobi Library System, serves the students and faculty in the health professions on the CHS campus, including Kenyatta National Hospital. The CHS Library has 8 full-time equivalents (FTE), with only 1 degreed librarian, the library director. The CHS Library provides circulation services, reference service, and instructional sessions delivered in an e-learning center equipped with 24 computers. The library's website links to University of Nairobi's shared collection of 76,000 online journals. The main library of the University of Nairobi Library System, the Jomo Kenyatta Memorial Library, is responsible for central services such as acquisitions and licensing of online journals. Information technology (IT) support such as website development for the CHS Library is provided though the CHS.

The service mission of the University of Maryland's HS/HSL is similar to that of the CHS Library, serving the Schools of Dentistry, Medicine, Nursing, Pharmacy, and Social Work; the Graduate School; and the University of Maryland Medical Center. The HS/HSL provides access to over 100 databases, 13,000 e-books, and 55,000 online journals and has a robust program of research and instructional support. The library has more than 60 FTEs, who serve 5,450 students and 2,600 faculty. Although the HS/HSL is part of the University System of Maryland, the library maintains its own cataloging, acquisitions, and IT departments.

METHODS

The library component of the PRIME-K project began in 2011, when the principal investigator on the PRIME-K project from the University of Maryland School of Medicine approached the HS/HSL Library executive director and the associate director for services to review the program's aims and discuss ways in which the HS/HSL could support the aim of improving the quality of medical education in Kenya. The first objective for the library's involvement focused on improving access to information resources for the CHS Library, with a concentration on HIV and AIDS resources. In the first step of the project, the associate director for services led the HS/HSL team in using tools such as Journal Citation Reports and ACP Journal Club to identify ninety-five core journal titles in the infectious disease specialty. The team compared the core list with titles held at the CHS Library and found all but fourteen titles already available online at the University of Nairobi, many through HINARI <http://www.who.int/hinari/en/>, the World Health Organization's program to provide resource-poor countries with access to large online collections of biomedical and health literature. HS/HSL librarians provided licensing information for the remaining fourteen titles to the Jomo Kenyatta Memorial Library's acquisitions department, and the titles were added to the collection in 2012.

Partnership for Innovative Medical Education–Kenya (PRIME-K) leadership

In the early stages of the project, the University of Maryland School of Medicine hosted administrators and faculty from the University of Nairobi's CHS PRIME-K program team. A visit to the HS/HSL was part of the itinerary. This visit allowed the HS/HSL team to hear directly from CHS faculty about their impressions of the CHS Library, including areas where improvement or growth was needed. The faculty members also shared their ideas and visions for the future of the CHS Library. In hosting this delegation, the HS/HSL project team provided a tour of the library, introducing the visitors to a state-of-the-art presentation practice studio, technology-enhanced classrooms, the HS/HSL's website and digital content, and the library's instructional and research support services.

In planning the PRIME-K project, program staff at the Schools of Medicine at University of Maryland and University of Nairobi emphasized the importance of establishing students' lifelong learning behaviors and creating a sustainable program that values the development of learning competencies over didactic teaching. As the dialog continued, University of Nairobi and University of Maryland program staff, in consultation with the HS/HSL project team, determined that the library collaboration and specific scope of work at the CHS Library would focus on the development of best practices in health sciences libraries, with an emphasis on sustainability (Figure 1).

Figure 1.

University of Nairobi's College of Health Sciences (CHS) Library and Health Sciences and Human Services Library (HS/HSL) collaboration scope of work

College of Health Sciences (CHS) Library/Information Technology (IT) staff visit to the Health Sciences and Human Services Library (HS/HSL)

To begin the librarians' direct collaboration, program staff in the United States and Kenya planned a learning visit to the HS/HSL. The purpose was to expose selected CHS Library staff to best practices; develop a working relationship; and, together, create a roadmap for success for the CHS Library. In July 2012, the CHS library director, an assistant librarian, and an IT professional visited the HS/HSL for a learning visit in the areas of public services, IT support, resources management, and library administration. The CHS library director retired in February 2013. To ensure the project's continuity, the new library director visited the HS/HSL in July 2013.

To develop content for these visits, the HS/HSL team worked with program staff both in the United States and in Kenya. The HS/HSL team reviewed the CHS Library website to see what resources and services the CHS Library offered and to gain an understanding of the relationship between the CHS Library and the Jomo Kenyatta Memorial Library. The team also granted CHS Library staff offsite access to e-resources a month ahead of the visit so that they could review HS/HSL resources and services to identify areas of interest to them. In a follow up email, CHS Library staff requested participation in seven workshops that the HS/HSL offered through its education and training program.

During two seven-day visits, in July 2012 and July 2103, CHS Library staff met with approximately twenty HS/HSL staff in thirty-three different sessions. The session topics included web design; computer security, maintenance, and imaging; serials management, collection development, and licensing policy; document delivery; digital archives; promotion and branding; continuing education and professional development; evaluation of services and measurement of success; development of a library liaison program; workshop and online tutorial development; instruction in the clinical setting; and service desks and services philosophy. The sessions offered a combination of discussion, demonstration, and hands-on classroom instruction. The HS/HSL team also hosted welcome and farewell receptions and arranged for a field trip to Washington, DC, and to the National Library of Medicine. The CHS Library staff, in turn, delivered a presentation on the CHS Library for the staff at the HS/HSL. The associate director for services and the CHS Library team met daily to ensure that the planned content was valuable and to adjust the itinerary. Feedback from the learning sessions was positive.

Following the visit, the associate director of services created a report to guide the proposed enhancements at the CHS Library. The guide was based on discussions among the CHS Library staff and HS/HSL staff and reflected the challenges and opportunities identified in the CHS Library. Recommended follow-up activities focused on three areas: enhancing professional skills, introducing new technology tools and software, and incorporating best practices.

Enhance professional skills

To enhance professional skills, the guide recommended hiring additional library staff. By increasing the size of the staff, the CHS Library would be better able to allow current staff the time to develop and deliver expert search services and instructional and research consultation services. These services can be developed and maintained by investing in continuing education and training for library staff. Only with an adequate number of staff can librarians develop innovative services and the required expertise to meet the information needs of faculty and students.

Invest in technology tools

The guide also recommended investing in technology tools such as LibGuides and Zotero. By investing in LibGuides, staff would be able to create web pages on special topics and push out online tutorials without having to rely on the central IT department. By promoting citation management tools such as Zotero, library staff would be providing students and faculty with the tools they need to organize information more effectively.

Incorporate best practices

The HS/HSL team encouraged the development of best practices in a digital environment to ensure consistent, quality service. This included active promotion of resources, user-focused website design, and regular communication to CHS faculty and students about library resources and services. It was recommended that, to ensure effectiveness, these endeavors be measured by regular evaluation.

HS/HSL staff visit to the CHS Library

To assess the progress of the collaboration, the HS/HSL's associate director for services and the reference services manager visited the CHS Library in August 2013 for five days. Through email exchanges with the associate director of services, the CHS library director and library assistant identified six areas of focus for the visit: (1) website design; (2) web content development; (3) online tutorial development; (4) creation of online, in-house surveys; (5) statistics gathering; and (6) expansion of reference desk service. To provide targeted assistance, the associate director of services followed up with a survey asking the CHS library director and library assistant to provide detailed information about their needs and expectations in these six areas.

The team developed questions in each topic area that identified specific ways that the HS/HSL team could advance the CHS Library. The survey asked the CHS librarians to indicate whether the HS/HSL team would facilitate a discussion on best practices in academic health sciences libraries and implementation of these practices in the CHS Library and/or whether the HS/HSL team could provide hands-on training or implement specific tools or products. The survey results guided the team as they prepared content for the visit.

The HS/HSL librarians' site visit to the CHS Library allowed the HS/HSL team to hear from all eight CHS Library staff members about their work processes, organizational values, and commitment to the success of the library. Sessions consisted of meetings with individuals, small meetings with departmental staff, and general library-wide meetings with all staff. The HS/HSL team provided instruction in PubMed and facilitated discussions with CHS Library staff on statistics, website design, collaboration tools, instruction, and more. The visit strengthened the HS/HSL team's understanding of the relationship between the main library and the CHS Library and how this might affect the change that the CHS Library would implement. It also confirmed the need for additional staff, specifically a degreed librarian who could assist with incorporating instruction into the curriculum and with developing additional research services.

OUTCOMES

The staff at the CHS Library and HS/HSL have developed a shared vision for the project that contributes to its sustainability. The ingredients for success are evident in the program: shared goals and values, shared vision for addressing challenges, easy communication, and a long-term commitment to the program's success. The program teams from the University of Nairobi and University of Maryland Schools of Medicine are clear in the expectations of the library component of the project: short-term goals that include innovative instruction and emphasis on quality digital collections and long-term goals that include improved medical education through the library's encouragement of students' lifelong learning skills. CHS Library staff will develop, implement, sustain, and evaluate enhancements.

DISCUSSION

Libraries, their digital collections, and their resources that support teaching and learning are part of a medical school's information infrastructure. To be successful, programs that aim to address weaknesses in medical education must also address improvements to their libraries, which is carried out most effectively with library staff participation. This participation can take a variety of forms, as there is a range of strategies that global partnerships employ to expand and enhance medical education. Librarians who are eager to participate in a global health partnership must first identify an initiative in their institutions and, working with the teams leading the project, develop a clear understanding of the projects' aims and strategies. Once librarians can envision and outline their role within the scope of the project, they can present the global partnership team with a way that they can contribute. Librarians' unique expertise in building information infrastructures and promoting skills in lifelong learning add value to global collaborations.

A key ingredient to the success of a global library collaboration is hosting site visits that allow staff to develop trusting relationships and experience each library's organizational culture and resource setting. Funding to support the important work of the library is also required.

The HS/HSL collaboration with the University of Maryland School of Medicine and University of Nairobi's CHS's program was an opportunity that has taken shape over several years. Although the overarching goal of the project was clear from the outset, the project plan and specific scope of work has emerged through discussion and negotiation. A productive, committed collaboration continues today between the HS/HSL staff and CHS Library staff. The libraries' participation in this program encourages the development of lifelong learning in the health care workforce, which contributes to the success of the PRIME-K program.