Concurrent Field Practice Act as an Efficient Teaching Pedagogy to Originate Public Health Professionals: A Bangladesh Context

Concurrent Field Practice-based teaching methods (CFPTM) have commenced globally parallel with the traditional teaching methods (TTM). The effectiveness of CFPTM in Bangladeshi educational settings has not been adequately studied yet. This study was undertaken to test the hypothesis that CFPTM is effective teaching method as compared to the TTM for Bangladeshi postgraduate public health students. Under a comparative interventional design two groups of postgraduate students [n=40 for each group], were selected purposively from the department of public health of the Daffodil International University, Dhaka, Bangladesh. Data were collected during pre and post intervention based on a topic that had been chosen to conduct the intervention followed interactive lecture method with CFP. Overall knowledge score (percentage) showed a significant increase in both the CFPTM (Baseline vs. Final, M±SD, 27±12 vs. 83±8, p<0.001) and TTM (27±18 vs. 40±17, p<0.001) among the groups. CFPTM showed a significantly higher knowledge score (p<0.001) as compared to TTM at the final time point. Analysis on individual components showed a result similar to the overall knowledge score. CFPTM seems to be superior and effective to TTM as a short-term interventional tool. CFPTM has been identified as an effective tool for postgraduate education in public health, which offers a new approach to equipping students with appropriate knowledge and skills that they need not only in their learning period but also in their service life.


Introduction
Educating the professional in social and health care has been a common pract ice nowadays but simultaneously has become challenging by the global circu mstances. Nu merous factors such as socio-economic conditions, difficult political environments as well as lack of awareness, have influenced the ability to provide training for these health care professionals, according to Shardlow [1]. For the social work pract itioners as well as public health professionals, field education is a pivotal feature for enrich ment of their skill and professionalis m. Many of the Universities achieved co mpetence in social work through field education and got it fu lly accessible for faculties and prospective students [2].
In 2003, Institute of Medicine (IOM ) Reports, Whom Will Keep the Public Healthy? Educating Pub lic Health Professionals for the 21st Century made it clear that academic public health programs should have a primary mission that is the preparation of individuals for positions of senior responsibility in public health practice, research, and teaching [3]. Public health programs need to ensure that their curricu lu ms are structured to meet the contemporary needs of the practice in commun ity. Thus, as there are needs to change the community, so, the curriculu m of the public health programs needs to adjust accordingly.
Innovative and effective in curricular modification and effectiveness in profession is going to meet the needs of educating the next generation of public health leaders. As creative and new ideas are explo red, such as "schools without walls", people must address the challenges posed by providing cohesive degrees to students with who m they rarely? interact other than via co mputer, text messaging, and cell phone [4]. Teacher's education and student's A Bangladesh Context participation in concerned field p lacements are more beneficial and create an opportunistic environment for learning. In this noble approach teachers become prospective and help the students for instrumental understanding that influence mu ltiple sources of informat ive learning [5]. An innovative research found field based science teaching method increases the general and personal science teaching efficacy of the pre-service teachers at a public elementary school [6].
In professional arena other than Public Health for instance accounting discipline, emphasis on using innovative teaching practices such as information and communicat ion technologies, the internet as well as various computer programs, simu lations, case studies on real and virtual work environ ments, help graduates meet and adopt to the demands for professional competency development [7].
Can blogs, vlogs and wikis be substitute for lectures and classroom discussions? Can schools that have no residential faculty provide public health degrees? These and other questions challenge faculty and administrators as providing education to more students are undertaken and bolstered the public health workforce. All one has to do is to look at the Council for Education on Public Health (CEPH)'s website to see that dozens of accredited programs and schools of public health now rely on alternative strategies (online, executive-style, distance education) [4] to prepare public health practit ioners. Yet there is still resistance to provide training via this mode, and for many universities outside the United States, online education is still viewed with skepticis m and is limited in its offerings fro m Council for Education on Public Health [8].
The public health workforce has changed dramatically due to rapid social, technological, po lit ical and economic changes [9,10] but public health education system has proceeded in general pattern and has not follo wed the approach of professions that consign internship or practical experience to the last phase of education. Instead, public health educators were not advanced among the early defenders and definers of experiential education and they saw fieldwork as a concurrent adjunct to classroom instruction; a sort of laboratory for the curriculu m [10]. Presently, departments of Public Health have become more responsible for the provision of basic knowledge to make effective the learn ing, and are more active in helping students to connect their field experiences with classroom learning through introducing group work wh ich encourages peer learning and peer support [11,12].
Whereas group work, under proper conditions, has been shown to encouraged peer learning and peer support [13], group work can also become the vehicle fo r acrimony, conflict and freeloading. It may also impose a host of unexpected stresses on, for example, students with overcrowded schedules liv ing long distances from the University [14].
Concurrent field practice (CFP) is a process by which postgraduate students can adopt theoretical knowledge appropriately by performing simu ltaneously different activities at the field level [15]. It reflects community-based research and problem-based learning. The objective of the CFP is to prepare professionals who will function at the interface of both fields in practice, research, planning, ad ministration, and policy development in public health field. Students will develop competence in social wo rk practice in co mmunity health, understanding of the organization and functioning of the health and social service delivery systems, and basic analytical skills necessary to conduct research and to perform co mpetently in a variety of public health social work ro les. Students will also have an opportunity for in-depth study of particular issues related to their special interests and career goals. CFP is a common ly included technique in postgraduate curricula in social sciences, but it is rarely practiced in public health disciplines [15].
Traditional teaching method (TTM) is usual practice in educational institutes. In recent years, concurrent field practice based teaching method (CFPTM) has gained a substantial imp lementation and is now as common as TTM [16]. A meta-analysis proved that non-traditional or evidence based teaching and learning methods designed to improve crit ical thin king wh ich is more applicable for Public Health and Clinical practice are significantly more effective than the conventional methods [17].
It is very essential to assess the effectiveness of CFPTM compared to TTM before reco mmend the method for adopting in the public health curricu lu m. But the effectiveness of CFPTM in Bangladeshi educational settings has not yet been adequately studied. This study was undertaken to test the hypothesis that CFPTM is effective teaching method as compared to the TTM for Bangladeshi postgraduate public health students.

Materials and Methods
The effectiveness of CFPTM was measured by comparing the change in knowledge of CFPTM group with TTM group. An interventional study was conducted over a period of six months during September 2017-February 2018. Subjects were public health students at the Daffodil International University (DIU) in Bangladesh. DIU is one of the leading private universities of Bangladesh and established in 2002. The depart ment of Public Health of DIU started its journey since 2012 with a great emphasis on both teaching and research. Initially all students of the Fall Semester in Master of Public Health Program (MPH) conducted by the department of Public Health, DIU were enrolled as the sample. A total of 96 students were the Semester and approximately 10 students were excluded fro m the study due to illness or absence. Considering insufficient number of students in the sample, a purposive selection into groups was made basing on the willingness of the subject to participate in the study. 03 students from each group were barred to continue in this study up to the final point and a total number of 80 students were available for this study with 40 students in each group. The groups were separated on the basis of section and 40 students from each section were taken. The data in both demographics and knowledge of selected topic were co llected in t wo phases (pre-and post-assessment) fro m all subjects via a self-ad min istered method with semi-structured questionnaire. The questionnaire was in the English version to assess knowledge on different components (Problem and need identification, goal, and objective setting, educational content setting, target group setting, selection of appropriate methods and media, detail plan of action, techniques of evaluation) of the selected topic 'Planning, Implementation and Evaluation of Health Educational Intervention'. The demographics included age; sex; relig ion; academic background of education (level of education, basic and academic result of last degree) and professional informat ion (types of current o rganizat ion, frequency of attendance in training and conference and publication if any. Before data collection, permission had been taken fro m the concerned authority of the university. All concerned students were informed about the study. After collection of pre-intervention data, educational intervention were conducted among these two groups. Both groups were provided instruction on the topic of p lanning, implementation and evaluation of health education programs. After the standard lecture, students in the intervention or Concurrent Field Practice Teaching Method (CFPTM ) group participated in an interactive process with practical/ demonstration part. But students in the non-intervention or Traditional Teaching Method (TTM) group were kept with the traditional lecture method. There was no practical/ demonstration conducted for TTM group after the lecture. The educational intervention was followed interactive lecture method with CFP by using module and practical sheet over a period of 6 hours (2 hours theory and 4 hours practical) for the CFPTM group and educational intervention follo wed only interactive lecture method over a period of 6 hours theory for the TTM group.
After coding, an overall knowledge score and individual knowledge score were co mpiled. Each correct response of knowledge was assigned a score of 1, each incorrect response was assigned a score of 0 and for mu ltiple answers, a score of 1 was divided by total nu mber of answers which were present. Afterwards, total scores were converted to percentage. Statistical package for Social Sciences (SPSS) 20.0 was used to analyze the data. Data were presented by mean and standard deviation values and compared using Paired-t-test between baseline and final values in each group as well as by using Independent t-test between the two groups at each time points. p-value ≤0.05 was considered as significant with 95% confidence interval.

Findings
The Mean ± (SD) of age (in years) was found to be similar (34±6) in both CFPTM and TTM groups in this research. The M (±SD) of total knowledge score (expressed as a percentage) of pre-assessment were 27(±18) & 27(±12) respectively in TTM and CFPTM groups. Total knowledge score showed significant (p <0.001) increase after educational intervention and the scores were 40(±17) & 83(±8) respectively in both TTM and CFPTM groups. The final scores of both groups, CFPTM group showed a significantly (p <0.001) h igher knowledge score as compared to TTM group in post-assessment. (Table 1) The M (±SD) of pre-assessment knowledge score of the planning component of the topic 'Planning, Implementation, and Evaluation of Health Educational Intervention' were 31(±24) & 36(±22) respectively in TTM and CFPTM g roups. Total knowledge score showed significant (p <0.001) increase after educational intervention and the scores were 48(±23) & 93(±10) respectively in both CFPTM and TTM groups. However, between the last scores of both groups, CFPTM group showed a significantly (p<0.001) higher knowledge score as compared to TTM group in post-assessment. (Table 2) The M (±SD) of pre-assessment knowledge score of the implementation component of the topic found 2(±15) &12(±33) respectively in TTM and CFPTM groups. Total knowledge score showed significant (p <0.001) increase after educational intervention and the scores were 5(±22) & 80(±40) respectively in both TTM and CFPTM groups. However, between the last scores of both groups, CFPTM group showed a significantly (p<0.001) higher knowledge score as compared to TTM group in post-assessment. (Table 2) The M (±SD) of pre-assessment knowledge score of the evaluation component of the topic revealed 42(±50) & 70(±46) respectively in TTM and CFPTM groups. Total knowledge score showed significant (p <0.001) increase after educational intervention and the scores were 55(±50) & 100(±0) respectively in both TTM and CFPTM groups. But, between the end scores of both groups, CFPTM group showed a significantly (p<0.001) higher knowledge score as compared to TTM group in post-assessment. (Table 2) Table 3 reveals that females do minated both groups (CFPTM 55% and TTM 65%) and total knowledge score found more among females than males of CFPTM group after the educational intervention. (Table 3).
The educational background of the study subjects showed, the majority comp leted undergraduate/ bachelor degree as their last degree, before they started their MPH course [CFPTM: 36 (90%) and TTM : 22 (55%)]. Their undergraduate background came fro m science [CFPTM: 38 (95%) and TTM: 40 (100%)]; most were non-medical A Bangladesh Context graduate [CFPTM : 25 (62%) and TTM: 22 (55%)] and with good academic result [CFPTM : 21 (52%) and TTM: 25 (62%)] in both groups. Moreover, total knowledge score were found higher during post-assessment among the students of CFPTM group who had completed postgraduate/ masters as the last academic degree, fro m a science background and medical graduate (Table 4). Table 5 shows that most of the students were fro m non-government or private organizat ion [CFPTM : 25 (62%) and TTM : 31 (77%)]; and with more attendance in different types of professional training related to public health [CFPTM : 24 (60%) and TTM: 23 (57%)]; few published articles [CFPTM : 02 (5%) and TTM: 06 (15%)] were done by either groups. Only around 30% of the CFPTM group had attended various types of professional conferences, with over 50% of the TTM group having attending a professional conference.

Discussion
In primary stage, both groups (CFPTM and TTM) have similar age and apply the educational intervention in both groups. Then the mean (±SD) knowledge score were found for both groups 43(±17) and 83(±8) respectively which was shown significant increase as pre-assessment knowledge score were 27(±18) and 27(±12) for TTM and CFPTM groups. Here, the CFPTM group's knowledge score was higher than TTM groups. This competency found in University at Albany wh ich achieving Co mpetence in Social Work through Field Education [2]. Another study recommended an enhancement of Health education theory, research, and training might lead to better foster successful efforts to modify social and polit ical environ ments to improve health [3].
So it is clearly shown that there is significant variat ion exist between two groups as initial stage both groups knowledge score was quiet similar but after applying educational intervention CFPTM g roup's knowledge score was mo re than TTM group. Here the knowledge was examined based on the topic 'Planning, Imp lementation, and Evaluation of Health Educational Intervention'. Then this study examined a significant increase in section (i.e. planning component) where the pre-assessment knowledge score of this section were 31(±24) and 36(±22). However, after applying educational intervention, the score of planning component of CFP group was 93(±10) which was higher than the knowledge score of TTM group though the significant (p<0.001) increase of knowledge score was happened for both groups by applying educational intervention. Similarly, another study showed the benefits of modern teaching strategies using technological intervention in premises. Using modern teaching methods, the learning process becomes more effective and students become ab le to enrich their knowledge, imp rove their skills and competencies, which make them competi ti ve in the practical fiel d as well as pros pecti ve successor in career [7].
For more checking, this study also examined the knowledge of imp lementation component for both CFPTM and TTM groups. Between the last scores of both groups, CFPTM group showed a significantly (p <0.001) h igher knowledge score as compared to TTM group in post-assessment. A similar result was found in a systematic review approach, which was aimed to reveal the effectiveness of non-traditional educational methods in critical thinking skill. The meta-analysis showed that nontraditional teaching methods (i.e., no lectures) were more effective co mpared to control groups (standardized mean difference [SMD]: 0.42, 95 % confidence interval [CI]: 0.26-0.57, p < .00001) [17].
In evaluation component of the topic, knowledge score of CFPTM group was mo re than TTM group in pre-assessment. Both groups showed a significant increase in knowledge score after using educational intervention. Then between the end scores of both groups, CFPTM group showed a significantly (p<0.001) higher knowledge score as compared to TTM group in post-assessment. Similarly, another study suggested that Educational meet ings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients [18].
This study explored that the three sections (planning, implementation & evaluation) of the topic the knowledge score of CFPTM groups was significantly higher than TTM group after applying educational intervention.

Conclusions
CFP has been identified as an effective tool for postgraduate education in public health, which offers a new approach to equipping students with appropriate knowledge, and skills that they need not only in their learning period but also in their service life. Although, the extent of the success of CFP based post graduate education sometimes depends on the academic and professional background of students. Moreover, the effectiveness and scrutinize factors of CFP through longer-term educational intervention need to observe critically. Larger studies with other areas of public health need to be taken for better evaluation of CFP.