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ORIGINAL ARTICLE  
Year : 2023  |  Volume : 66  |  Issue : 1  |  Page : 129-134
Development and implementation of a self-directed learning module on antimicrobial resistance for Phase 2 MBBS students


1 Department of Microbiology, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Pharmacology, Christian Medical College and Hospital, Ludhiana, Punjab, India

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Date of Submission14-Jun-2021
Date of Decision21-Jun-2021
Date of Acceptance07-Jul-2021
Date of Web Publication18-Jan-2023
 

   Abstract 


Background: The first objective of the Global Action Plan proposed by the WHO in preventing and controlling Antimicrobial resistance is to improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Self-directed learning is a student oriented teaching learning method ideal for imparting lasting knowledge on topics of national and global importance such as antimicrobial resistance among medical students, which will help them develop an in-depth understanding of the topic and hence the aim of this study was to develop and implement a Self Directed Learning Module on Antimicrobial Resistance. Material and Methods: The study was conducted in the department of Microbiology with the Phase 2 medical students. Four self-directed learning sessions were developed and disseminated which included case scenarios, class assignments, obtaining antibiotic history from admitted patients, brain storming sessions, final assessment and feedback from students and faculty. Results: 62 out of 80 students gave their consent for the study. 72.6% students attended all the SDL sessions. 55 students gave their final assessments and feedback and all students scored above 50% marks. More than 70% of students said that the SDL aroused curiosity about the topic, while making it interesting, interactive and enjoyable. Conclusions: The self-directed learning module on antimicrobial resistance evoked interest and enthusiastic participation among the medical students. The discussions, assignments and the brainstorming sessions helped to deepen their knowledge on this emerging threat at the local, national and global levels.

Keywords: Antimicrobial resistance, Phase 2 medical students, self-directed learning

How to cite this article:
Varghese SR, Kwatra G. Development and implementation of a self-directed learning module on antimicrobial resistance for Phase 2 MBBS students. Indian J Pathol Microbiol 2023;66:129-34

How to cite this URL:
Varghese SR, Kwatra G. Development and implementation of a self-directed learning module on antimicrobial resistance for Phase 2 MBBS students. Indian J Pathol Microbiol [serial online] 2023 [cited 2023 Feb 2];66:129-34. Available from: https://www.ijpmonline.org/text.asp?2023/66/1/129/367966





   Introduction Top


Antimicrobial resistance (AMR) is rapidly becoming a global public health emergency mainly because of the emergence of untreatable bacterial infections due to their resistance to virtually all available antibiotic treatment options.[1] Stakeholders such as national and state governments, pharmaceutical giants, and animal breeders have recognized this impending catastrophe and are trying to put into place policies and practices to curb the threat of antibiotic resistance. But all these efforts may not make a lasting impact unless antibiotic usage practices and prescribing patterns change.

The World Health Organization has proposed a Global Action Plan to prevent and control AMR of which the first objective is to improve awareness and understanding of AMR through effective communication, education, and training.[2]

In the traditional Microbiology curriculum, little stress is laid upon the pressing issue of AMR, the various mechanisms of resistance, and strategies to prevent AMR. However, this education among the medical students in their formative years will translate into proper understanding and rational antimicrobial use in their own clinical practices and also drive in the impact that they, as budding doctors, can have in the society in bringing about change in the behavior, knowledge, and attitudes towards the rational use of antibiotics.[3]

Learning relevant to the health requirements of the community is the need of the hour for medical undergraduates.[4] Introduction of student-oriented teaching-learning methods can improve the students' perception of applied aspects of the subject and helps in increasing the learner's knowledge and in developing the art of critical thinking.[5]

Though some innovations in teaching Microbiology have been introduced in different colleges, more such active learning methods are required in order to enhance learning and encourage active participation in knowledge acquisition and practice.[6] So this study was designed with an aim to develop and implement a module on Anti-microbial resistance and encourage self-directed learning (SDL) among second-year MBBS students.


   Methodology Top


After due approval by the Institutional Research Committee and Ethics Committee, the study was conducted among Phase 2 MBBS students who had given informed consent for participation.

The SDL module on AMR was planned with the faculty and developed to include various activities over a period of 4 h including assessment and feedback. The topic was integrated with Pharmacology where the students were taught the basics of antimicrobial agents before the SDL session on AMR. The 4 hours of SDL were divided as follows:

SDL hour 1: Introduction with case-based learning, assignment, and activity

In the first SDL hour, the topic of AMR was introduced and the students were given an overview of the problems of indiscriminate antibiotic misuse and overuse. Two clinical scenarios [Annexure 1] highlighting the problem of AMR were presented. The students were given the assignment questions [Annexure 2] to research and answer after due guidance on appropriate educational resources.

The students were also asked to follow up on two in-patients in their clinical posting areas who were admitted with an infectious disease and note the details of the antibiotic history of the patient on the prescribed format [Annexure 3] which they submitted in the next SDL session.

SDL hour 2: Discussion and research

In the second SDL hour, the students were randomly asked to present their patient findings and the answers to the first assignment were also discussed. Then, a brief was given on the extent of the spread of AMR in our country and globally. The students were then presented with another set of related questions to research. [Table 1] and [Annexure 4] Again, the students were specially guided to go through the WHO guidelines and strategies for prevention of AMR. Also in the national context, they were prompted to research various national initiatives taken to combat AMR such as the Jaipur and Chennai declarations and present their findings in the next SDL session.
Table 1: Marking scheme used for the SDL session

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SDL hour 3: Seminar and brain storming

The students randomly presented their findings in the class in the form of a seminar. Then, hospital-level initiatives such as the need for antibiograms were discussed and the students were shown the current antibiogram of the hospital to highlight the prevalent resistance patterns among various commonly isolated bacteria present in the hospital. The importance of a Hospital Antibiotic Policy and Antibiotic Stewardship programs were also discussed.

The students were then divided into small groups and were asked to brainstorm and come up with innovative ideas to curb the menace of AMR.

SDL hour 4: Assessment and feedback

In this session, the peer-reviewed assessment questions [Annexure 5] and the feedback questionnaire were completed by the students. The department faculty also provided their feedback regarding feasibility of the module [Figure 1].
Figure 1: Final Assessment Performance at the end of the SDL session

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   Results and Data Analysis Top


The study was conducted during November–December 2019. A total of 62 out of 80 students gave their consent for the study. Only 45 out of 62 (72.6%) students attended all four SDL sessions. Fifty-six out of 62 (90.32%) students attended the first SDL session on AMR which was the introductory session and set the pace for the coming sessions.

The assignments were graded and assessment was evaluated and the feedback questionnaire of students and faculty were analyzed. The grading scheme followed for the marking of the assignments was as follows:

For the first SDL assignment, 23 out of 56 (41.07%) students obtained B+ grade followed by 17 out of 56 (30.35%) with B grade. Ten students (17.85%) received A grade and one student got the A+ grade. Three students got C grade and one each got C+ and D grades.

Fifty-seven out of 62 students (91.93%) visited any two patients who were admitted in the hospital ward to obtain their antibiotic histories and submitted their findings.

79% of the students attended the second SDL session and demonstrated a marked improvement in the answering pattern and 26/49 (53.06%) students obtained the B+ grade while 7/49 (34.69%) got B grade and 6 students (12.24%) received A grade.

In the third SDL hour, 55 students were present for the brainstorming session in small groups of five members each and came up with at least five innovative ideas to solve the problem of AMR [Figure 2] and [Figure 3].
Figure 2: Student feedback on the self-directed learning experience

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Figure 3: Faculty feedback on the self-directed learning experience

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In the fourth SDL hour, 55 students gave their final assessment and feedback. The assessments consisted of five questions of four marks each and were marked out of twenty. The marks ranged from six to fifteen.

Feedback form: A total of 55 students filled up the feedback forms. 71% (39/55) of students said that the SDL learning process was enjoyable and an equal number were of the opinion that the SDL helped in interactive learning. 75% (41/55) of students said that SDL made the topic interesting and an equal number said that this method of teaching aroused curiosity about the topic [Figure 2] and [Figure 3].

Some ideas that emerged from the brainstorming session are presented below:

National level/governmental initiatives

  • More governmental regulations and regulatory control on over the counter sale of antibiotics
  • Value-based pricing of antibiotics
  • Fund raising by government for further research
  • Proper vaccinations programs
  • Regulations/guidelines to prevent indiscriminate use of antibiotics in the agriculture industry and in animal husbandry.


Local level/hospital level initiatives:

  • Training for doctors
  • Proper surveillance systems
  • Implementation of strict infection control protocols
  • Formulate and implement strict antibiotic policies
  • Implement Prescription audits
  • Clinicians to educate patients about proper antibiotic usage practices
  • Spreading awareness among HCP's regarding the rise of resistance against antibiotics in particular area/community.


Community level initiatives:

  • Education and awareness campaigns among the public using various platforms such as social media, Instagram, Facebook.
  • Regular camps, workshops, CME's, and advertisements.
  • Conducting awareness marathons, street plays, events at public places to inform people regarding the ill-effects of AMR.
  • Use of organic farming methods
  • Awareness about indiscriminate antibiotic usage among domesticated animals,


Research needs:

  • More money dedicated towards research for newer antibiotics
  • More collaborations between labs and research facilities/organizations in the west.
  • Genetic engineering in gene mutation and gene silencing to make bacteria free from antibiotic resistance genes.
  • Bacteriophage therapy.



   Discussion Top


Raising awareness of proper antibiotic usage and antibiotic resistance is the first step in tackling the menace of resistance. Various studies have shown the lacunae in medical education in this area. Bharath Kumar V.D and Kalpana L assessed the knowledge of the usage of antibiotics and antibiotic resistance among first-year and second-year medical students and found the second-year medical students to be more aware of appropriate antibiotic usage and the ill-effects of indiscriminate usage of antibiotics but had no awareness about antibiotic resistance.[6]

In another study among undergraduate medical students in Gujarat, only one-fourth of the participants agreed that they received adequate information regarding antibiotic resistance and the study implicated the need for budding doctors to receive correct information regarding AMR.[7] Another study conducted in Senegal showed that 28% of the study population thought they did not receive enough information about bacterial resistance during consultation in health facilities for which continuing medical education among health care professionals was also recommended.[8] Our study was conducted among the ongoing batch of Phase 2 medical students of which only 62 students could be part of the study as it was the time for supplementary exams.

Only 72.6% of students actually attended all 4 SDL sessions. This is a matter of concern as the continuity is usually lost and this can lead to loss of motivation and lack of sensitivity to the grave reality of the problem of AMR. Garrison DR stresses that it is a challenge to integrate the cognitive-motivational and social dimensions of SDL in an educational setting and more such endeavors are needed for improving this aspect of learning in students.[9]

90.32% of students attended the first introductory SDL session which was encouraging as the extent of the problem of AMR was discussed and the presentation of the case scenarios gave the students a proper perspective on the real-life decisions and choices that doctors and people in general make regarding the use or misuse of antibiotic usage. Studies have found that case-based learning is an interactive student-centered exploration of real-life situations and is successfully used as a trigger to initiate learning.[10]

The students could attempt their first assignment fairly well considering that this was their first time that were studying a topic of great national and international significance as well as personal implications in an SDL format.

As a corollary to their class assignment, the visit to the wards to obtain the antibiotic history of two patients, was an eye opener to most students as it helped to obtain firsthand experience of the menace of AMR in their local settings. This activity also encouraged maximum interaction between the facilitator and the students and helped to clarify doubts and difficulties. Some students also visited the Microbiology lab to obtain the antibiotic susceptibility report and this was revelatory for them as they encountered first-hand the level of resistance among all the isolates that were tested.

The second SDL session had a lesser attendance, but among the students who attended there was a marked improvement in the answering pattern as they developed a better understanding of AMR and measures taken world-wide to combat this menace.

The third SDL hour had the interesting brain storming session where the students were divided into 11 groups of five members each. The students were motivated to think out of the box and came up with innovative strategies with a long lasting impact to curb AMR.

The assessment results showed that the students had obtained a fairly good view about the problem of AMR. The problem came in recollection of hard facts regarding mechanisms of resistance among bacteria and specific WHO strategies on control measures for preventing AMR. More importantly, students were able to understand the need for dissemination of information/knowledge about Antibiotic Resistance among the public, the need for doctors to exert restraint in prescribing antibiotics, the role of doctors in educating the public and the patients about the misuse of antibiotics and to ensure proper compliance of patients already on antibiotic therapy for various illnesses. The medical curriculum should include SDL experiences and time for independent study to allow the students to develop the skills of lifelong learning, and the new medical curriculum implemented from 2019 onwards is indeed a welcome initiative.[11] Also, as reiterated by Premkumar et al., SDL is essential to enable medical students to develop independent learning skills, increased responsibility, assertiveness and accountability which are key attributes to a medical professional's career.[12]

The feedback showed that students found the SDL experience interesting, enjoyable and aroused curiosity and created confidence in learning. Students also were of the opinion that SDL is a useful method for studying Microbiology and helped to study the topic better. These findings are similar to the findings of Devi S et al. where they found that SDL in certain topics in Microbiology had a more impressive outcome on the learners than the passive learning in didactic lectures.[13]

This exposure to the problem of AMR will have a lasting impact only if this learning is reiterated in the successive years of study. The understanding that the Phase 2 students received through this study should be continued even in the continuing years especially as they go for their clinical postings and the rural outreaches through their Community Medicine posting. Also, as elucidated by Ventola CL, the lack of new antibiotic development in the pipeline due to a variety of reasons leave us with little option but to judiciously preserve the existing antibiotics in circulation.[14]

This was an introductory attempt from the department of Microbiology to develop a SDL module on this important topic among the Phase 2 medical students. A limitation of the study that it could be done for only one batch of medical students.

Implications

Teaching medical students about the menace of AMR and instilling in them the importance of their role in curbing AMR while they are in their learning phase will have a great bearing on their own clinical practices in the future and cause them to inculcate judicious and prudent antibiotic usage practices.

Learner-centered educational innovations can indeed become an integral part of the Microbiology curriculum and enhance active learning as well as analytical and communication skills. It will also aid in the development of a research-oriented attitude and evoke higher order thinking skills among the students. Also the students will learn about their role as leaders and effective communicators who can use their position and authority as medical practitioners to influence society. This will also encourage innovative teaching strategies and inter-departmental collaborations.

Acknowledgement

Faculty of Advanced Course of Medical Education, Faculty of Microbiology department and Phase 2 students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Annexure 1: Case Scenarios for SDL on Antimicrobial Resistance: Top


Case 1:

A 16 year old boy is brought into see the doctor with complaints of fever, mild headache, malaise and sore throat. He generally has been feeling tired but is able to continue his normal routine after taking Paracetamol 8 hourly. The mother is worried as the boy has an important exam later that week and wants the doctor to prescribe antibiotics because she thinks that her son will recover faster. Is this recommended? Why/Why not?

Case 2:

A 26 year old healthy pregnant lady is scheduled to have her baby delivered by Caesarean section. She is given a dose of Cefazolin as pre-operative prophylaxis four hours before the operation starts. The baby is delivered successfully without any complications. After delivery, the obstetrician continues the patient on Cefazolin 1 gram every eight hours for three more days. Is this necessary? Why/Why not?


   Annexure 2: Assignment Questions for SDL Module 1: Top


  1. Why is Antimicrobial Resistance such a dilemma in the world today?
  2. Are bugs winning the battle against drugs and how?
  3. What are some of the implications of drug resistance in treatment and who should take the responsibility for the predicament that the world is facing?
  4. How would you as a budding doctor help in fighting this menace?



   Annexure 3: Antibiotic History Format Used in SDL Module 1: Top


Patient Unit Number: ____________________________________

Age/Sex: ______________________________________________

Chief Complaint of the patient: ____________________________

Culture Report: 1) ______________________________________

Culture Report: 2) ______________________________________

Antibiotic Susceptibility Report: ___________________________

Antibiotics used for treatment: _____________________________

Any change in antibiotic therapy following the culture report? ___________________________________________________________________________

Duration of antibiotic treatment: _________________________________


   Annexure 4: Assignment Questions for SDL Module 2: Top


  1. Is Antimicrobial Resistance (AMR) a major, potential catastrophic event in the world today?
  2. What is the extent of the problem of AMR in India and around the world?
  3. What are some measures taken worldwide to combat AMR?
  4. Who are the potential stake holders in addressing this issue?
  5. Do you think there is enough knowledge about AMR among the public?



   Annexure 5: Assessment Questions: Top


Q1) Name the various mechanisms of antibiotic resistance.

Q2) Name some measures taken worldwide to combat Antimicrobial Resistance

Q3) What are some specific measures that can be taken at the hospital level to curb Antimicrobial Resistance?

Q4) Is it necessary to educate the public about Antimicrobial resistance? Why?

Q5) Will following Strict Infection Control Practices and implementing good vaccination programs be helpful in curbing antimicrobial resistance? How?



 
   References Top

1.
Toner E, Adalja A, Gronvall GK, Cicero A, Inglesby TV. Antimicrobial resistance is a global health emergency. Health Secur 2015;13:153-5.  Back to cited text no. 1
    
2.
World Health Organization. Antimicrobial Resistance: Global action plan on antimicrobial resistance 2015. Available from: https://www.who.int.antimicrobial-resistance/global-action-plan/en/. [Last accessed on 2019 Nov 28].  Back to cited text no. 2
    
3.
Khan AK, Banu G, Reshma KK. Antibiotic resistance and usage of a survey on the knowledge, attitude, perceptions and practices among the medical students of a southern Indian teaching hospital. J Clin and Diagn Res 2013;7:1613-6.  Back to cited text no. 3
    
4.
Singh T, Gupta P, Singh D. Teaching and Learning and Taking a Lecture in Principles of Medical Education. 4th ed. Jaypee; New Delhi; 2013. p. 1-8 and 39-44.  Back to cited text no. 4
    
5.
Garg R, Singh VA. Introduction of case based learning in microbiology at undergraduate level. Nat J Lab Med 2018;7:M006-10.  Back to cited text no. 5
    
6.
Bharath Kumar VD, Kalpana L. A comparative study to assess the awareness of antibiotic resistance amongst first and second year medical undergraduate students in a medical college. Int J Basic Clin Pharmacol 2018;7:1567-71.  Back to cited text no. 6
    
7.
Brahmbhatt KR, Patel AB. Knowledge of antimicrobial resistance among undergraduate medical students in a medical college of Gujarat: Institution based cross sectional study. Int J Community Med Public Health 2018;5:754-8.  Back to cited text no. 7
    
8.
Bassoum O, Sougou NM, Diongue M, Lèye MMM, Mbodji M, Fall D, et al. Assessment of general public's knowledge and opinions towards antibiotic use and bacterial resistance: A cross-sectional study in an urban setting, Rufisque, Senegal. Pharmacy (Basel) 2018;6:103-9.  Back to cited text no. 8
    
9.
Garrison DR. Self-directed learning: Towards a comprehensive model. Adult Educ Q 1997;48:18-33.  Back to cited text no. 9
    
10.
Ciraj AM, Vinod P, Ramnarayan K. Enhancing active learning in Microbiology through case-based learning: Experiences from an Indian medical school. Ind J Pathol Microbiol 2010;53:729-32.  Back to cited text no. 10
    
11.
Hill M, Peters M, Salvaggio M, Vinnedge J, Darden A. Implementation and evaluation of a self-directed learning activity for first year medical students. Med Educ Online 2020;25:1717780.  Back to cited text no. 11
    
12.
Premkumar K, Vinod E, Satishkumar S, Pulimood AB, Umaefulam V, Prasanna Samuel P, et al. Self-directed learning readiness of Indian medical students: A mixed method study. BMC Med Edu 2018;18:134.  Back to cited text no. 12
    
13.
Devi S, Bhat KS, Ramya SR, Ravichandran K, Kanungo R. Self-directed learning to enhance active learning among the 2nd year undergraduate medical students in Microbiology: An experimental study. J Curr Res Sci Med 2016;2:80-3.  Back to cited text no. 13
  [Full text]  
14.
Ventola CL. The antibiotic resistance crisis: Part 1: Causes and threats. P T 2015;40:277-83.  Back to cited text no. 14
    

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Correspondence Address:
Shereen R Varghese
Department of Microbiology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpm.ijpm_600_21

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