Continuing professional education for general practitioners on chronic obstructive pulmonary disease: feasibility of a blended learning approach in Bangladesh

Uzzaman et al. BMC Family Practice (2020) 21:203 https://doi.org/10.1186/s12875-020-01270-2 RESEARCH ARTICLE Open Access Continuing professional education for general practitioners on chronic obstructive pulmonary disease: feasibility of a blended learning approach in Bangladesh Md. Nazim Uzzaman1,2, Tracy Jackson2, Aftab Uddin1, Neneh Rowa-Dewar3, Mohammod Jobayer Chisti1, G M Monsur Habib2,4, Hilary Pinnock2* and RESPIRE Collaborators Abstract Background: Continuing medical education (CME) is essential to developing and maintaining high quality primary care. Traditionally, CME is delivered face-to-face, but due to geographical distances, and pressure of work in Bangladesh, general practitioners (GPs) are unable to relocate for several days to attend training. Using chronic obstructive pulmonary disease (COPD) as an exemplar, we aimed to assess the feasibility of blended learning (combination of face-to-face and online) for GPs, and explore trainees’ and trainers’ perspectives towards the blended learning approach. Methods: We used a mixed-methods design. We trained 49 GPs in two groups via blended (n = 25) and traditional face-to-face approach (n = 24) and assessed their post-course knowledge and skills. The COPD Physician Practice Assessment Questionnaire (COPD-PPAQ) was administered before and one-month post-course. Verbatim transcriptions of focus group discussions with 18 course attendees and interviews with three course trainers were translated into English and analysed thematically. Results: Forty GPs completed the course (Blended: 19; Traditional: 21). The knowledge and skills post course, and the improvement in self-reported adherence to COPD guidelines was similar in both groups. Most participants preferred blended learning as it was more convenient than taking time out of their busy work life, and for many the online learning optimised the benefits of the subsequent face-to-face sessions. Suggested improvements included online interactivity with tutors, improved user friendliness of the e-learning platform, and timing face-to-face classes over weekends to avoid time-out of practice. Conclusions: Quality improvement requires a multifaceted approach, but adequate knowledge and skills are core components. Blended learning is feasible and, with a few caveats, is an acceptable option to GPs in Bangladesh. This is timely, given that online learning with limited face-to-face contact is likely to become the norm in the on-going COVID-19 pandemic. Keywords: Blended learning, COPD, GP, Post-graduate training, Primary care, Continuing medical education, Mixed-methods feasibility study * Correspondence: 2 NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Uzzaman et al. BMC Family Practice (2020) 21:203 Background Provision of postgraduate training in Family Medicine is increasing in Asia Pacific, but rarely uses innovative online learning [1] that could enhance access to continuing medical education (CME) essential for building and maintaining a high-quality primary care workforce [2]. Traditionally in Bangladesh, post-graduate training involves face-to-face study, but shortage of physicians in many rural and semi-urban areas [3], mean that physicians often cannot leave their practices to attend several days of training. Blended learning is a combination of face-to-face and online learning [4], which has become possible in Bangladesh with recent substantial improvements in internet coverage, and may be a useful way to achieve CME [5]. Chronic obstructive pulmonary disease (COPD) is an exemplar of a condition in which there are concerns that limited awareness of guideline recommendations amongst general practitioners (GPs) [6, 7] leads to misdiagnosis and inappropriate management [8, 9]. COPD affects an estimated 251 million people worldwide [10] and globally, is predicted to be the third leading cause of death by 2030 [11]. Although COPD burden varies between countries, almost 90% of COPD deaths occur in low- and middleincome countries (LMICs) [10]. The national COPD guideline [12] is not widely used in Bangladesh. Some clinicians follow global guidelines [13], however, substantial gaps exist between guideline recommendations and GPs’ practice. Closing this gap is a priority research need for the International Primary Care Respiratory Group (IPCRG) [14]. Blended learning was introduced initially in undergraduate teaching [15–18] and is now extending to postgraduate learning [19], though the concept is relatively new in Bangladesh [20]. An online component allows practitioners increased time and flexibility for study, wider and easier access to learning resources, and a higher level of autonomy in learning than in exclusively face-to-face courses [21, 22]. Management of COPD requires acquisition of practical skills (spirometry; inhaler technique) necessitating a face-to-face component. Therefore, we aimed to assess the feasibility of a blended learning approach to a COPD CME course for GPs in Bangladesh. Methods Study design Our mixed-methods feasibility study was conducted in June to August 2019. Quantitative data measured pre-post self-assessment of adherence to COPD guidelines and qualitative focus groups and interviews explored trainee and trainers’ perspectives of the blended learning. Page 2 of 10 Inclusion and exclusion criteria GPs providing public and private primary healthcare services in Bangladesh were invited to participate. GPs in Bangladesh have an MBBS (Bachelor of Medicine and Surgery) are registered by the Bangladesh Medical and Dental Council, have at least two years’ experience of clinical service but with no specialist post-graduate training. We excluded GPs who had previously participated in post-graduate COPD training at any time (...truncated)