Renovating medical education in a changing vietnam

CHAPTER 1 INTRODUCTION 1.1 Rationale and justification of the study Oral diseases, such as dental caries and periodontal diseases are most common chronic infectious diseases. Most caries and periodontal diseases are preventable, as recommended by resolution WHA 53.17 of the Fiftythird World Health Assembly in 2000 (1). However, the consequences of oral diseases are not only affected to oral cavity, but also to other systemic diseases such as diabetes, cardiovascular diseases, or respiratory diseases, preterm and low birth weight (2). There are several bacterial strains in normal flora of the oral cavity. Most of them are pathogens. Bacteria exist mainly inside the dental plaque and dental calculus and on the surface of soft tissue. Dental plaque was formed from mixture of food, saliva and other organic compounds inside oral cavity and it is the main cause of oral

MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION

IN A CHANGING VIETNAM

Luu Ngoc Hoat

MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION

IN A CHANGING VIETNAM

Luu Ngoc Hoat

ISBN: 978-604-66-0001-5

Front cover illustration:

Photograph of the main building of Hanoi Medical University, the institution that led the process of change in medical education in Vietnam, with the support of the Ministry of Health, Ministry of Education and Training and the Netherlands-financed project The building was completed in 2002 but in the style of the original university established 100 years earlier

VRIJE UNIVERSITEIT

MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION

IN A CHANGING VIETNAM

ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan

de Vrije Universiteit Amsterdam,

op gezag van de rector magnificus prof.dr L.M Bouter,

in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Aard- en Levenswetenschappen

op dinsdag 25 november 2008 om 10.45 uur

in de aula van de universiteit,

De Boelelaan 1105

door

Luu Ngoc Hoat

geboren te Nam Dinh, Vietnam

prof.dr G.J van der Wilt copromotoren: dr E.P Wright

dr J.E.W Broerse

“N ếu kế hoạch một thì quyết tâm phải mười và biện pháp phải hai mươi.”

“If the plan is one, the determination must be ten and the measure must be twenty.”

Ho Chi Minh The first President of Vietnam

• Prof.dr J.C.C Borleffs, University Medical Centre Groningen

• Prof.dr J.F.G Bunders, VU University Amsterdam

• Prof.dr F Scheele, VU University Amsterdam

• Prof.dr Truong Viet Dzung, Hanoi Medical University

TABLE OF CONTENT

Chapter 1: Introduction 1

1.1 Aim and purpose of the thesis 1

1.2 Theoretical Background 2

1.2.1 Medical education development 3

1.2.2 Management of change 5

1.3 Research design 17

1.3.1 Main objectives and research questions 18

1.3.2 Brief case description 19

1.3.3 Research methods 21

1.3.4 Research validity 25

1.3.5 Research team 27

1.4 Outline of the book 27

Chapter 2: The context for development of medical education in Vietnam 37

2.1 Health system in Vietnam 37

2.2 Human resources in the health system 40

2.3 Health indicators and changing disease patterns 44

2.3.1 Health indicators 44

2.3.2 Changes in disease patterns 46

2.4 Development of medical education in Vietnam and need for intervention 47 2.4.1 Colonial occupation by France (1886 – 1945) 48

2.4.2 Wars with France and America (1945 - 1975) 49

2.4.3 After the wars but before innovation (“Doi moi”) (1975 – 1985) 50

2.4.4 After innovation but before the intervention of a Dutch project for medical education (1986 – 1994) 50

Chapter 3: Medical education changes with support from an international project 55

3.1 Situation analysis at the beginning of the project 55

3.2 Main objectives, strategies and activities of the first phase of the project 59 3.3 Main objectives, strategies and activities of the second phase in comparison with the first phase of the project 67

3.4 Changes along the way: revision of plans on the basis of experience during

implementation 74

3.5 Limitations of the project in medical education development and efforts to overcome them 76

Chapter 4: Constraints, challenges and lessons learned of the first phase of the project 85

4.1 Obstacles to the introduction of change in the medical schools 85

4.1.1.Isolation of Vietnam and its medical schools until recent years 85

4.1.2 Lack of standards for medical doctors as end-points for medical training 86

4.1.3.Low status of public health in medical schools 86

4.1.4.Time constraints 87

4.2.Constraints and obstacles in project implementation 88

4.2.1.The understanding between the four medical schools and KIT 88

4.2.2.Misunderstandings after Workshop 1 on curriculum 90

4.2.3.Conceptual differences 91

4.2.4.Identification of indicators for project monitoring 91

4.2.5.Sustainability 93

4.3.Lessons learned 93

4.3.1.Language 94

4.3.2.Balance between motivation and sustainability 94

4.3.3.Time 95

4.3.4.Strengths and weaknesses of the schools 95

4.3.5.Future developments 96

Chapter 5: Participatory identification of learning objectives in eight medical schools in Vietnam 99

5.1 Introduction 99

5.2 Project aim 101

5.3 Methods to identify learning objectives (needed KAS) 101

5.4 Results of the steps in the process 102

5.4.1 Step 1: Inter-school workshop on KAS process 102

5.4.2 Step 2: Policy documents 103

5.4.3 Step 3: Formulation and selection of KAS topics 103

5.4.4 Step 4: Teaching staff contributions 105

5.4.5 Step 5: Achieving consensus 106

5.4.6 Step 6: Skills levels 106

5.4.7 Step 7: KAS survey 107

5.4.8 Step 8: Final KAS book 107

5.5 Difficulties with key concepts 107

5.5.1 Distinguishing among knowledge, attitudes and skills 107

5.5.2 Selecting the problems and issues for KAS lists 108

5.6 Coordination system 108

5.7 Discussion 109

5.8 Conclusion 111

Chapter 6: Practicing doctors’ perceptions on new learning objectives for Vietnamese medical schools 115

6.1 Background 115

6.2 Methods 117

6.2.1 Study design 117

6.2.2 Study participants 117

6.2.3 Data collection tools 117

6.2.4 Qualitative data 119

6.2.5 Data analysis 119

6.3 Results 119

6.3.1 Key characteristics of the study population 119

6.3.2 Relevance of skill levels set by teachers and perception of the practicing doctors 120

6.3.3 Frequency of using selected skills according to discipline 122

6.3.4 Appropriateness of skill levels set by teachers compared to frequency of use by practicing doctors 123

6.3.5 Priority of the selected skills as perceived by practicing doctors 125

6.3.6 Discrepancies between skill levels set by teachers and priority rating by practicing doctors 125

6.3.7 Focus group discussions 127

6.4 Discussion 129

6.5 Conclusions 131

Chapter 7: Perceptions of graduating students from eight medical schools in Vietnam on acquisition of key skills identified by teachers 135

7.1 Background 136

7.2 Methods 137

7.2.1 Study design 137

7.2.2 Study participants 138

7.2.3 Data collection tool 138

7.2.4 Data collection 139

7.2.5 Data analysis 140

7.3 Results 140

7.3.1 Students’ perception on whether they reached the level of skill listed in the KAS book 140

7.3.2 Students’ perception of skill achievement 141

7.3.3 Study sites for learning skills 146

7.4 Discussion 148

7.5 Conclusion 151

Chapter 8: Community - University Partnership: Key elements for improving field teaching in medical schools in Vietnam 155

8.1 Introduction 155

8.2 Methods 157

8.3 Results 158

8.3.1 Challenges for FT before intervention 158

8.3.2 Building a community-university partnership model 161

8.3.3 Main strategies and activities to improve FT in the eight schools .163

8.3.4 Intervention activities for field teaching 165

8.3.5 Results after interventions 165

8.3.6 Evaluation of intervention by different stakeholders 168

8.4 Discussion 169

8.5 Conclusion 172

Chapter 9: Motivation of university and non-university stakeholders to change medical education in Vietnam 179

9.1 Introduction 179

9.2 Methods 181

9.3 Results 182

9.3.1 Ministry representatives 184

9.3.2 Health service providers 185

9.3.3 Part-time teachers from hospitals and other institutions 185

9.3.4 Local FT preceptors 186

9.3.5 Community leaders and members 187

9.3.6 University stakeholders 188

9.4 Discussion 192

9.5 Conclusion 194

Chapter 10: Discussion and conclusions 197

10.1 Discussion 197

10.1.1 Medical education – why change it? 197

10.1.2 Medical education – change in which direction? 199

10.1.3 Research in medical education 206

10.2 Conclusions 208

Abbreviations 219

Summary 221

Samenvatting 225

Tóm tắt 229

Acknowledgements 234

List of Publications

Chapter 4: Hoat L N and Wright E P (2001) Constraints, challenges and lessons learned (In

TT Bach and D Burck (eds), Implementing community-oriented teaching in medical education - A case from Vietnam (pp 77-88) KIT Health, Bulletin 348, Amsterdam, ISBN: 90-6832-837-9.) (Reproduced with the permission of the publisher.)

Chapter 5: Hoat L N, Yen N B, and Wright E P (2007) Participatory identification of learning

objectives in eight medical schools in Vietnam; Medical Teacher 29 683-690 Chapter 6: Hoat L N, Dung D, V, and Wright E P (2007) Practicing doctors' perceptions on

new learning objectives for Vietnamese medical schools; BMC Medical Education 7 19

Chapter 7: Hoat L N, Son N M, and Wright E P (2008) Perceptions of graduating students

from eight medical schools in Vietnam on acquisition of key skills identified by teachers; BMC Medical Education 8 5

Chapter 8: Hoat LN, Wright EP: Community - University Partnership: Key elements for

improving field teaching in medical schools in Vietnam, accepted for publication

in Rural and Remote Health, September, 2008

Chapter 9: Hoat, LN, Viet, NL, van der Wilt, J.E.W, Broerse, J., Ruitenberg, E.J and Wright,

E.P Motivation of university and non-university stakeholders to change medical education in Vietnam, submitted for publication, October, 2008

CHAPTER 1 INTRODUCTION 1.1 Aim and purpose of the thesis

Medical education systems must be able to train doctors with qualities that satisfy the needs

of society for medical care (Dowton & Brown, 2004; Lewkonia, 2001; Peabody, 1999, Woollard, 2006) In consequence, when society changes, medical education has to change

as well (Boelen, 1999; Gibbons, 2006) To change medical education in relation to societal needs is not a straightforward process It demands commitment from the education and health policy makers as well as from the medical universities themselves To ensure that the process responds to the needs of the society, involvement of stakeholders outside the university is important, but often less convenient to organize and achieve In this thesis, the recent and successful process of change in medical education in Vietnam is dissected and analyzed to provide evidence about how to develop a community-oriented medical curriculum in eight medical schools in only a few years

Vietnam has changed rapidly over the past two decades; economic development and an open door policy have stimulated both economic growth and social change, and have brought Vietnam into a different phase of epidemiological transition The main diseases for large segments of the population are no longer the diseases of poverty, but increasingly diseases that are seen in wealthier societies (Ministry of Health, 2007) However, development is unequally distributed around the country, and the gap between rich and poor is increasing While health problems related to a more prosperous lifestyle, such as cardiovascular disease, diabetes and obesity, have started to appear more often among the wealthier and usually urban segment of the population, those in both urban and rural poor communities still commonly suffer from infectious diseases and malnutrition (World Bank et

al, 2001)

As social and policy changes brought about alterations in disease patterns and other health issues, medical education in the medical schools of Vietnam also needed to change Because making the needed changes was beyond the financial and technical capacity of the Vietnamese medical schools and ministries at that time, assistance was sought from external sources and found from the Netherlands’ Government The Dutch-supported project started its first phase late in 1993, and continued with a second phase for a total of 12 years, involving the eight main medical schools in Vietnam The first phase included a situation and organization analysis, resulting in the aim to integrate the topics of Primary Health Care and Epidemiology in the curriculum of four medical schools The second phase focused on strengthening the community orientation of the curriculum and the quality of teaching in all eight medical schools

In the second phase, the systematic process of change started with better-defined learning objectives, leading to a revised curriculum, appropriate teaching and learning materials and methods, and student assessment tools It was a long process that involved the

participation of many institutions and contributors from within and outside the medical schools Stakeholder involvement during the process was very important for the success and sustainability of the innovations supported by project interventions Even with external support, the project was a long and complex process that required moving and motivating thousands of teaching staff in eight schools around the country, bridging not only geographical distances, but also differences in ideas, experience and expectations Because

of this complexity, a number of strategies and approaches were applied at different times, in different situations, at different steps of the process

In this thesis, the complex and complicated process of change in the eight medical schools

is described and dissected The aim is to identify and to analyze the factors, actors and conditions that influenced the achievements and failures of this project in its efforts to change medical education in eight medical schools The results and lessons learned from the study provide evidence to support the Ministry of Health, the Ministry of Education and Training and the medical schools in Vietnam to continue with the successes and to overcome difficulties to continue the cycle of renovation in medical education The results are also made available for medical educationalists and scientists in other countries through published books and articles as well as this thesis

This chapter is the introduction to the thesis research It includes a brief description of the aims and purpose of the thesis, followed by the theoretical framework, presenting the theories, models and approaches that were used to facilitate the changes in medical education and to analyze the process of change, in the context of the project Next it describes the research design, mapping how the theories, models and approaches were applied in the two phases of the project, chapter by chapter, and the publications related to each set of results The chapter finishes with an outline of this book

1.2 Theoretical Background

The work described in this thesis grew from the context of medical education in Vietnam but was strongly influenced by changes taking place in medical education around the world As described in the first section below, the past decades have seen a great deal of innovation and experimentation in medical education, some of which was in response to social changes

in many countries The analysis of the process of change in this thesis made use of a number of models that were developed for management in the commercial sector but have been fruitfully applied to education as well The choices of models applied to help understand the process of change in the Vietnamese medical schools are explained in the second part of this section

“Trying to change the teaching in medical schools is harder than trying to move

a mountain!”

Remark made by a teacher in one medical school during an evaluation survey

1.2.1 Medical education development

Education in general, from primary through secondary to university education, has been undergoing a change in approaches to learning during the past few decades (Bush and West-Burnham, 1994; McNeil et al 2006, Guilbert, 2004) In Western countries this was partly in response to other social changes taking place at the same time (Prideaux 2007) Although those changes have not all necessarily been paralleled in Asia, many universities in Asia have taken up the lessons learned from the experience in other countries and have started to adapt their training programs as well (Amin et al, 2005; Cheng, 1991) The focus

on the learning by the student instead of the teaching by the teacher has also profited from the developments in technology and the increasing availability of information (Peer & Martin, 2005; Prideaux 2007)

If the graduates of medical schools are to meet the needs of the health system even as those needs change with the evolving economic and social situation, then the medical curriculum should focus on the desired outcome (Dowton, 2005; Harden 2002; Harden et

al., 1999; McNeil et al, 2006; Wellbery, 2006) Outcome-based education is focused on the capacity of the graduates, the products of the training process, more than on the training process itself This focus has been at the basis of many of the developments in medical education during recent years (Harden et al, 1999a and 1999b) Focusing on the expected capacity also demands reviewing and revising the process, including the curriculum contents and the materials and methods used in the teaching In several European countries, a set of learning objectives based on expected outcomes was developed by groups of experts, to guide the development of the curriculum and teaching in all medical schools in that country (Metz et al, 1991, 2001; Rubin & Franco-Schwarz, 2002; Simpson et al, 2002) As Hays (2007) described, graduates of different medical schools in different countries or even regions within one country may be expected to have different capacities, related to the demands of the local situation There have also been attempts to develop a basic standard curriculum that could be applied for medical education around the world (Core Committee, 2002; Schwartz & Wojtczak, 2002), with the idea that any doctor practicing anywhere would need at least a basic set of competencies that could be defined by international agreement These attempts, however, have not yet resulted in a consensus about the minimum requirements for medical education

Innovation in medical schools has often been proposed to take advantage of an opportunity such as establishment of a new medical school in a new region For example, in Malaysian medical schools, new approaches were seen in new medical schools, while existing schools were slow to take up the innovations (Azila et al, 2006) The innovative curricula were first developed according to professional expectations, while the movement towards community-orientation and student-centered learning gradually made them more responsive to internal and external factors that affected outcomes (Azila et al, 2006) In this process, dissemination of information and involvement of teachers in decision-making were keys to ensuring that they implemented the renovated teaching as planned (Azila, 2002)

Reform of medical education, like other change processes, is closely related to the existing organizations and the power structures in each country and context For example, Jippes and Majoor (2008) recently compared the power structures in different countries and the

success of introduction of problem-based learning among more than 100 medical schools in Europe It was clear that PBL was more successful where there was more openness to innovation In Vietnam, the process of change proceeded slowly and over several years, using lessons learned from the experience of other countries as described in reports and publications, as well as visits from experts and study visits But the process and the changes were adapted to fit the Vietnamese cultural context, in which the authority of the leaders is still highly regarded, at least in the traditional organizations such as state enterprises and universities (Nga, 2005; Quang & Vuong, 2002)

Changes in a university’s curriculum can be introduced either from the top – using the authority of the leaders to require participation by the staff – or through involvement of staff at all levels and other stakeholders – a more bottom-up approach (Prideaux, 2001; Stratton et al, 2007) The top-down approach was more common in earlier decades, and the bottom-up approach was introduced in the 80s Currently a mixture of the two is considered necessary, depending on the local situation and culture (Macdonald, 2003) The conflicting demands between the need to steer curriculum development and the advantages of a participatory approach require exploration of different strategies to find the balance that can work in each situation Stratton et al (2007) compared the management and monitoring of the educational process to the production of a complex product, because the education of a medical doctor also requires a series of processes that have to be structured, sequential and measurable

One feature of the complex process is the involvement of a wide range of stakeholders in

the process both of medical education and of medical education reform To be successful, the process should involve the different stakeholders within the school, including not only the managers and decision-makers, but also teachers and students (Genn, 2001; McLean, 2003) Wahlkvist et al (2006) were able to assess the effects of input from student feedback and found that descriptive, open-ended feedback both initiated and validated long-term development of the training

The curriculum reform can take any of several directions, and hybrid or mixed approaches are common One feature that is increasingly common is increased orientation to the needs

of the community, which often involves a period of time for the students to work in the

community, in one of a variety of approaches An early example of the community-oriented approach was at the Christian Medical College in Vellore, India, where many inexpensive strategies were developed to provide community experience for the students (Abraham & Abraham, 1993) Many other schools followed with increasing community orientation, especially – but not only – in developing countries (Mash and De Villiers, 1999; Mennin et al, 1996; Okasha, 1995; Sharma et al, 2007; Tamblyn et al, 2005) Wellbery (2006) reported that although a medical curriculum should be patient-centered as well as student-centered,

in fact in many cases what was taught in the schools was not quite relevant enough for what the students encountered during placements in real working situations

Another feature of the reform can focus on the methods and related materials used in the

teaching The range includes the classical lecture approach as well as a variety of more active and interactive approaches, including problem- or scenario-based learning (Schmidt, 1993) Problem-based learning (PBL) was pioneered and is still used at McMaster University

in Canada (Neufeld & Barrows, 1974); since then many medical schools around the world have used it, often blended with other approaches (Wood, 2003) In this strategy, students work together in small groups to collaborate on solving typical problems designed by the teachers, and to reflect on their experiences In PBL, learning is driven by presenting students with challenging, open-ended problems that they solve by reading and discussing

in their groups The role of the teacher becomes that of a facilitator, to support the learning

by the students The main advantage of PBL is reported to be the development of communication, problem-solving, and self-directed learning skills by the students, in addition to a deeper learning of the content (Koh et al, 2008; Schmidt et al, 1987) However, opinions about PBL and its effectiveness, compared to more traditional curricula, are not uniformly positive, and most medical schools have not adopted a ‘full’ PBL but have mixed it with other methods, including traditional lecturing (Gwee & Tan, 2001; Williams & Lau, 2005)

The need to ensure enough opportunity for practice of skills has led to the development of extra practical sessions using models and simulated patients in the ‘skills laboratories’ (Remmen et al, 2001) Especially in medical education, the opportunity for students to take the first steps in using a skill on a model instead of a real patient brings benefits both to the students and to the patients (Nielsen et al., 2003) Good use of the skills laboratory, however, requires a detailed plan for what actually needs to be learned there, as part of the overall learning objectives in the curriculum (Nikendei et al, 2005)

These experiences and results from many medical schools all over the world contributed a wealth of information that helped in the choices made for the directions of change in Vietnam Many of them, however, were going on at more or less the same time in other countries and in Vietnam, so that the lessons from other countries also often acted as confirmation of appropriate choices, rather than examples to be copied The achievements

of the curriculum change process in Vietnam were both a curriculum that is more appropriate to the needs of the community-oriented medical doctor and a system in which change can continue in a cycle of review and revision in response to changing needs

1.2.2 Management of change

The literature provides a number of models to describe organizations and how they go through a process of change Usually they have been applied to commercial enterprises, but examples of application to health systems and community development can also be found (Greenhalgh et al 2005; Ellis et al, 2005; Stratton et al, 2007) Stratton et al (2007) applied them to analyze a hybrid quality-assurance governance structure in Kentucky; they used the experience from industry to separate management from implementation of the process of teaching the medical students They also recommended a more management-oriented approach to ensure the maintenance of curriculum quality

In this thesis, the development of a more appropriate common medical curriculum and the aim to improve medical education for the eight main medical schools in Vietnam is followed and analyzed using different organizational models Introducing new ways of working in the universities is a process of change that can be compared to other change processes studied

by management researchers during the past decades Most of the models and tools

developed to follow changes and guide change processes have been developed for industry and agriculture, but they can also be applied to education, including medical education (Stratton et al, 2007; Sansom-Fisher & Lynagh, 2005)

Situation analysis

Change processes commonly start with an analysis of the present situation, and for that a heuristic model is useful to identify which features should be considered for intervention Many models and tools for conducting a situation analysis can be found in the literature (e.g 56 are described in ten Have et al., 2003) Lusthaus and Adrien (1998) reviewed management models that could be applied to management of organizations around the world, finding weak points in many of them, and ended by developing their own model This model was applied to assess the performance of non-governmental organizations; it focused

on performance However, it provides fewer opportunities to assess categories useful for the universities than some other models do, particularly the Integrated Organization Model (see below) and was not chosen for the analysis in this study

Another potentially relevant model was the SOSTAC, developed for marketing communications planning (Smith, 1990) that includes six basic elements for a Marketing Plan:

Situation: Where are we now?

Objectives: Where do we want to get to?

Strategy: How are we going to get there? – The Big Picture

Tactics: How are we going to get there? – The Detail

Actions: Who is going to do what and when?

Control: How can we control, measure and develop the process?

This model is useful for assessment and planning in a project planning cycle; although situation analysis is its first important step, the criteria to analyze the situation are not provided, so the model was less useful for our purposes

Some of these management models and concepts have also been applied to the management of education (O’Neill, 1994) However, few of them seemed appropriate in the context of both medical education and the culture in Vietnam A selection was made of four

in particular that seemed to fit in the context of this study: the IOM, the Rogers’ Diffusion of Innovation model, the Herzberg Theory of Motivation and the Johari Window These models and their application in this study are described in the following sections

features of an organization (Boonman, 1999) It takes into consideration both external and internal components, as well as their relationships to each other and to effectiveness, legitimacy, efficiency, flexibility, continuity and suitability, all of which affect the changes and interventions (see Figure 1-1)

This model was developed by Management for Development Foundation (MDF) in the Netherlands and has been applied in their Institutional Development and Organizational

Strengthening training courses to support change as part of development processes in all kinds of organizations in many countries, including Vietnam1 (see www.mdf.nl) The external components in this model consist of mission, inputs, outputs, factors and actors Factors here appear in the general environment (economic, political, natural, socio-cultural, technical factors) and actors are the specific entities in the environment (individuals or organizations that play roles as providers, target groups, donors, supporters, competitors or collaborators) The internal components are aspects inside an organization, such as strategy, system, structure, management style, personnel and culture (see Figure 1-1)

Figure 1-1: The Integrated Organization Model according to MDF

* Source: Training materials distributed by MDF in IOM training course, Hanoi 2004

The IOM model has been widely used as a diagnostic tool to select intervention strategies,

to plan a process of change and to assess the results of implementation, based on an understanding of the existing organization in its environment As part of the IOM, standard management tools, such as the environmental scan and the strengths, weaknesses, opportunities and threats (SWOT) analysis (ten Have, 2003) are applied to analyze the situation This model was selected for the situation analysis for medical education in Vietnam (details of the analysis are presented in Chapter 3)

Staff motivation

Organizational culture

Strategy Hardware (visible)

Diffusion of innovation

Change is brought about by implementing interventions As a result of interventions, change can spread through the organization or members of a network either actively, through planned dissemination activities, or more passively, by diffusion (Greenalgh et al, 2005) Diffusion even without activities to promote dissemination will occur when the new ideas have relevant characteristics that make them attractive to others in the organization or the community (Denis et al, 2002) These characteristics are discussed below, with reference to medical education in particular In the project, activities were also organized to promote diffusion of innovations that were introduced

The concept of ‘innovation’ in processes comes from business and agriculture, where it is defined simply as “something new to the people to whom it is being introduced” (Rogers, 2003) That means that an innovation that has been established for a long time in one context can

be new in another context and will have to undergo similar processes to become established there In the process of change in the Vietnamese medical schools, key innovations included the process of reviewing and renewing the curriculum to identify the knowledge, attitudes and skills (KAS) needed by medical graduates in Vietnam, necessarily followed by new methods of teaching and the related appropriate teaching and learning materials and assessment tools

Studies in management and social science have shown that the process of introduction and spreading of innovation through a system or organization follows similar dynamics and show similar features, even in quite different organizations (Rogers, 2003) The first point about innovation is that it has to start somewhere It usually comes from information acquired from new connections, insight gained from exploration of other disciplines or visits to other places, or from active, collegial networks But innovation can only enter when at least one door is open Innovation arises from exchange, when information is not just accumulated or stored, but also created and shared (Wheatley, 1992) In some way, such connections act as a ‘trigger’ for innovation The main triggers for innovation may vary for different types of organizations with different cultures To get innovation started, it is important to find the appropriate triggers for the specific context The context of a medical school may differ in some ways from the context of a commercial business or sports organization For the Vietnamese medical schools, the type of culture is most compatible with what Rogers called, ‘communal culture’ and the triggers he identified for that culture (teamwork, participation) and its characteristics (strong leadership, longer-term projects) are clearly related to the success of the process of change in Vietnamese medical schools (Rogers, 2003)

Once the process of innovation has started, the challenge is to maintain interest and support the gradual spreading of the innovation throughout the organization – in this case the network of eight medical schools and the two related Ministries The diffusion of innovation model emphasizes that the diffusion and change process is often gradual and that it depends on a number of key factors: (1) the characteristics of the innovation itself, (2) the social system in which the innovation is introduced, (3) the available channels of communication, and (4) the change agents who help to spread

the new idea Rogers used a curve in the shape of an ‘S’ to describe the process of cumulative adoption of an innovation (Rogers, 2003) The curve represents the small number of people who adopt the new approach early, followed over time by the majority until the innovation becomes commonly accepted, and finally another small number who lag behind in accepting the change (and may never accept it) Rogers also noted the existence

of a very important period in which a “critical mass” has to have accumulated before the uptake curve can start to rise steeply (Figure 1-2)

This relatively simple representation of a complex reality helps to visualize the process and therefore to influence it Besides the rate of change, other factors influence adoption rates (Rogers, 2003) For example, if another innovation is introduced when the adoption of the first one is in mid-curve, then that could change the diffusion pattern of both in a significant way When the innovation involves networks, as for several processes in the innovation pathway in the medical schools, they can interact and either reinforce or interfere with each other and correspondingly increase or slow the rate of adoption of innovations In the Vietnamese context, the network factor tended to increase the rate of change in the curriculum renovation process; the cultural emphasis on relationships and exchanges (originating with the family networks) promoted network strengthening (Quang & Trung, 2005)

Figure 1-2: Shape of curve of diffusion for an innovation over a period of time,

showing the point at which critical mass is achieved

* Source: Adapted from Rogers, 2005

Change in an organization is brought about by the actions of the members, the people working there Rogers classified the people responsible for the adoption and diffusion of change into five groups (Figure 1-3; Table 1-1)

Critical mass

Figure 1-3: Relationship between types of adopters classified by innovativeness

and location on the adoption curve

* Source: Rogers, 2003

A few people, who are innovators, either come up with or take up innovations, because they have an interest in trends but also because they have access to information resources (language, Internet, travel) These people – usually only about 2.5% of the group – are, however, not always well integrated with their peers in the local networks (Table 1-1, Rogers, 2003) and therefore not always able to ensure that their innovations are taken up

Are typically not closely integrated with peers in local networks

Well integrated and respected in local networks; similar to their peers in socioeconomic status and in other personal characteristics Effective opinion leaders emerge from this group Early majority

(34% of typical

group)

Contemplate their adoption of a new idea for a longer period of time than either of the first two groups

Not opinion leaders within their local networks

Not opinion leaders within their local networks

Laggards (16%

of typical

group)

Last among the local network to adopt

a new idea; peer pressure is always necessary

Usually isolated from the rest of their network

The next group to take up the innovation – the early adopters (about 13.5% of a typical group) – is essential, because they adopt new ideas that they choose carefully, but then pursue them enthusiastically These people are well integrated and respected and therefore important in the further diffusion of the innovation All other groups follow them The last group – the laggards – may not adopt the innovations at all, or only partly, at least during the time available in the project

Several examples of innovative practices in education can be appreciated through the insights of the diffusion of innovation model, such as the spread of problem-based learning (Sansom-Fisher and Lynagh, 2005) or the uptake of IT-based continuous education by practicing doctors (Harris et al., 2003) This model supports good curriculum planning, because it encourages reflection about which people should be involved in the interventions, and what results could be expected from their involvement It also suggests which skills are most needed by, and fit into, the interests of the different stakeholders: teachers, students, healthcare providers and the communities Based on the model, the best ways and routes to introduce new ideas and skills can be estimated, and which activities might best support learning and adoption, and which might best support the further diffusion of ideas and skills

The model also provides a structure to help investigate features of the system that can affect the diffusion of the change through it According to Rogers (2003), these features are:

Social system:

The spread of new ideas is influenced by the social system they are introduced to The social system of health and medical education is complex and includes representatives of many different professional groups They are also hierarchical; for example, clinical medicine tends to have more political power than does public health Therefore, if we want to change the medical curriculum, we need the collaboration of the clinical departments

If the promoters of change belong to the clinical departments, they may have more impact on the rate of diffusion of the proposed innovations

This means the modification of an innovation during the process of adopting it Rogers (2003) found that an innovation that can be more easily re-invented could diffuse more rapidly and sustainably In the context of medical education, many of the new ideas introduced by the project could easily be adapted to fit the situation in each school or class,

by the institutions and by individuals This concept has been used to explain why some new educational models could diffuse relatively rapidly in new universities and new countries, such as PBL (Sansom-Fisher & Lynagh, 2005)

Channels of communication:

For rapid diffusion, the information about the innovation, its methods and its advantages have to be communicated to the target groups Most of the new information in health is disseminated by professional journals and at seminars, workshops, conferences and meetings for each professional specialty In other countries, the choices are either to get the topic onto the agenda of meetings of all

specialties or to attract members from the specialties to meetings on medical education, both of which may be difficult In Vietnam, professional societies are limited

in size and mobility, so they might not be a main route to spread information on medical education However, examples of including medical education on the program

of national associations were seen, for example by the Associations for Parasitology and Traditional Medicine On the other hand, there are not yet any associations of medical education in Vietnam So a third route, using workshops and meetings to present and support the diffusion of the innovative approaches, methods and materials, was chosen Health specialists from different fields were invited to participate This was possible mainly because of the financial support of an international project and perhaps also the lack of competition from other kinds of specialist meeting

Change agents and channels of communication:

The model suggests that information and ideas are best transferred by people who are similar to those who will be introduced to the new ideas For example, people who consider themselves health educators may be the best agents to introduce new ideas

to teachers in the medical schools, but where these are not available in sufficient numbers, as in Vietnam, other medical specialists who are respected as teachers and leaders in their schools will be important to contribute to the change process

The importance of communication was evident from the results from a study looking at the process of curricular reform in eight medical schools in the USA (Dannefer et al, 1998) Using a four-stage model of change (recognizing the need for change, planning, implementing, and institutionalizing change), they showed that good communication was a decisive element in each stage They also felt that communication was often neglected in the planning of reform processes Lessons learned from another two American medical schools undergoing a process of change also emphasized the importance of communication, along with the involvement of all elements in the school in the change process (Bernier et

- PBL had a perceived relative advantage that justifies investments;

- PBL were compatible with existing values and needs;

- level of complexity of PBL was suitable (easy enough to understand and use);

- trialability of PBL is good, can be piloted even by individuals;

- PBL observability is good, easy to observe in practice

Not all of the innovations in the project in Vietnamese medical schools were as easy to demonstrate or to try as PBL But one advantage of the many products, such as teaching and learning materials, was to make the new approaches more visible and tangible to the teachers and students as well as the leaders in the schools and ministries

Diffusion of change clearly depends on a number of factors One that is especially important, according to Rogers (2003), is the role of the early adopters, especially when they include key opinion leaders, who contribute greatly to acceptance by others

It may seem obvious that the example provided by people whose opinions and actions are respected by others will lead to adoption of change by the others, but evidence is needed to evaluate the importance of their role, and to suggest how to involve them in the process At the same time, the importance of strengthening not only individual leaders and teachers, but also the organization as a whole, and its features, needs to be clear

Key features supporting educational innovation in the UK and the USA were identified (McKim, 2004; Spencer & Jorden, 2001; Susman & Pascoe, 2001) and found to include clear support from the leaders of the school as well as key opinion leaders The ability of the agents of change to fit the process to the institutional culture, and a pragmatic and flexible approach to change were also essential The basis for change should be an explicit statement of expected outcomes, which can inform selection of methods to ensure that the intended learning actually takes place and of tools to assess whether it has taken place This list is close to a description of the process followed in the project in this thesis, although not all of the steps were as successfully completed as could be desired

On the other hand, Dowton (2005) lamented the lack of attention to the need for good leadership in medical education, noting the many types of relationship that good leaders can maintain, with politicians, other educational institutions, health service providers and the university staff

Stakeholder involvement and motivation

To bring about change, not only the university staff, but also others who will be asked to contribute to medical education have to be motivated to become and to stay involved in the process, especially when it is a process of change that asks extra effort from them To facilitate changes, especially changes in a long-term and complicated process like medical education, motivation is a key issue Attention to motivation is important to get involvement and to maintain the contributions of all the different stakeholders in the process From the literature on motivation, we identified the following models that could assist in investigating motivation: Adams’ Equity Theory, Maslow’s Hierarchy of Needs and Herzberg’s Motivation Theory Each is briefly described below

This theory was introduced by Adams in 1963 (Huitt, 2004; Lindner, 1998) and is illustrated

in Figure 1-4 People will be motivated to do their job if what they get from the job is a fair reward for what they put in (in their view) Workers need to feel that there is a fair balance between inputs and outputs In this model, the fairness of the balance is measured by comparing the balance of one employee with the proportion observed for others who can act as a reference This model shares many features with the Herzberg model described below, but offers fewer aspects related to the process of change that was investigated in our study

Figure 1-4: Adams’ Equity Theory - Job motivation

* Source: Chapman, 2002, based on Adams, 1963

This theory was developed by Maslow in 1943 to explain how people satisfy their various personal needs in the context of their work He concluded, based on his observations as a humanistic psychologist, that there is a general pattern of needs recognition and satisfaction that applies to most people, generally in the same sequence A key feature is that according

to Maslow, a person cannot recognize or pursue the next higher need in the hierarchy until her/his currently recognized need has been substantially or completely satisfied Maslow's hierarchy of needs is shown in Figure 1-5 It is often illustrated as a pyramid with the survival need at the broad-based bottom and the self-actualization need at the narrow top (Gawel, 1997) This description of human needs is closely related to the model developed

by Herzberg that is presented below, but is less directly related to the analysis of motivation

in the workplace and to the process of change in the medical schools and was therefore less directly applicable to our analysis

Herzberg separated factors that influence workers into two groups: one called ‘hygiene’ (or

‘maintenance’) factors and the other called ‘motivation’ factors The roles and relationships

of these two types of factors in the motivation process are different, as illustrated in Figure 1-6 If an organization’s managers only pay attention to improving the hygiene factors, for example, they will create conditions that do not dissatisfy their staff, but will not motivate them to move ahead with a process of change (Herzberg, 2003; Gawel, 1997)

Outputs Inputs

Scales ‘calibrated’ and measured against comparable references in the market place

What I put into my job: time, effort,

ability, loyalty, tolerance, flexibility,

integrity, commitment, reliability, heart

and soul, personal sacrifice, etc

What I get from my job: pay, bonus,

perks, benefits, security, recognition, interest, development, reputation, praise, responsibility, enjoyment, etc

People become demotivated, reduce input and/or seek change/improvement whenever they feel their inputs are not being fairly

rewarded Fairness is based on perceived market norms

Figure 1-5: Maslow’s Hierarchy of Needs

* Source: Chapman, 2001

Figure 1-6: Roles of Hygiene and Motivation Factors according to Herzberg

* Source: Adapted from www.valuebasedmanagement.net/methods_herzberg_two_factor_theory.html

Considering these three motivation models, we found that the Adams and Maslow models focused more on individuals and their life situations, and less on their interaction in the workplace Herzberg’s Motivation Theory was therefore more appropriate for our analysis,

Esteem needs

achievement, status, responsibility, reputation

Self-actualization

personal growth and fulfilment

Belongingness and Love needs

family, affection, relationships, work group, etc

Safety needs

protection, security, order, law, limits, stability, etc

Biological and Physiological needs

basic life needs - air, food, drink, shelter, warmth, sex, sleep, etc

Stakeholders

satisfied and motivated

5 Policy & administration

6 Relationships (with supervisors,

subordinates and peers)

7 Personal life

Motivation factors

1 Achievement

2 Recognition for achievement

3 Interest in the job

4 Responsibility for tasks

5 Advancement to higher level tasks

6 Personal growth

because the process of change in the medical schools demanded that stakeholders, both inside and outside the organization, make efforts to deliver a higher performance

Capacity building and behavior changes

The project aimed to support the renovation of medical education in Vietnam, to change it from its orientation to the high-level hospitals and hospital-based teaching to more community-oriented and community-based teaching, with the involvement of many stakeholders at different levels and institutions It was essential to focus on both capacity building and behavior change, not only of individuals but also of the teaching institutions involved in the project

The project started with identifying the knowledge, attitudes and skills (KAS) that students were expected to learn during their six years of study (that is, the learning objectives) To

do that, nearly 1,000 teachers from all eight medical schools participated in identifying the topics and then the KAS and K and S levels for each topic The involvement of other stakeholders was based on the Johari Window Model (Handy, 1990) This is a communication model that is used to improve understanding between individuals within a team or in a group Based on disclosure, self-disclosure and feedback, the Johari Window can also be used to improve a group's relationship with other groups, and in our case, to put together a more comprehensive and hopefully more accurate picture of the needed KAS

To develop the KAS book, the senior teaching staffs in the eight main medical schools were requested to propose topics in the form of problems that they thought new graduates should be able to solve or to address in the right way Then they prepared lists of the knowledge, attitudes and skills that would be needed to address those issues, with attention

to the level at which newly-graduated doctors would be working That meant a more community-oriented approach to both problem selection/description and the possible skills

to be used in addressing them The last step was to decide at what level of proficiency those skills should have been acquired by the time the students graduate and leave the school for practice (see Chapter 5 for a detailed description of this process)

But teachers might not be familiar enough with the real health care needs and conditions in the places where the students will work after graduating They might not understand well enough whether the teaching conditions in their schools are appropriate to teach students

up to the expected skill levels As the Johari Window shows, they might need better views

of the windows closed to them, to enlarge their open area in parallel with the reduction of their blind area (Figure 1-7) To get a look in the other windows meant getting feedback from other stakeholders, to adjust the KAS descriptions and skill levels By improving the teachers’ awareness and knowledge about community-oriented teaching, and by providing them opportunities to join community research, field teaching activities and exposure visits

to community health projects, they had disclosure and self-disclosure to reduce their hidden and unknown areas and to enlarge their open area at the same time

Using the Johari Window model, the project could identify first the fact that the teachers did not know all of what they should know, that they did have blind areas, and then start to identify what should be in those blind areas, to increase the open areas and improve the capacity of the teachers to plan and implement the new curriculum This was made clear by

the discrepancies between the teachers’ ideas for the KAS and those of the practicing graduates (Chapter 6) or of the students about to graduate (Chapter 7), as well as the opinions of the stakeholders outside the universities (Chapters 8 and 9)

Figure 1-7: Concepts and Approaches in Johari Window Model

* Source: Adapted from www.mindtools.com/CommSkll/JohariWindow.htm

1.3 Research design

This thesis focuses on the changes that took place in medical education in Vietnam, during a period of 12 years, with support from a project funded by the Netherlands Government The project was not a research but an implementation project However, the researchers monitoring and reflecting on the change process were also involved in developing project proposals and managing this long-term project as project coordinators and senior technical advisers This dual role brought advantages for designing and implementing the research, because the researchers understood the project well, had access to project documents, and participated in planning, organizing and implementing the project activities, especially surveys, research among stakeholders and inter-school supervisions and assessments However, this dual role can also bring bias, such as subjective assessment of findings and results from the research about the project This bias was addressed in the research methodology

# 1: Open area # 3 Hidden area

# 2: Blind area # 4: Unknown area

Unknown by Others

Known by Others

- Quadrant 1: Open or Public Area: What is known by the person about him/herself and is also known

by others

- Quadrant 2: Blind Area, or "Blind Spot": What is unknown by the person about him/herself but

which others know

- Quadrant 3: Hidden or Secrete Area: What the person knows about him/herself that others do not

- Quadrant 4: Unknown Area: What is unknown by the person about him/herself and is also unknown

by others

This research is a case study evaluation, analyzing the achievements and failures of the medical education project This approach is valuable where broad, complex questionsare addressed in complex circumstances and no one methodis sufficient to capture all relevant aspects of a project; case studies typically use several methods (Keen & Packwood, 1995)

1.3.1 Main objectives and research questions

The general objective of the study is to identify and analyze factors, actors and conditions that influenced the achievements and failures of a long-term process to change medical education in eight medical schools of Vietnam, with the support of a project from The Netherlands, in the context of other concurrent changes in Vietnam

The specific objectives are:

1 To identify and analyze factors and conditions related to organizational changes in changing medical education with project support, using appropriate theories and models;

2 To identify and analyze the ways that different stakeholders were involved and their contributions to better and more community-oriented learning objectives for students in medical schools in Vietnam;

3 To identify factors that motivated stakeholders (both university and non-university) to participate actively in the medical education renovation activities supported by the project, based on motivation theory and other theories;

4 To identify the features of the project that contributed to the success and sustainability

of the process of changing medical education in Vietnam

The central research question of this thesis research is:

What are the conditions, required inputs and activities for a project to make sustainable contributions to updating medical education in the context of the changing economic and social situation in Vietnam?

This central question is divided into the following sub-questions:

1 What are the factors, related to organizational change, that need to be taken into account when changing medical education in Vietnam?

2 To what extent can a participatory and community-university approach be applied to develop more appropriate learning objectives for students in Vietnamese medical schools, as a framework for development of curriculum, teaching methods/materials and assessment tools?

3 To what extent can a range of stakeholders be involved in making medical education more appropriate for the tasks of graduates and the needs of society?

4 What features of the project contributed to the success and sustainability of the change process in medical education?

1.3.2 Brief case description

Under the pressure of changes in policy, economics and society of Vietnam, a need to change medical education was recognized and a project was formulated to support that process The process started in 1994 with a first situation analysis, followed by an intervention period that was implemented in two phases The first phase lasted from 1994

to 1999 and the second phase covered the period 2000-2006

In the situation analysis, using the IOM, the changing disease patterns and health care needs, the history and trends of medical education development inside and outside Vietnam, and the existing capacity of schools and teachers were identified

The first phase mainly focused on the integration of primary health care (PHC) and epidemiology (EPI) into the existing curriculum and teaching/learning materials in four medical schools (Hanoi, Hue, Ho Chi Minh City and Cantho) At the same time, a start was made in developing a more systematic and student-centered way of teaching in these schools and in making the training in medical schools more community-oriented according

to the requirements of national policy Several groups of intervention activities were selected with the participation of different stakeholders to make sure the project objectives were achieved

The second phase was developed with consideration for both the lessons learned in the first phase and the more recent changes in the social and economic situation The four medical schools involved in the first phase were joined by four more schools: Thainguyen, Thaibinh, Haiphong and Taynguyen The main strategy of the second phase was to continue and to maximize the quality and effectiveness of the outputs and outcomes of the first phase, to promote collaboration among the schools and to ensure that a range of stakeholders could contribute to the process of change The interventions in this phase were more comprehensive, following almost the whole cycle of medical education reform, starting with changing the learning objectives and curriculum and ending with student evaluation To have more community-oriented medical education in the second phase, the project supported the involvement of many stakeholders that had not been included in the first phase, especially non-university stakeholders

The second phase resulted in many successes; many of the lessons learned have already been applied to the development of other interventions and projects during and after the second phase Also several limitations and gaps were identified, issues that the project could not cover or new needs that arose during project implementation Links were therefore created with other medical education projects and additional projects were developed to help fill the identified gaps

The last step in the renovation cycle, the final evaluation of the impact, must wait until the graduates of the renovated curriculum are out of the school and into their medical practice Figure 1-8 summarizes the main intervention activities of the project and the involvement of different stakeholders during the two project phases

Figure 1-8: Case study: project involvement and interventions

• Building capacity of teachers on application of PHC and Epi

• Integrating PHC and Epi in teaching, learning materials

• Applying developed materials using active methods

• Assessing students using objective tools

• Exchanging TLM products among four medical schools

• Identifying learning objectives (KAS

book)

• Renovating the curriculum

Social, economical, political factors affecting heath

The second phase: Strengthening of community-oriented teaching in eight medical

schools (four old and four newly involved medical schools)

The first phase of the project: Primary health care (PHC) & epidemiology (Epi) integration

in existing teaching of four medical schools

Results, achievements and lessons learned from the first phase

Changing disease pattern and health care

needs of society Medical education development and capacity inside medical schools

Results, achievements and lessons learned of the second phase led

to development and sustainability after the project

Financial support of the project

Vietnamese technical adviser Health staff from

• Assessing student using objective tools

• Exchanging TLM products among eight medical schools

Activities introduced and stakeholders involved only in the second phase

* Note:

- MoH: Ministry of Health, MoET: Ministry of Education and Training

- TLM: teaching, learning materials; KAS: knowledge, attitude and skills

- COE: community-oriented education; CBE: community-based education

1.3.3 Research methods

This thesis describes the results of a number of studies and analytical processes that were carried out during and after the project support for the renovation of medical education in the eight schools A wide range of methods was applied to collect the many different kinds

of data from highly varied sources; these methods are described below

Research methods

In this research, case study evaluation methods were used to analyze and evaluate how the two-phase project supported and contributed to a process of change in medical education in Vietnam during 12 years, in the context of the rapid economic and social change in the country The data collection methods included comprehensive desk studies (literature review and analysis of different types of documents) and surveys (using structured and semi-structured questionnaires, structured, semi-structured and open interviews, focus group discussions, and in-depth interviews with key informants) In addition, participant observation (including direct observation, formal and informal dialogues and meetings) was

an important data collection method Each of these methods is described below

project proposal development to ensure that the project design took into consideration the local situation, social environment and political background, so that the project objectives, strategies and activities were suitable and feasible The situation and organization analysis could also help the researchers to explain some of the successes and failures of the project This method included reviewing relevant government policy and regulatory documents and other relevant local reports To analyze the factors in the successes and failures of the work during the project period, the large collection of project documents, including reports from the schools and the project activities, and the products developed by the schools, provided

a wealth of information

Through literature review, information was collected for analyzing the local situation, social environment and political background (the situation and organization analysis) It also served to find international references about the trends in medical education development

as well as models, theories, and approaches in that field and in the fields of management of change, stakeholder involvement and motivation, that the researchers could apply as tools

to evaluate the case study Because the project continued over more than a decade, and not all the tools were available or known to the researchers from the beginning of the project, the research was partly retrospective That means that the selection of tools was also influenced by the availability of data from the earlier years, and that some interesting questions could not be answered by the retrospective analysis

research for two different purposes On the one hand, questionnaires were used as part of the project, to collect data from different stakeholders on the project products (such as the KAS book), as part of project implementation The results of these questionnaires were also used by the researchers to evaluate the case On the other hand, the research team also designed questionnaires for data collection from different stakeholders to provide more information to complete the evaluation, such as the questionnaires to get feedback from

students on learning environment and from students, local people, authorities and health staff about field teaching programs Details about each of these tools are provided in the separate chapters in the thesis describing the studies in which they were used

main researcher and the writer of this book was also the coordinator of the project for several years (from 1996-2000) and later was the national technical adviser (2001-2006) This cross-position facilitated his understanding about the project and his access to project documentation In addition, he has an appropriate background, with a degree in medicine followed by a two-year master course abroad on epidemiology and more than 10 years experience in teaching biostatistics, epidemiology and research methods in Hanoi Medical University (HMU) He also benefited from management training on several occasions through collaboration with the Royal Tropical Institute in Amsterdam and others That meant that he could bring a strong basis of scientific knowledge, management theories and models, and research methods to the design of the project proposals and the surveys, to provide good information not only for the project, but also for the research In this case, the participant observation consisted of a range of methods such as informal dialogues, direct observation, participation in the project activities, departmental and group discussions, self-analysis, and life-histories of medical education and the medical schools

The large diversity in data collection methods, including both qualitative and quantitative methods, and the large numbers of people involved in the project activities and studies allowed for triangulation, which enhanced the validity of the research (see below)

Research methods applied for each research question

The study included four research sub-questions, each needing different research methods

For the first sub-question: What are the factors related to organizational change that need to be taken into account when changing medical education?, the main data collection methods were document analysis and literature review to select appropriate theories

or models that could help the researchers to integrate as many relevant factors and actors inside and outside medical schools as possible in the analysis The IOM (Boonman, 1999) was used to analyze the situation and organizations, as presented in detail in Chapter 3 The constraints, challenges and lessons learned from a review of the products and results of the first phase of the project are presented in Chapter 4

For the second sub-question: To what extent can a participatory and university approach be applied to develop more appropriate learning objectives for students

community-in Vietnamese medical schools, as a framework for development of curriculum, teachcommunity-ing methods/materials and assessment tools? the data mostly came from activities and surveys

that the project designed to get contributions from different stakeholders to the develop learning objectives (KAS book) The first contribution came from nearly 1,000 teaching staff, department heads and school leaders in the eight medical schools, as well as the MoH, MoET representatives, all of whom participated in the process to identify the KAS topics and contents Participant observation methods as well as review of documents were used

to collect data for many of the results presented in Chapter 5 (Hoat, et al., 2007b) After the KAS book was drafted by the teachers, two extensive surveys were conducted to get

feedback from a range of relevant stakeholders on that proposed KAS The first survey included nearly 800 recently graduated doctors practicing in the field (Chapter 6; Hoat et al.,

2007a) and nearly 300 other stakeholders such as doctor’s employers, local health staff and authorities, patients and relatives (Chapter 9) The second survey included more than 1,100 sixth-year students from eight schools (Chapter 7; Hoat et al., 2008) Both quantitative and qualitative methods were used to collect data in these two surveys, including structured questionnaires, in-depth interviews and FGD

To answer the third and fourth questions: “To what extent can a range of stakeholders

be involved in making medical education more appropriate for the tasks of graduates and the needs of society?” and “What features of the project contributed to the success and

sustainability of the change process in medical education?”, a desk study was used to select models and theories to explain the motivation strategies of the project The best fit

was found to be with the Diffusion of Innovation Model (Rogers, 1995), Motivation

Theory of Herzberg (Herzberg, 2003) and Johari Window Model (Handy, 1990), which

were used to analyze how the project succeeded in involving different stakeholders in a long and complicated process to identify the learning objectives and improve the curriculum The researchers also conducted several surveys among students, local health staff involved in teaching students in the field, and community people, using semi-structured questionnaires, FGD and informal interviews, and used data from participant observation to get more information to have a complete evaluation of the case study (Chapters 8 and 9) More details on the different research methods are provided in the following chapters

Other models and approaches selected to analyze the case study

Apart from the above mentioned theories and models, the literature review also suggested other concepts relevant to the strategies and interventions of the project As presented in Chapter 2 (The context for development of medical education in Vietnam) and Chapter 8 (Model of community-university partnership), in the early 90s Vietnam had just started to come out of the isolation imposed by the US embargo At that time, the capacities

of teaching staff in medical schools in Vietnam were still insufficient to develop, manage and

provide technical inputs for big projects Therefore, the North-South collaboration

approach that the project selected in this first phase was an appropriate strategy for the

intervention at that time Dutch experts came to assist the medical schools in Vietnam to design the project and to draft the project proposal, with contributions from Vietnamese experts When the project was approved for funding by the Directorate General for International Cooperation in the Netherlands, the Royal Tropical Institute (KIT) was designated the institutional manager for both technical and financial aspects of that first phase (see Figure 3-3) In that phase, most of the expert inputs also came from the Netherlands; only about 60% of the total project budget was for Vietnam Another strategy

of the project in the first phase was to focus mainly on individual capacity building to

create the “critical mass” needed to support the innovation, according to the Diffusion of Innovation Model (Rogers, 2003) The project managers tried to recruit and train appropriate project team members who belonged to either the group of “innovators” or even better, to the “early adopters” for the interventions Later on, these groups would encourage other stakeholders to become involved

Stakeholder involvement and especially the active participation of teaching staff in

the four medical schools were also important, since teaching staff had to improve their

capacity as well as change behavior to adopt the new ideas from the project, such as

integration of PHC and epidemiology, active teaching methods and objective student assessment methods

To maximize the use of the project products (mainly teaching/learning materials and

student assessment tools), another strategy was applied, that is, exchange among the

related departments in the four medical schools, so that they could use and learn from the products from other schools, to enrich especially their Vietnamese reference materials During the second phase, the project continued to apply the models and strategies of the first phase where they were still appropriate, such as the Diffusion of Innovation Model, individual capacity building, stakeholder participation, behavior change and exchange among medical schools, but new approaches were also introduced, such as Johari Window and Herzberg’s Motivation Theory Examples of new approaches applied included:

South-South collaboration: One of the important strategies and expected outcomes of

the first phase was to maximize effectiveness of inputs from the Northern partners to improve capacities of the Southern partners, so that at the end they could perform better and be able to help each other During the second phase, when the project was expanded into four younger, smaller and less experienced medical schools, many of the Vietnamese teachers from the four older and bigger medical schools involved in the first phase could serve as experts or resource persons for project activities in their schools or other schools, especially for the new partners A few international consultants were invited for special topics, but they were usually recruited from the countries in the region The model of the collaboration had shifted from North-South collaboration in the first phase to more South-South collaboration in the second phase This had enormous consequences for the budget –

in the second phase, the budget allocated to payment of international consultants was approximately 10%, half of which went to an international Senior Technical Adviser who contributed inputs amounting to 4–8 weeks per year throughout the project period This approach was highly appreciated by Vietnamese partners, because it meant that a much greater proportion of the funds was available for the activities in Vietnam, and because the strong involvement of local human resources contributed to the sustainability of the project outcomes The resulting strengthening of local networks within Vietnam and in the region contributed to institutional capacity building, as described in the next section

Capacity building not only for individuals, but also organizations and institutions:

From the literature review and the local experience, it was understood that changing medical education is not easy Some may have felt that changing a medical curriculum would be more difficult than moving a mountain (as stated by one of the project participants during an evaluation interview) But when a society changes, the medical education should change along with it, to provide better health staff to serve the evolving needs of communities, as described above From this understanding, in the second phase the project tried to pay attention to building both individual and organizational capacity to change medical education One strategy was to establish and strengthen a network among the eight medical schools, so that when the project ended the schools could still continue using the capacities and experiences they shared while participating in the project This