Abstract
Objectives:
Problem-based learning (PBL) is a well-known student-centered instructional approach that is known to enhance problem-solving skills among the learners. Because teaching/learning methods in most of the Ayurveda colleges in India are still didactic and teacher centric, the effects of introducing PBL have not yet been evaluated. The primary objective of this study was to develop PBL modules for Kriya Sharira (Ayurveda Physiology) and their implementation in a hybrid format. In this method, PBL is used as an add-on component along with didactic lectures. The secondary objective of the study was to compare the learning outcomes achieved through hybrid problem-based learning (HPBL) with those achieved through conventional teaching.
Design:
This is a prospectively planned post-test-only, controlled interventional design with nonequivalent groups. However, the results have been analyzed in a retrospective manner.
Subjects:
Students enrolled in the first professional Bachelor of Ayurvedic Medicine and Surgery program during two consecutive academic sessions 2016–2017 and 2017–2018 at the Banaras Hindu University were included in the study. While the cohort from 2016 to 2017 session served as the control group, the one from 2017 to 2018 session served as the experimental group.
Interventions:
The instructional method commonly known as HPBL was introduced to the experimental group.
Outcome measures:
Five test papers containing mostly Multiple Choice Questions for five different topics were used as the tools for evaluating the learning outcomes in both the groups. Feedback forms regarding the experiences of undergoing HPBL were obtained from experimental group.
Results:
While the test results for three topics showed that the outcomes of HPBL were comparable with conventional teaching, the results on other two topics suggested that HPBL was slightly better. Feedback obtained showed that there is a considerable acceptance for HPBL over conventional method.
Conclusions:
The study shows that it is possible to implement HPBL method in a large classroom in the context of Ayurveda education. The findings also indicate that students find HPBL as an acceptable teaching method.
Introduction
Ayurveda is one of the ancient traditional systems of health care that is native to Indian subcontinent. The government of India officially recognizes Ayurveda as an independent system of health care and is being governed by the Ministry of AYUSH. AYUSH is an acronym that stands for Ayurveda, Yoga, Unani, Siddha, Homoeopathy, and Sowa-Rigpa. The Central Council of Indian Medicine (CCIM) established under an Act of Indian parliament is responsible for creating and maintaining the standards of Ayurvedic education. All Ayurvedic educational institutions are accredited by CCIM. At present there are >250 colleges that are recognized by CCIM and are conducting a graduate-level program leading to a degree of Bachelor of Ayurvedic Medicine and Surgery (BAMS). This graduate program is 5.5 years long with 4.5 years of didactic education followed by a year of compulsory internship. 1
A major problem that ails the system of Ayurveda education is that its graduate-level program does not give sufficient training in basic clinical skills and problem-solving skills, often leading to Ayurveda physicians becoming diffident in practicing and prescribing Ayurveda. This is mainly because the BAMS curriculum focuses more on theoretical principles than on their application. 2 Most of the colleges and their affiliated hospitals either do not have good patient inflow or get only a few specific types of patients and hence students do not get exposure to a variety of cases. This situation, coupled with a lack of innovation in teaching/learning methods has led to a monotonous learning experience that encourages rote learning. 3 The current teaching environment mostly lacks any formal exercise that inculcates curiosity and induces excitement of being an active learner. A recent critical review of “complementary medicine education research” has highlighted the evident lacunae in the published peer-reviewed literature in this domain. 4 As far as the research scenario of Ayurveda education is concerned, only a few good studies have been published in the recent past evaluating the effectiveness of newer educational experiments. 5 This observation is important considering the fact that most of the medical educators now recommend competency-based medical education. 5,6
It may be noted that, in the first year of BAMS curriculum, many topics from contemporary physiology have been placed in parallel to Ayurveda Kriya Sharira without emphasizing on their possible integration with each other, and thus, ultimately leading to a cognitive dissonance among learners. 3 In this context, the problem-based learning (PBL) assumes its importance as this happens to be one of the popular methods of introducing students to problem-solving skills. Furthermore, an advantage with this method is that it integrates knowledge across different disciplines and subjects. 7
Objectives of the study
To develop PBL modules and their implementation in Kriya Sharira (Ayurveda Physiology) at the graduate level of Ayurveda education in a hybrid format following the previous studies published in other disciplines. 8,9
To compare the learning outcomes achieved through hybrid problem-based learning (HPBL) with those achieved through conventional teaching, indicated by the term “lecture-based learning” (LBL).
Materials and Methods
An approval from the Institutional Ethics Committee was obtained before starting with the experiment (Dean/2016-17/EC/769 dated March 31, 2017).
Study design
This is a prospectively planned post-test-only, controlled interventional design with nonequivalent groups. However, the results have been analyzed in a retrospective manner. Intervention was in the form of teaching and learning method called HPBL, wherein PBL is introduced in addition to conventional LBL. While the control group received instructions through conventional didactic teacher-centric LBL, the experimental group received instructions through HPBL method on five different topics. Learning outcomes were assessed at the end of each topic through the written test papers consisting of mostly multiple choice questions (MCQs). A structured student feedback was also obtained after the completion of all the modules to evaluate student perception about the usefulness of HPBL.
Population
Population for the present study was defined in terms of the students who were enrolled in the first professional BAMS program conducted in our institution for the academic years 2016–2017 and 2017–2018 (henceforth denoted as “2017 batch” and “2018 batch” respectively). Every year, about 60 to 65 students are admitted in the first year BAMS program, and, as the year progresses some students drop out. Students who do not fulfill a minimum required attendance, are detained and are readmitted along with the next fresh batch. These students give final examination along with the fresh batch. In the 2017 batch (total 61), 1 student dropped out while 4 students took readmission. In the 2018 batch (total 65), 11 students dropped out and 1 student could participate only in a single session of HPBL.
Sampling
Purposive sampling method was followed in the study and hence, one full batch of students was taken as the control group and the other full batch, as the experimental group. Randomization, if introduced, would have led to the formation of two groups—control and experimental—out of a single batch, and hence would have deprived the control group of the benefits the intervention could have had. This would have posed ethical issues and therefore, two nonequivalent groups were taken up for the study.
Control group
All the students enrolled in the first professional BAMS program for academic year 2016–2017 were included under control group. These students were taught by the conventional method (LBL). The senior author of this article was the common teacher who taught all these topics. PBL sessions were not conducted for this group.
Experimental group
All the students enrolled in the first professional BAMS program for academic year 2017–2018 were included under experimental group. PBL sessions were introduced to 2018 batch on all the chosen topics. This batch served as the experimental group as it was exposed to all PBL sessions. Both the groups received teaching through the conventional (LBL) method by a single common teacher (senior author), however, PBL was used as an add-on component in the experimental group and hence, the term “Hybrid PBL” has been used to denote it. 8,9
Timeframe
This study was conducted over a period of 24 months (August 2016 to July 2018). The number of students varied according to attendance pattern during different sessions. In case of LBL, the duration required for both the groups was nearly equal as it was according to the academic schedule decided by the department every year. Total time consumed for conducting all the PBL sessions for 2018 batch was about 12 h. The time taken for conducting tests in both the groups was about 6 h. This duration, however, does not include the time consumed by the students for out-of-the-class research (self-study).
Selection of topics
The selection of the topics was based on the distribution of topics among the different teachers of the department. The senior author of this communication was allotted with five topics and hence the following topics were shortlisted: (1) Nerve/Muscle physiology and Musculoskeletal system in Ayurveda (Mamsavaha Srotas, Peshi), (2) Physiology of autonomic nervous system and Autonomic functions in Ayurveda (Vata Dosha), (3) Cardiovascular physiology and Cardiovascular system in Ayurveda (Rasavaha Srotas), (4) Gut physiology in Ayurveda [Annavaha Srotas, Agni (digestive fire), Avastha-paka (stages of digestion), Vipaka (metabolism), Mala (excretion), Aahara (Diet), Dhatuposhana Nyaya (tissue nourishment processes)], and (5) Contemporary gastrointestinal physiology. All the chosen topics remained the same for both the groups.
Intervention
The control group received conventional teaching (LBL), which sometimes included the use of audiovisual aids on the selected topics and was conducted by the senior author. Regular two lectures per week (each of 1 h duration) were allotted in the yearly academic schedule for the teaching purpose of the chosen topic. The experimental group received lectures through LBL followed by introduction of PBL case scenario on each topic. Selected topics, duration, and methods for LBL were same for both the groups.
Construction of the PBL case scenario
Case scenarios were selected from standard textbook, but were contextualized to Indian scenario by modifying the names and some other details as and when necessary. 10 Madhava Nidana was used as the reference book to construct an imaginary case scenario on Amlapitta (acid/peptic disease). 11 The content in each scenario was verified by the senior author. Table 1 summarizes the different case scenarios that were used.
Summary of Problem-Based Learning Case Scenarios
PBL delivery method
Each case scenario was introduced in two main sessions mostly 1 week apart (first session of 1 h and reporting back session of 1 h) after weekly scheduled practical classes for the subject Kriya Sharira. The PBL scenarios were introduced by the investigator (the first author) of this study in the presence of the senior author. These scenarios were introduced according to generally accepted seven classical steps of PBL. 7 To summarize, these seven steps are: (1) Making the problem clear, (2) Formulating questions and queries, (3) Identifying current knowledge and learning needs, (4) Structuring ideas, (5) Formulating the learning aims and distributing assignments, (6) Individual activity/research, and (7) Discussing and evaluating the information. 7 HPBL format as described by Lian and He was adopted, where a single tutor handles multiple groups. 8 To promote integrative approaches while learning Ayurveda through PBL, a few learning objectives specific to Ayurveda aspects were additionally derived for each topic. To generate the content required for integrating the two domains, that is, Ayurveda and contemporary physiology, a previous study 3 and other relevant resources 12 were utilized.
Evaluation methods
The learning outcomes of the study were evaluated by using two approaches (1) test scores and (2) student perception.
Test scores
Separate test papers were developed for each topic. After completion of each topic, a written test was administered in the classroom. The questions in these tests were mostly of MCQ type and students were asked to return the question papers immediately after check-marking their answers. In one test paper (on fifth HPBL scenario), however, five additional descriptive questions that assessed “comprehension” were included along with 25 MCQs. This was done to increase the difficulty level as most of the MCQs in this test assessed only the “Recall” component. This was in fact the only topic that was exclusively Ayurveda oriented. Hence, developing MCQs to assess higher-order thinking skills was difficult as these students had only a preliminary exposure to Ayurveda at the time of conducting this session. Test papers were collected immediately to avoid spill-over effect, which would have otherwise led to a disclosure of the questions. Test papers were not returned back to the students after evaluating them and only total test score was announced. This was done to ensure the integrity of the test process. The preparation time for the test varied from 1 to 3 weeks. This variation was unavoidable because of the factors that influenced the overall academic schedule of the institution (such as extracurricular events, holidays, etc.). Both the groups were evaluated by the same set of test papers. Most of the MCQs were collected from standard textbooks of physiology. 13 A few of the questions were framed by investigator of this study especially for Ayurveda components in each test paper. Content validity of newly framed questions was done by the senior author. In case of MCQs and descriptive questions, each correct answer was awarded with a score of one and two, respectively. Wrong answers carried a score of zero. In case of descriptive questions an answer key consisting of four essential points against each question was developed. Each single point received 0.25 marks.
The questions in each topic were categorized according to different levels of Bloom's taxonomy considering their difficulty levels. Altogether, there were 165 questions from all the five test papers. There were 52, 83, and 29 questions to evaluate the first three levels of Bloom's taxonomy, namely “Recall,” “Understanding,” and “Application” components, respectively. There was only one question that assessed “Evaluation” component. 14
Feedback
Students' perceptions regarding HPBL in the form of feedback were obtained anonymously after the completion of university final examinations. Effectively, this was done after 3 months of conducting the last session of HPBL. A web-based questionnaire was created to obtain students' feedback and was sent through email to students of the experimental group (2018 batch). This form consisted of 30 statements. Out of these 30 statements, 6 statements were framed against HPBL to make sure that the students expressed their opinions only after attentively reading the items. The five levels of agreement were “strongly agree,” “agree,” “undecided,” “disagree,” and “strongly disagree.” The five-point scale was so adjusted that a score of one would mean a strong agreement in favor of HPBL and a score of five would mean a strong agreement against the HPBL. This was true irrespective of whether the question was framed positively or negatively. During the analysis, a mean score of “lesser than three” was considered to be indicative of an agreement in favor of the HPBL and a mean score of “greater than three” was considered to be indicative of an agreement against the HPBL.
Reliability and consistency of the feedback forms
A reliability test in the form of Cronbach's coefficient α was carried out. The value of Cronbach's α obtained was 0.945. The analysis shows that the questionnaire was reliable and consistent because the value of the “Alpha if item deleted” was not >0.945 for any item. 15,16
Statistical analysis
SPSS software (version 16) was used to conduct the statistical analysis of data and the level of significance was set at 0.05 for all the tests. Independent t test was used for analyzing the results of all the test scores for all the topics. The overall effect of intervention in terms of Blooms' levels was assessed using z test for two proportions.
Supplementary Data describe the steps followed while conducting the first session of PBL for one topic in detail as an example.
Results
Table 2 depicts the comparison of test scores of both the groups in each topic. For the first, second, and third topics, the performance of experimental group (HPBL) was comparable with the performance of the control (LBL) group (p = 0.386, 0.810, and 0.162, respectively) as no statistically significant difference was found between the mean scores. For the fourth and fifth topics (“Ayurveda gut physiology” and “Contemporary Gastrointestinal physiology”) the performance of the experimental (HPBL) group was better than the control (LBL) group as the mean scores were significantly higher for HPBL group than the mean scores for LBL group as indicated by the p-values (p = 0.048 and 0.028, respectively).
Topic Wise Comparison of Test Scores
Mann-Whitney Test
HPBL, hybrid problem-based learning; LBL, lecture-based learning; MCQs, multiple choice questions; SD, standard deviation.
Table 3 shows the overall comparison of the number of questions that were correctly answered by a maximum number of students (in percentage) for each group. The table also shows the classification of questions based on Bloom's taxonomy. As the results show, the HPBL group performed better than the LBL group for “Recall” component (p = 0.029), whereas the performance of both the groups was comparable for “Understanding” and “Application” components (p = 0.875 and p = 0.189, respectively). There was one question belonging to the “evaluation” category and this was insufficient for the purpose of comparing outcome between two groups, as z test cannot be applied in this case. So, this question was excluded from the analysis. HPBL group performed better in overall performance (without considering Bloom's levels) with 90 correctly answered questions (by maximum number of students in percentage) over LBL group with 72 correctly answered questions (by maximum number of students in percentage) (p = 0.046).
Batch-Wise Comparison in Terms of Number of Questions That Were Correctly Answered by a Maximum Number of Students (in Percentage) Classified on the Basis of Bloom's Taxonomy
Note: Three questions were deleted from total of 165 questions (1 from “Recall” and 2 from “Understanding” categories) because of an equivalent response in both the groups.
HPBL, hybrid problem-based learning; LBL, lecture-based learning; NA, not applicable.
Table 4 displays all the 30 statements that were included in the feedback form along with mean scores received for each statement. We could obtain feedback from 53 students of the 2018 batch. On analyzing the feedback received, we observed that the mean scores were <2 for 28 (93.33%) statements suggesting a definite and considerable acceptance for HPBL. The mean scores for the remaining two statements were also less than three and suggest that HPBL was found to be acceptable by all the students.
Results of Student Feedback
Negative questions have been marked as (N).
HPBL, hybrid problem-based learning; LBL, lecture-based learning; PBL, problem-based learning.
Discussion
The primary results of our study as depicted in Table 2 show that the scores of the HPBL group were equivalent (and hence comparable) to those of LBL group for first, second, and third topics. On the other hand, the HPBL group performed slightly better than the LBL group for fourth and fifth topics. Hence, the overall results indicate that HPBL did not have a considerable impact on test scores. This observation may be attributed to the fact that, the evaluation tools used in our study focused primarily on the short-term effect of HPBL on learning outcomes. Most of the systematic and narrative reviews on the effectiveness of PBL have also reported similar outcomes and have pointed out that the outcomes of PBL may not show immediate consequential differences and instead may require a period of 3 to 4 years to show definite benefits. 17 –19 Furthermore, most of the studies also suggest that the PBL does not always have a direct effect on knowledge, but it primarily promotes the skills of applying the knowledge and enhances problem-solving skills. 19 Since our test papers were designed to evaluate only knowledge domain, we could not evaluate any improvement in the problem-solving skills. Hence, this could be a limitation of our study. It may be noted that the fourth topic (Ayurveda gut physiology) was the only topic that had exclusively Ayurveda contents. A better performance by HPBL group in this topic may indicate its usefulness in learning Ayurveda. However, it is difficult to conclude anything based on the performance in a single topic.
Our study indicates that the HPBL group performed better in the Recall component (Table 3). Although the Recall is first level, mastery of lower levels is required to achieve the higher levels. 20,21 This finding is consistent with other studies suggesting that PBL enhances recall. 22,23 The performance of HPBL group was comparable with LBL group in the category of “Understanding” and “Application” levels. The overall performance of HPBL group in our study was slightly better than LBL group when all types of questions were considered. However, any conclusion cannot be drawn based on these preliminary results.
Student perceptions
The results of the responses received from students to assess their perceptions (as depicted in Table 4) suggest that there is a clear indication toward considerable acceptance of HPBL. Previous studies too largely agree that despite desirable and undesirable results of PBL programs, students enjoy PBL over traditional methods. 24 –26 In our study, the student perceptions suggested that HPBL was perceived to be promoting critical thinking skills and analytical skills leading to an appreciation of the application aspect of the information. It also suggested that students perceived the HPBL sessions to be encouraging active learning, learning from peers and self-directed learning. The results also suggest that HPBL provided an open environment that encouraged the students to freely express their thoughts. These results are strong enough to suggest a possible formal integration of HPBL in Ayurveda educational programs.
Implications of the study
The current study can provide direction in planning future courses in Ayurveda education. Similar HPBLs can be planned in other subjects of BAMS program. Training of teachers as HPBL instructors is a very important factor in the implementation of HPBL. This can be achieved by incorporating this approach in faculty development programs. HPBL methods may be recommended in future curricula after gathering enough evidence in its support.
Limitations of the study
This study has the following limitations: (1) Assessment of long-term learning outcomes (2–3 years) was not possible because of time restrictions and also because HPBL was introduced in only a limited number of topics. It could have had long-term effects if introduced concurrently in multiple topics and subjects. (2) In this study, we could evaluate the effect of HPBL only on cognitive and affective domains and not on the skill domain. (3) It was not possible to control some of the confounding factors like students' absenteeism and students' casual approach, as HPBL was not a mandatory requirement while implementing the BAMS curriculum. (4) A single case scenario on each topic was insufficient to cover many of the learning objectives for a given topic. (5) Limited availability of time because of a tight teaching schedule of the institution is another factor that could have affected the results. (6) Since we had nonequivalent groups, the performance in both the groups could have been influenced by factors such as their previous educational background, their previous Grade Point Average, etc.
Conclusion
The present study implies that it is possible to implement HPBL successfully in a large classroom. When outcomes of HPBL and conventional method were compared on the basis of obtained test scores, the HPBL showed either comparable or slightly positive results, but not inferior. On the other hand, on the basis of qualitative measures (student perception), the study indicates that HPBL was accepted well and students had an overall positive perception toward it.
Footnotes
Author Disclosure Statement
Authors declare that they do not have any financial or other conflicts of interest to disclose.
Funding Information
We thank the Ministry of Human Resource Development, Government of India, for supporting the work under Pandit Madan Mohan Malaviya National Mission on Teachers and Teaching.
Supplementary Material
Supplementary Data
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
