INTRODUCTION
Peer-assisted learning (PAL) as a learning method has gained some attention in medical education worldwide during recent times. PAL is facilitating the discussion to the students by the students, who have undergone the training process. This method prompts students to gain academic aptitudes and skills in teaching and learning. It is beneficial for both student tutors and student learners in understanding the subject in depth.[ 1 ]
PAL not only helps in strengthening the learners understanding, clinical reasoning, self-confidence, and collaborating with others but also benefits the students tutors in enhancing their knowledge, skills, speaking abilities, and interaction with peers and to obtain leadership competencies.[ 2 ]
The relationship equation between the student tutor and student learner, their interpersonal qualities, and unconstrained communication establishes a friendly learning environment that encourages an open exchange of ideas and personal concerns.
PAL can be delivered as small group activity, seminar, interactive modules, revision of the completed topics, and debates on tricky problems.[ 3 ]
Breast cancer is a very sensitive issue when it comes to open discussion. There is fear, anxiety, and stigma that surround the breast cancer among most of the women across the globe. This may be because of fear of being diagnosed with breast cancer, fear of pain or discomfort, fear of undergoing surgery, complications or social stigma about the family, children, cosmetic issues, etc.[ 4 , 5 ]
PAL is likely to create a safe and friendly environment to learn about breast cancer, breast self-examination (BSE) and discuss about the psychosocial aspect of it. Creating awareness of breast cancer and BSE in earlier age can help in early detection of cancer as it motivates to do self-examination regularly. Students can also be motivated to create awareness to their family and friends so that the awareness can be spread to whole communities. Students generally have attitude to learn newer things and adapt it. Hence, PAL seems to be a better method of sharing knowledge on breast cancer and practice the skills of BSE.
It was inevitable for the educational institutions to adapt online mode of teaching to continue the ongoing academic events without interruptions during the COVID-19 pandemic. There were a lot of trials being done on various distance teaching–learning methodology during the COVID-19 pandemic. The teaching faculty and the students did develop the skills to embrace the online mode of teaching–learning method during the pandemic.
The traditional face-to-face PAL method had been in practiced over time by some of the educators; however, there are not enough literature evidence to show the effectiveness of online PAL sessions.
The purpose of this study was to assess the effectiveness and impact of online PAL session in enhancing the knowledge of breast cancer and BSE among medical students.
SUBJECTS AND METHODS
This was a cross-sectional, quasi-experimental study done using mixed-method design. A total of 93 students attended the breast cancer awareness workshop. The workshop was conducted as an online program using WEBEX software due to the COVID-19 pandemic on March 16, 2020. The session included presentation on the aspects of breast cancer and practice of BSE. Ethical approval was obtained from the Ethics and Biosafety Committee: Reg no-NU/COMHS/EBC001/2019 on December 31, 2019, to conduct the study.
Recruitment of tutees and tutors
All the premedical and preclinical students were sent the Google Form for registration to the workshop.
Those who registered for the workshop were included in the study. Convenient sampling was done.
The PAL tutors were selected based on the interest shown and volunteered to do PAL Session. The PAL tutors had earlier attended the breast cancer workshop conducted by the faculty. The PAL tutors were trained by the faculty mentors before the actual PAL session for student’s tutees was conducted.
Peer-assisted learning intervention evaluation
The effectiveness of the PAL intervention was evaluated by giving tutees the questionnaire before (prequestionnaire) and after the intervention (postquestionnaire). The purpose of the study was explained and instructions for filling out the questionnaire and survey forms were given. The participants expressed their consent by completing an informed consent form. Knowledge of breast cancer and BSE was compared with the pretest and posttest scores.
Analysis of the PAL workshop satisfaction was done by survey. A satisfaction questionnaire was given to tutees, tutors, and faculties for PAL intervention improvement purposes in future.
The pretest and posttest questionnaire and satisfaction survey were given in the Google Forms to fill. Adequate time was given to fill the forms.
All the 93 medical students (premedical and preclinical) filled the pretest and posttest questionnaire and only 30 students filled the postworkshop satisfaction survey questionnaire.
Clinical year students and students who had earlier attended the breast cancer workshop were excluded from the study.
For pre- and posttests, self-administered questionnaire was derived from prevalidated questionnaire from previously published article by Ranganath et al .[ 6 ] Questions were categorized based on the knowledge of BSE (five questions) and breast cancer. Subcategories for breast cancer included risk factor (9 questions), signs and symptoms (10 questions), and screening (4 questions).
For the satisfaction questionnaire, comprehensive review of literature was done. The questionnaire basically addressed the conduct and usefulness of PAL session. The feedback questionnaire for PAL tutees consisted of 12 quantitative and 2 qualitative items (open-ended type) for PAL tutors, there were 15 quantitative and 6 qualitative items (open-ended type) on the PAL experience, and Faculty feedback questionnaire comprised of 11 quantitative and 2 qualitative items. For quantitative items, scoring was done using Likert scale. Scores of five, four, three, two, and one for “strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree,” respectively. The qualitative data were analyzed by inductive content analysis. Firstly, the articulations were simplified and grouped according to their content. Simplified expressions with similar content were grouped and classified into subcategories which were named according to their content. To avoid response bias, questions were framed simple and clear enough that was understandable by the participants. To avoid nonresponse bias, participants were given enough time to complete the questionnaires.
A Cronbach’s alpha value of 0.962 was obtained for the 12 (quantitative) items of the feedback questionnaire for PAL tutees, indicating a good level of internal consistency. Results of the Shapiro–Wilk test of normality for all the survey items (P < 0.001) indicate that participant’s responses were not normally distributed.
Statistical analysis
Data obtained were analysed using IBM’s Statistical Package for Social Sciences version 22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (Armonk, NY: IBM Corp). Descriptive data were presented as frequency and percentage, while continuous data were presented as mean and standard deviation. Descriptive and thematic analysis was done for open-ended questions. Paired sample t -test was applied to look for statistical significance of pretest and posttest data collected for breast cancer and BSE questionnaires.
RESULTS
The total participants who attended the program were 93. All the participants were female. The average age of the participants was 22 years. The distribution of the participants based on the academic year is 51% were from the MD 2, 31% from MD 3, 11% from MD 1, 6% from MD 4, and 1% from MD 5, as shown in Figure 1 .
Figure 1: Demography
The results are divided into three sections (i) participants, (ii) peer leaders, and (iii) faculty mentors.
Participants
A statistically significant improvement was observed in the posttest scores for knowledge on risk factors, BSE (P < 0.001) and signs and symptoms <0.05). The mean of pre- and posttest scores for screening tests was low both in pretest and posttest. There was not much improvement seen in the posttest scores and is statistically not significant [Table 1 ].
Table 1: Pre- and post-test scores on knowledge on breast cancer
There was improvement of BSE technique among the participants following PAL program. 48.40% students admitted that they were not aware of BSE before the PAL Program. It increased to 96.8% after the program, as shown in Figure 2 .
Figure 2: Awareness on breast self-examination technique
Feedback response was positive and encouraging as about an average of 83.3% of the response from the participants showed very well agreement for all the 13 items. Ten students did not have prior experience with peer-to-peer training. The mean score for all item varied from 3.83 to 4.73, as shown in Figure 3 .
Figure 3: Feedback from the participants
Thematic analysis: Participant’s experience of peer-assisted learning session
Cognitive aspect
“It opened my mind to things I did not notice.”
“I gained a lot of knowledge, it taught me about the strength of women, and it helped me expand my thinking.”
“Basically, I have been to many events on Brest cancer, but l feel that this event gave a clear idea about the topic in simplest way. It added to me a lot.”
About peer educators
“It’s pretty interesting and they were enthusiastic which make the session more excited.”
“I’m very happy to see students get the opportunity to conduct such a useful and entertaining session.”
“Very interesting thing that we could see all the efforts made by them.”
Learning environment
“It was interesting and fun.”
“It was really useful and enjoyable.”
“It was relaxing and amazing.”
Session organization
Three “I’s: Informative, interesting, and inspiring.”
“Everything was awesome, activities included lots of information.”
“It was engaging and well organized. I felt that my time was well spent.”
Peer leaders
Six peer leaders were selected based on their interest to become peer educators. All the six peer leaders were female students aged from 19 to 22 years, as represented in Table 2 .
Table 2: Characteristic data of peer tutors
The responses from the peer leaders show that their experience of being peer educator and interaction and discussion with peers were enjoyable. The mean score of satisfaction about ability to work as a team, problem solving, decision-making ability, communication and presentation ability was high. The peer leaders felt that they could see improvement in communication, presentation, problem solving, decision-making, leadership, and planning ability. Knowledge and confidence of PAL leaders increased after this experience. Faculty guidance and rehearsals were important to perform better during presentation. Mean score of willing to train other students was high, as shown in Table 3 .
Table 3: Peer leaders’ feedback on peer assisted learning session
Thematic analysis is shown in Table 4 .
Table 4: Thematic analysis: Peer-assisted learning leaders experience of peer-assisted learning session
Faculty mentors
Feedback for peer leaders was given from three supervising faculty. The average mean for all the items scored was 4.6, as shown in Table 5 .
Table 5: Faculty feedback for peer leaders
DISCUSSION
Breast cancers among younger women are generally more aggressive and have poor prognosis. This necessitates the importance of awareness on breast cancer and practice of BSE for early detection and to reduce the morbidity and mortality.[ 7 ] Inculcating positive behavior toward self-care by teaching the skills of BSE in younger age groups is convenient. PAL is being aptly used recent times in many institutions to foster learning among the students. We have used the online PAL approach in our study to create awareness on breast cancer and practice skills of BSE.
The result of the online PAL shows that there was improvement in the posttest scores of knowledge and skills of BSE among the students. This shows the effectiveness of online PAL intervention among the students as reported in earlier studies.[ 8 ] However, the improvement in scores of pretests and posttest of screening method for breast cancer was not significant, which is also reported in some studies.[ 9 ] There can be some challenges encountered in training the tutees. Several reasons can be attributed for this and had been mentioned in earlier studies like tutors’ ability to make tutees to understand the topics because of their limited knowledge. Online mode of delivery gives limited opportunity to recognize the tutees reactions on understanding of the topics. Proper training of the tutors is important in preparation for the topics of delivery as well as faculties’ supervision on tutors’ preparation to keep in check that unwanted or inadequate information’s are not included in the teaching, etc.[ 10 ]
The feedback on conduction of online PAL session was satisfactory. There was mention of three “I” (Informative, Interesting, and Inspiring): the session was informative indicating that the online workshop provided lot of information about breast cancer and BSE which the students were unaware. I – Interesting that the students enjoyed learning together in safe and relaxed environment. PAL sessions are generally intended to provide a comfortable atmosphere for students to share their ideas and knowledge to make it joy of learning.[ 11 ] There was scope and opportunity to discuss the matter with the tutors and peers freely without any apprehension. The PAL setting gives freedom of open discussion and encourages for interactions between the tutors and tutees. The third “I” was inspiring that session had motivated the tutees to take up the role of tutor. The tutees expressed their satisfaction toward tutors’ way of presenting and making them understand the concept of breast cancer and BSE. Similar findings were also noted in the study by Veerabhadrappa, et al .[ 12 ]
The peer tutors who were chosen to deliver the PAL session were in the same academic year or 1–2 years seniors to tutees. The feedback on peer tutors’ performance was appreciative. The tutors enjoyed the role of peer educators and their interaction with their peers. Tutors acknowledged that they got the opportunity to work as team to prepare for the workshop. During preparation for the PAL session, they had acquired several skills such as planning the event, communicating with the peers, delivery of the presentation, decision-making and problem solving. PAL sessions are useful not only for the tutees, but it also greatly impacts the peer tutors. The tutor needs to well understand the subjects before they teach the tutees. This gives them the opportunity for deeper understanding of the topics. During this process, the tutors also acquire the skills of communication and public speaking. Some of the reports did mention that PAL provides leadership, coaching, learning skills, enhance confidence, intrinsic motivation, and encourage an academic interest.[ 13 ]
The successful training sessions are the result of hard work, dedication, perfection, persistence, and learning from the failures. Improvisation happens when the mistakes are identified and rectified. In our study, tutors had recognized some of the factors to improve for future sessions. To mention some of them are, to do more research and review more on the topics to be delivered, to take consultation from the seniors or the faculty in charge for improvisation and needs additional practice to be more confident could be some factors which needs to be taken care while preparing for the events or training sessions.[ 14 ]
The delivery and conduct of PAL session by peer tutors was well appreciated by the faculties. The sense of satisfaction to any faculty is when the outcome of a training event demonstrates improvisation in the knowledge and skills that the sessions were intended to do. Also, when the feedback from the participants and the tutors are extremely gratifying.
CONCLUSIONS
Online PAL session was successful in creating awareness on breast cancer and BSE. It can be an effective method to deliver sensitive information related to health and education. Online PAL session can be cost-effective and can be reached to larger participants. PAL is beneficial to both tutors and tutees in gaining knowledge and acquiring skills on various aspects of career development. Incorporation of peer education in the medical universities can be considered. Use of peer education for delivery of sensitive health-related topics is worthwhile.
Limitation
The study results cannot be generalized as the results are based on limited number of students and belong to a particular region. Further research on PAL needs to be carried out especially on the sensitive health issues to know the effectiveness of this method. Implementation of more such online PAL sessions needs to be explored to support the successfulness of this method.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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