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ORIGINAL RESEARCH ARTICLE
Year : 2022 | Volume
: 35
| Issue : 3 | Page : 89-95
Combining an experiential learning model and interprofessional peer-mentoring to improve maternal and neonatal health: Lessons learned from Indonesia
Prattama Santoso Utomo1, Robertus Arian Datusanantyo2, John Hartono3, Aemilianus Yollan Permana4, Triharnoto Triharnoto5
1 Department of Medical Education and Bioethics, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada; Department of Emergency Medicine, Panti Rapih Hospital, Yogyakarta, Indonesia
2 Department of Surgery, Prof. Dr. W. Z. Johannes General Hospital; Department of Surgery, Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Kupang, Indonesia
3 Physical Medicine and Rehabilitation, Panti Rapih Hospital, Yogyakarta, Indonesia
4 Finance and Asset, Panti Rapih Hospital, Yogyakarta, Indonesia
5 Internal Medicine-Nephrology, Panti Rapih Hospital, Yogyakarta, Indonesia
Correspondence Address:
Dr. Prattama Santoso Utomo
Department of Medical Education and Bioethics, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Jalan Farmako, Sekip Utara, Yogyakarta 55281
Indonesia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/efh.EfH_375_20
Background: High maternal-neonatal mortality rate in the East Nusa Tenggara Timur Province, Indonesia, has raised a concern about improving quality health care and prevention. A task force team consisting of the district health office and the corresponding hospital implemented an interprofessional peer mentoring for improving maternal-neonatal health initiative involving various health professionals and community members. This study assesses the effectiveness of the interprofessional peer-mentoring program in improving health-care workers' capacity and community members' awareness of maternal-neonatal health in the primary care setting. Methods: A mixed-methods action research was conducted to measure the effectiveness of the peer-mentoring program. The task force appointed 15 personnel to be trained as peer mentors for 60 mentees from various professions. Peer mentors' perceptions of knowledge and skills improvement were measured before and after the training program. A reflective logbook was then developed to document mentoring activities. Surveys and logbook observations were performed to measure the effectiveness of the 8-month peer-mentoring program. Mentees' capacity and perception were measured before and after the mentoring program. Quantitative data were analyzed using the descriptive statistics and Wilcoxon's paired-rank test, whereas open-ended responses and log-book reflection were analyzed using the content analysis. Results: The peer-mentor training program improved peer mentors' knowledge and readiness from 3.64/5.00 to 4.23/5.00 (P < 0.001). Moreover, mentees viewed the program as effective in improving self-confidence and working capacity in maternal-neonatal health services from 3.47/5.00 to 3.98/5.00 (P < 0.001). Open-ended responses and a reflective logbook revealed that both mentees and peer mentors gained positive learning experiences. Seniority might become an obstacle to the mentoring process since peer mentors reported barriers in engaging elderly mentees due to seniority issues. Discussion: The interprofessional peer-mentoring program was effective in improving both mentors' and mentees' knowledge, self-confidence, and working capacity in maternal-neonatal primary health services and experiential learning. Further observation of the long-term outcomes of the program should be undertaken.
Keywords: Experiential learning, interprofessional practice, maternal and neonatal health, peer mentoring, primary care, rural health care
Maternal and neonatal health has become a concern in many countries globally. The quality of maternal and neonatal health in each region or country is reflected in their maternal mortality rate (MMR) and neonatal mortality rate (NMR). Both indicators are acknowledged in many countries, including Indonesia, as the indicators of health system evaluation. The WHO suggests that the major causes of maternal and neonatal mortalities are severe bleeding, postdelivery/puerperal infection, gestational hypertensive disorders including preeclampsia and eclampsia, and unsafe abortion.[1] Indonesia is dealing with relatively high MMR and NMR compared to other countries. A similar concern is also found in other developing countries. The MMR of Indonesia is 126/100,000 in 2015,[2] with some provinces and districts having higher rates, especially in the eastern regions of Indonesia.[3]
The Australia-Indonesia Partnership on Maternal and Neonatal Health was founded in 2008 as a partnership between the Indonesian government in several provinces and the AusAid to improve maternal and neonatal health in Indonesia. The focus area is the East Nusa Tenggara Province (Provinsi Nusa Tenggara Timur [NTT]) which had a considerable MMR 133/100,000 in 2015.[4] Some initiatives have been conducted to improve maternal-neonatal healthcare quality, such as hospital staff training and procurement of medical devices for high-care units. This program found that the main challenge of maternal and neonatal health in the area is the shortage of health-care professionals. Many hospitals and primary health-care centres were faced with low numbers of health-care workers to the population rate. East Nusa Tenggara Province had a ratio of 13.2 physicians to 100,000 population, very low even in relation to Indonesia's already low ratio of 16.06/100,000 in 2015.[2] Within this context, providing health-care technology and supply alone will not suffice. In addition, past work has reported that the number of health-care workers in the region is a major determinant of maternal mortality in Indonesia.[5] Improving the quantity and quality of health-care professionals in the area should be a priority.
This shortage has been addressed by the implementation of a clinical contracting out program, commonly referred to as the “sister hospital.”[6] The partnership was mainly pairing hospitals from several districts in NTT with some major government and private hospitals from Java, Bali, and Sulawesi. The partnership was able to reduce MMR in NTT by 1.14/100,000 live births.[7] Our hospital was involved in one of the partnerships and was acknowledged to have a unique approach to experiential learning for nurses, midwives, medical doctors, and hospital managers.[8]
Based on the above concerns, an interprofessional peer mentoring program, “Puskesmas Ari-Kae,” was designed to be piloted in Ende District, NTT (”Puskesmas”: Primary healthcare centre; “Ari”: Younger sibling; “Kae”: Elder sibling). The peer mentors were primary healthcare staff (i.e., doctors, nurses, and midwives) as well as community members of the respective primary health-care area who had been actively involved in community awareness on maternal and neonatal health, “Desa Siaga.” The mentees were other primary healthcare staff and community people from other areas within the Ende District. The peer mentors were selected based on their neonatal and maternal health awareness and initiative. These mentors were considered more advanced than the mentees regarding neonatal and maternal health.
Learning from peers has been proven effective for delivering many kinds of materials in medical and health professions education. Peer-assisted learning (PAL) can be as effective as learning from experts,[9] while providing convenience in learning due to similar social and expertise levels.[10] Nevertheless, the peer mentor should be trained and monitored to ensure the quality of learning.[11] Interprofessional peer learning has been reported as effective in the educational setting involving both faculty and students.[12] However, interprofessional peer mentoring in the community setting of health care and nonhealthcare professionals is still rarely implemented and investigated.
Within this context, we evaluated the effectiveness of the interprofessional peer mentoring “Puskesmas Ari-Kae” program that involved both health and nonhealth professionals.
MethodsDesign
We used mixed-methods action research with a pretest-posttest design to evaluate the effectiveness of the program. The evaluation was conducted in several phases based on Kolb's Experiential Learning Model.[13] The program was conducted from February to October 2015.
Participants
A total of 15 peer mentors and 60 mentees were involved in the program and included in the evaluation to implement total population sampling. The 15 peer mentors were from 3 subdistricts and consisted of 33.3% of health-care professionals from the respective primary health-care centers (i.e., physician, head nurse, and midwife) and 66.7% of nonhealth professionals (i.e., chief of the village and head of the village's safe motherhood awareness committee). The 60 mentees were from 12 subdistricts consisting of 61.7% healthcare professionals and 38.3% nonhealthcare professionals, with a similar configuration to the mentors. Each peer mentor would facilitate four mentees from the surrounding subdistricts. Participants were provided with transportation fees for each visit.
Program description and evaluation phases
Initially, all stakeholders gathered in Yogyakarta for a preparatory meeting for concept development and to prepare the tools to conduct the mentoring process. A 2-day preparatory training course was then conducted in Ende to prepare both peer mentors and mentees for the “Puskesmas Ari-Kae” program.
Peer mentors were the champions of local maternal and neonatal health initiatives in the Ende district and were chosen by the district health office. Selection of the mentors was based on previous involvement in maternal-neonatal health prevention, promotion, and innovation programs. Peer mentors were both health professionals (midwives, nurses, and primary care doctors) and nonhealth professionals (tribe leaders, local village representatives, and women representatives). Peer mentors were trained on best practices in safe motherhood and neonatal care, mentoring and facilitation skills, and the use of a reflective logbook for mentoring and learning.
In addition, we provided training to the mentees before the mentoring session. This training introduced the general aspects of maternal and neonatal health, the concept of the mentoring program, how to use the logbook, and how to receive feedback for the learning process.
The peer mentors and mentees then underwent the mentoring process following four steps of Kolb's Experiential Learning Cycle:[13]
Concrete experience: mentees visited the mentor's site to learn good practices in the setting of the mentors' health-care facilities environmentReflective observation: mentees performed reflection based on their observation findings while mentors facilitated the mentees' reflection processAbstract conceptualization: mentees developed a plan for improvement based on their findings on the observation of their institution or community. Peer mentors guided the plan to become more feasible and achievableActive experimentation: mentees returned to their institution or community to implement changes based on their previous improvement plan. Peer mentors visited the mentees during the implementation to provide feedback and guidance.The interprofessional peer mentoring program was conducted for 8 months. [Figure 1] illustrates the program's cycle.
Figure 1: Program, evaluation, and data collection phases of experiential learning and inter professional peer-mentoring. (Orange background: Peer mentors' roles; Blue background: Mentees' roles)During the mentoring process, mentees learned both aspects of maternal-neonatal health issues and also the principles of experiential learning and interprofessional practice. The mentees are expected to become peer mentors later and expand the peer mentoring program to other primary health-care centers and subdistricts. The interprofessional peer-mentoring program was supported by the project for 1 year and subsequently maintained by the district health office. This evaluation focused on the initial implementation of the interprofessional peer-mentoring program.
Data collection
The data collection phases of the program evaluation are presented in [Figure 1] in green background with red font color. Two questionnaires were used to gather the quantitative data from the participants. Peer mentors' readiness for facilitating the interprofessional mentoring was assessed before and after the preparatory training using a 15-item mentor's readiness questionnaire with a 5-item Likert scale. Mentees' perception of their maternal and neonatal health capacity was measured using an 8-item mentee's perception questionnaire with a 5-item Likert scale. The evaluation questionnaire items were developed based on the topics covered during the training, including interprofessional practice, experiential and reflective learning, learning style, facilitation and mentoring skills, and maternal and neonatal health contents. The evaluation questionnaires were completed independently by peer mentors and mentees, respectively, in the time indicated in [Figure 1].
During the peer mentoring program, logbooks were distributed to be completed by each mentee and mentor. The logbooks recorded participants' observations, reflections, plan of action, and suggestions for the program. Information from the logbooks was used as the qualitative data source of the evaluation (see [Figure 2]).
Figure 2: Preparation for peer mentors and mentees. (a) Peer-mentor training activity, (b) Logbook for peer mentors and menteesData analysis
The evaluation questionnaire results were analyzed using the descriptive statistics to measure the mean and standard deviation of the data. The Kolmogorov–Smirnov test showed that questionnaire data results were not normally distributed (P = 0.001) for both mentors and mentees. Hence, the difference between prementoring and postmentoring results was analyzed using the Wilcoxon's paired rank test. In addition, the qualitative data retrieved from the logbook were analyzed using the content analysis with an inductive approach.[14],[15] The content analysis applied a conceptual approach to ensure that all suggested information from the logbook was included and interpreted.
ResultsEvaluation of peer mentor training
[Table 1] shows the results of peer mentors' readiness evaluation results based on the questionnaire using a 5-item Likert Scale before and after the training session. The peer mentor training improved peer mentors' confidence in facilitating interprofessional mentoring of the Puskesmas Ari-Kae program, with an overall mean of 3.64 ± 0.43–4.23 ± 0.30 (P < 0.001). The results show an increase in all mentor evaluation items, and 10 of 15 items were statistically significant. The three most significant improvements were in experiential learning aspects (Q3–4) and constructive feedback skills (Q11).
Table 1: Peer mentor's evaluation of their mentoring capacity in the interprofessional peer-mentoring program (n=15)Evaluation of peer mentoring program
[Table 2] presents the results of mentees' perceived capacity improvement based on a 5-item Likert scale questionnaire; before and after the 8-month experiential peer mentoring. The peer mentoring program improved mentees' perceived capacity for all 8 evaluation items of maternal and neonatal health, experiential learning, and interprofessional practice aspects, with an overall mean of 3.47 ± 0.32–3.98 ± 0.41 (P < 0.001). The three most-significant improvements are in interprofessional practice (Q1), constructive feedback (Q7), and maternal-neonatal health principles (Q8).
Table 2: Mentee's evaluation of their maternal and neonatal health capacity and experiential learning skills (n=60)Reflective log
Several themes emerged from the logbook analysis, including: advantages of peer mentoring, barriers to mentoring, and the learning/facilitation process in peer mentoring.
In terms of advantages and benefits, the program was viewed as a mutual learning opportunity.
”It was such an opportunity to learn and improve our healthcare service to mothers and newborn babies. We can learn good practices from our mentors. The learning process was rich and based on our context and needs” (L-Lb. 4.12).
”Despite my role as a peer mentor, I learn many new things during the program. Learning how to be a mentor is a delightful new experience for me. During my visit to all mentees, I learned something interesting that might be useful to be taken back to my institution. Being a mentor is not only teaching but also learning” (M-Lb. 2.09).
”I think it was not just teaching the mentees, but we learned many things too, such as blood donor list assigned to each high-risk pregnant mother and many community initiatives” (M-Lb. 9.22).
Several barriers in peer mentoring emerged from the evaluation and reflection of study participants, including healthcare professions shortages and cultural barriers, where some peer mentors reported difficulties in facilitating more senior mentees.
”The mentor's primary health care employs three midwives while our site only has one midwife to provide service to a larger coverage area. We urgently need more midwives, or at least maternity-trained nurses, in order to improve service coverage and more detailed screening” (L-Lb. 7.44).
”It was fun to facilitate mentees who were at a similar age and level to me. However, teaching more senior mentees was difficult. Some of them rejected my advice based on their personal beliefs, and I hesitated to push further. Maybe, I am not influential enough to ensure more senior people easily” (M-Lb. 11.75).
In general, both peer mentors and mentees perceived that learning from best-practice and experiences was enriching despite a minimum of resources and learning technology. The use of simple learning resources did not hinder the motivation and benefit of learning.
”We are amazed by the learning motivation of our mentees despite many obstacles and limitations in both our and their institutions. We even learned based on experience using simple learning media, such as pamphlets and flipcharts. Yet, it was effective and enjoyable” (M-Lb. 9.22).
”I believe that our willingness to learn overcomes economic and learning technology limitations. Thanks to our mentors' passion and persistence, we can learn many aspects to provide quality service to our community” (L-Lb-5.32).
In addition, an important theme in relation to health professions education and health outcomes was that peer mentors and mentees reported similar goals when participating in the program. They indicated that the program might decrease the maternal and NMR in the municipality.
”I am happy to be included in this program. We can contribute to preventing more deaths for pregnant mothers and newborn babies although we are not health professionals” (M-Lb. 2.11).
”I am grateful to become a mentee of this program. I have learned many useful tips from our mentors. We were desperate with the high maternal mortality rate, but I believe this program will help us to prevent more deaths” (L-Lb. 3.31).
DiscussionThe peer mentoring evaluation revealed a significant overall increase in mentees' perceived understanding and skills in interprofessional maternal and neonatal care and reflective learning capacity. The experiential learning principles applied in the program are also associated with the increase in mentees' improvements. Several studies reported that experiential learning is effective for the professional development of health-care professionals both in the clinical and community settings.[16],[17],[18] Experiential learning improves learners' capacity through a continuous-active learning cycle guided by reflection.[19] An increase in reflective learning capacity may support mentees' continuous personal development. Reflective learning is highly associated with life-long learning skills, which is important for healthcare professionals' skills development.[20]
The “Puskesmas Ari-Kae” applied peer mentoring can be considered a PAL program.[21] The benefit of the program was consistent with the benefit of PAL programs, as indicated by both mentors and mentees. PAL provides advantages to both peer facilitators and learners.[22],[23] Learning activities might be safer and more enjoyable in learning environments that promote cognitive and social congruence between peer mentors and learners,[10],[24] where learners might perform more efficiently during the learning process. Subsequently, peer mentors also obtain benefits from the learning process. PAL has been reported to improve peer mentors/facilitators' capacity on the topic being taught,[25] enhancing communication skills[21] as well as self-management skills.[21] Therefore, PAL activities, such as “Puskesmas Ari-Kae,” might provide a meaningful learning experience for both learners and mentors.
Our interprofessional peer mentoring program did encounter an obstacle related to the seniority between mentors and mentees. More junior mentors complained about senior mentees' attitudes toward younger advisors. The finding is relevant to collectivistic cultures, such as Asian countries, where age/seniority may be highly influential related to the value of trustability.[26] Senior mentees might be apprehensive of younger mentors.
An interesting finding of participants' reflection was the use of relatively nonhigh-technology learning media. The peer mentoring activities were perceived effective and beneficial despite simple learning resources, like flipcharts and pamphlets as mentoring media. These learning media are often categorized as simple visual media, which is less interactive and low-tech.[27] However, learning quality and experience are not always related to the use of high-tech learning resources. A past study reported that learners perceived that both high and low-tech learning resources are equally valuable.[28] The main advantages of using low-tech learning resources are that they are more affordable and user-friendly.[27],[28] Hence, simple learning media can still be favourable in many contexts.
Our study has several strengths and limitations. The main strength was the inclusion of both health professionals and nonhealth professionals in the project. The experience of both groups was valuable and showed the importance of interprofessional collaboration to be extended to nonhealth sectors.[29] The study also included a reflective logbook which enabled an in-depth understanding of participants' perceptions of the interprofessional peer mentoring program.
As a limitation, this study was a relatively short program that only allowed a limited evaluation of reported changes in behavior (Kirkpatrick Level 3).[30] The impact of the program toward maternal and neonatal death (Kirkpatrick Level 4) has not been evaluated due to time constraints. Finally, in our evaluation, we used a self-administered questionnaire, where there could be the possibility of ambiguity in participants' responses to the questionnaire items due to different perceptions or interpretations of such terms as “I understand.”
ConclusionThe interprofessional peer mentoring program is perceived as effective and beneficial for both peer mentors and mentees for improving knowledge and skills related to maternal and neonatal health using the experiential learning approach. Importantly, simple learning resources were appreciated in this program, showing feasibilty for use in the rural areas. Overall, the involvement of peers is perceived as enjoyable, motivating, and inspiring by mentees.
The interprofessional peer mentoring of health professionals and nonhealth professionals can be implemented to enable professional development in areas with limited resources. Studies on the long-term evaluation of interprofessional peer mentoring, including the impact on patient care and outcomes, should be undertaken to address any questions about or hesitance in allowing peers to teach others.
Acknowledgment
This project received funding by the Australia-Indonesia Partnership for Maternal and Neonatal Health of the Puskesmas Ari-Kae Project. This publication is also a tribute for our friend, Mamnun Hatma, who passed away after significantly contributing on the “Puskesmas Ari-Kae” project.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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