Development of community based curriculum on ophthalmology for under graduate medical course in Bangladesh.

The curriculum represents the expression of educational ideas in practice. Ophthalmic education is the corner stone to improve eye care globally. Curriculum needs continuous modification varying in different geographic locations. Though 90% of common conditions are either preventable or curable but emphasis on the common conditions is inadequate. This is a stepwise descriptive study aiming to develop a community based ophthalmology curriculum for undergraduate medical course in Bangladesh conducted during March 2007 to February 2008 at UniSA School of Public Health and Life Sciences, University of South Asia, Banani, Dhaka. Delphi technique, a modified qualitative method was used to accumulate data and reaching a consensus opinion for developing the curriculum. Study approach includes two iterative rounds and finally a workshop. Iteration of round-I was "What are the eye diseases with overall knowledge of their management one MBBS physician should acquire"; followed by a list of eye diseases and topics for expert opinion. The response was collated. Iteration round-II was "How much a MBBS student should have percentage of knowledge, attitude and skills on each topic while being taught". The response was collated and presented to panel of expert ophthalmologists for discussion and validation. In the round-I Delphi, 400 (62%) out to total 641 ophthalmologist were randomly selected dividing in categories (62% in each) of Professor-22, Associate Professor-12, Assistant Professor-26, Consultant-27, ophthalmologists working in NGO-56 and ophthalmologists in private sector-257. Sixty (15%) responded with opinion. In the round-II, 200 (31%) including 60 of round-I, selected randomly but proportionately as before. Forty five (22.5%) responded with opinion. Result collated. The results and opinion of respondents were presented at a workshop attended by 24 (80%), out of 30 invited expert ophthalmic specialists for discussion, criticism, opinion, addition, modification and finally for validation. On the basis of the opinion of the respondents, reviewing literature, analyzing the ocular disease pattern in Bangladesh and also analyzing the present ophthalmology curriculum, a community and need based ophthalmology curriculum for undergraduate medical course in Bangladesh was developed. This research would help developing community and need based ophthalmology curriculum for undergraduate medical course in Bangladesh.


Introduction
The curriculum represents the expression of educational ideas in practice.It includes all the planned learning experiences of a school or educational institution.Curriculum development is a continuous process and always open for critique 1 .
Ophthalmic education is the cornerstone to improve eye care globally.Expert realizes the wide variability of educational standards, pattern and prevalence of diseases, social structures for provision of eye care in geographical regions.Therefore encourages continuous modification of curriculum according to the needs of different global communities 2 .
A curriculum should have room range for making it fit to prepare student for better future career opportunities and equip them efficient enough to meet the community need and demand.Curriculum should reflect society's need and should contribute in making shift the society for fulfilling the needs 3 .
Curriculum development should be a conjoint effort of all stake holders including the community, educational institute and recipient organization, who will be using the successful students in future.Developing curriculum in isolation will merely a guideline for teachers but those who will be taught will not be able to meet the need of the service providers 4 .
The purpose of the curriculum is to bring order, coherence and intellectual discipline to the transmission of stored human experiences 5 .
The curriculum exists at three levels: what is planned for the students, what is delivered to the students, and what is the student's experience.

Figure-1: Three levels of a curriculum
In contemporary medical education it is argued that the curriculum should achieve a "symbiosis" with the health services and communities in which the students will serve.The values that underlie the curriculum should enhance health service provision.The curriculum must be responsive to changing values and expectations in education if it needs to remain useful.Students Education improves clinical service

Curriculum Health Service communities
Clinical service improves education Figure-2: "Symbiosis" necessary for a curriculum 6 Bangladesh, a thickly populated country over 160 million inhabitants of which 72% are rural, farming is main occupation, 40% live below national poverty level and 44% are illiterate 7 .Rural people are poor, illiterate and under privileged and they are backbone of agro-based economy of Bangladesh and produce food for us.
There are approximately 626 Ophthalmologists in Bangladesh, 45% resides in Dhaka city alone 8 , 1 to 3 at district level and virtually none at upazilla level for 3.5 lac population.Whereas WHO recommends one for 50,000 in developing countries 9 .
There are approximately 675,000 blinds in the country, 75-80% of which is avoidable, either preventable or curable.Main causes of low vision are cataract 74% refractive error 18.7%, corneal deceases, retinal diseases, glaucoma, optic nerve diseases, diabetic retinopathy and so on 10 .There are about 40,000 blind children in Bangladesh 8 .The Government of Bangladesh has identified blindness as a critical and social health problem and has ratified the WHO program 'Vision 2020-The Right to Sight'.The national eye care plan is adopted for Bangladesh 8 .
The right to sight is equal for urban and rural people but reality is there is virtually no Ophthalmologist for rural 72% people.Last 10-15 years trend of producing Ophthalmologists and their distribution nationwide predicts least possibility of improvement by next 15-20 years.At this situation graduate physician working in rural area has great role to play at least to give primary eye care for unreached people.
General physicians' (GP) view their undergraduate ophthalmic medical education as inadequate and is reflected in their confidence and understanding 11 .
Inadequate clinical exposure and lecture at the undergraduate level is important reason why many GP do not treat the eye conditions but refer them to eye specialist 12 .
Medical education in South East Asia Region (SEAR) follows legacy of colonial past and perceived to be divorced from the real needs of the people 13 , also true for ophthalmology.Ninety percent common eye conditions are avoidable but emphasis on Primary Eye Care (PEC) is inadequate.However undergraduate students are not adequately exposed to primary eye care, which is essential for proper eye care in all countries of the South East Asia Region 12 .
In Bangladesh ophthalmology training is a part of surgery and evaluation is done with surgery during professional examination 14 .WHO recommends that, the curriculum for ophthalmology at undergraduate level needs to be reconstructed urgently, community eye care needs more attention, community oriented and community based teaching should be an integrated part of curricula, community ophthalmology should have designated teaching hours, training of faculty and faculty student ratio should draw attention & prioritization of learning topics should be done 12 .
Curriculum is product of consensus of all concerned.Through community need based development of ophthalmology curriculum and it's implementation maintaining a standard throughout nation to improve capability of graduate physicians during undergraduate education can ensure PEC and fulfill the obligation to serve unreached rural people to address the success of Vision-2020, The Right to Sight.
Current curriculum 14 determines a list of content rather than a total community need based curriculum, is effective as such for the last 8 years since 2002 without any enrichment.It could not adequately equipped enough the medical graduates with knowledge, attitude and skill to meet the community health needs.This is high time for modification to make it an effective training tool, to prepare efficient medical graduates to address the growing local eye care needs and for fulfillment of global commitment of elimination of avoidable blindness.
The objective of the study was to develop a community based curriculum on ophthalmology for undergraduate medical course in Bangladesh.Four key features may be regarded as necessary for defining a procedure as a 'Delphi'.These are: anonymity, iteration, controlled feedback and the statistical aggregation of group response.The original Delphi method used experts panel members 15 .In this study an attempt was made to select a sample of broadly representative ophthalmologists who within the term of this study represent a panel of informed experts by reason of their day to day involvement with eye patients in urban, sub-urban and rural areas dispersed throughout Bangladesh.Study approach includes two iterative rounds, validation workshop and finally development of new curriculum.

Research Instrument Round-I
A pretested questionnaire used in the first iteration which was designed as part of the largest study.The question was "What are the eye diseases with overall knowledge of their management one MBBS doctor should have?"The iteration was followed with a list of eye diseases, essential eye equipments, examination procedure required for diagnosis for opinion with a room to add new topics.

Round-II
Responds to first questionnaire was collated and the subject/ topics in each group rearranged according to the priority of importance and necessity from above bellow on the basis of the opinion of the respondent.Additional 33 topics proposed by the respondents were included in the list.The second questionnaire than developed, pre testing done and the question was "How much a MBBS student should acquire percentage of knowledge, attitude and skill on each subjects while being taught?"The list of the subjects/topics followed the question.In this round respondents requested to mark for knowledge, attitude and skill out of 100, according to importance considering each topic individually.Explanation with an example added how to respond in this iteration.These ratings were collated.Mean of knowledge, attitude and skills for each topic calculated.
Validation workshop: A workshop was organized chaired by the most senior ophthalmic scientists of Bangladesh, for discussion, question and answering, opinion, criticism, evaluation, addition, change or modification and finally validation.

Result
In the round-I Delphi, 400 (62%) out to total 641 ophthalmologist were randomly selected dividing in categories (62% in each) of Professor, Associate Professor, Assistant Professor, Consultant, ophthalmologist working in NGO and Private ophthalmologists.Sixty (15%) responded with opinion in round -I.In the round-II 200 (31%) ophthalmologists including 60 of round-I, selected randomly but proportionately as before and 45(22.5%)responded.
Result collated and finally presented at workshop participated by randomly selected panel of 24(80%) out of invited 30 expert ophthalmologists for discussion and validation.

Objective of the study
To develop a community based ophthalmology curriculum for undergraduate medical course in Bangladesh.

Selection of experts
Ophthalmologists working in teaching Institutions, consultant NGO & private practitioner ophthalmologists.
What are the eye diseases with overall knowledge of their management one MBBS doctor should acquire.

First round of Delphi
Second questionnaire How much a MBBS student should acquire percentage of knowledge, attitude and skills on each topic while being taught.

Second round of Delphi
Result analysis Workshop Discussion on the results and opinion of respondents by the expert ophthalmologists for evaluation, addition, criticism & validation Curriculum Newly developed community based ophthalmology curriculum for undergraduate medical course in Bangladesh.

Literature review Present curriculum analysis
Ocular disease pattern

Result and analysis of round -I
As a part of Delphi technique Round-1 questionnaire was mailed to the respondents for opinion against the question "What are the eye diseases with overall knowledge of their management one MBBS doctor should acquire?" A list of topics were given arranged around different concentrate like orbit, lid and so on.Topics were chosen by putting tick () in box marked with "agreed" or "disagreed".
Respondents opinion were calculated in terms of number and percentage showed against each topic.Result and analysis of round-2.
The second questionnaire in this round was: "How much a MBBS student should acquire percentage of knowledge, attitude and skill on each topic while being taught?" A rearranged list of topics according to priority followed this question.Respondents had the opportunity for allocating the proportion (out of 100) of knowledge, attitude and skill the student should acquire.Appropriate boxes were given against each topic to provide their choice.Respondents' opinions were calculated in terms of mean.

Discussion
In 1999 and 2000 The International Council of Ophthalmology (ICO) 2 and the Academia Ophthalmologic Internationalis developed an international strategic plan to preserve and restore vision: "vision for the future".This strategic plan involved multipronged approach to reduce visual impairment and blindness worldwide.As part of this strategic plan four international task forces were established one for to develop curriculum for training of medical students.
The taskforce while developing a curriculum on ophthalmology for medical students noted that: 1.In the 21 st century eye care has become increasing important in the general practice of medicine.
2. Vision is one of the vital factors influencing quality of life.Doctors should be aware of the community health need and their knowledge, attitude and skill should be shaped appropriately to address all those problems.Like other priority health problems, eye diseases are getting the attention of the health care provider due to its magnitude and undesirable outcome on the quality of life.But it is also hopeful that many of the eye diseases and its sequel are preventable.Many world health forum have taken eye care as one of the primary component of basic health care.These professionals are giving stress to general doctors as well as ophthalmologists capable enough to provide those primary eye care.
Doctor should be prepared in such a way that he will not play only the role of curer but also organizer for the community to lead forward for making a healthy community which Dr. Charles Boelen 16 mentioned in his word as a "Five Star Doctor", a doctor possessing a mix of aptitudes to carry out the range of services that health settings must deliver to meet the requirements of relevance, quality, costeffectiveness and equity in health.The five sets of attributes of the "Five Star Doctor" are: care provider, decision-maker, communicator, community leader and manager.Medical schools have an important role to play to produce such doctors.
The ICO 2 taskforce queried members of the International Federation of Ophthalmological Society and determined that all medical students should demonstrate competency in the following areas:-a) Measurement of distant and near visual acuity with and without correction.b) Determination of visual fields by confrontation technique.c) Assessment of extraocular motility in the six cardinal position of gaze and primary position.d) Measurement and interpretation of pupillary size and reaction to light.e) Penlight examination of the anterior segment including upper lid eversion.f) Examination of the optic nerve and posterior pole with direct ophthalmoloscope.g) Removal of superficial corneal or conjunctival foreign body.Our research reflects the same opinion.
In addition ICO suggested the graduating medical student should be able to make the following diagnoses and initiate an appropriate treatment or referral plan for the following conditions: conjunctivitis, cataract, corneal ulcer, corneal and conjunctival foreign body, hypertensive retinopathy, glaucoma, uncorrected refractive error, ocular trauma, papilledema, hemianopic and bi-temporal visual field defects, acute onset of cranial nerve palsies III, IV, VI, VII, acute onset strabismus and leukocoria.
The current curriculum on ophthalmology for undergraduate medical course in Bangladesh is effective from 2002 14 , which determines a list of content rather than a total community need based curriculum.The goal of the present curriculum is to make the students to be competent in taking appropriate history, carrying out examination of eye with the ability to diagnose and plan for the treatment of stye, chalazion, dacryocystitis, conjunctivites, corneal ulcer, iritis, glaucoma, cataract, retinoblastoma, ocular injury, vit-A deficiency (ocular manifestations), refractive errors and orbital diseases.
In round-I of the study respondents chosen all those topics areas as priority.Pattern and prevalence of eye diseases differs time to time in geo-graphic region, country to countries and place to place inside a country.So it needs continuous modifications of curricula according the needs of different global community.
The study was conducted on randomly selected 8409 (even numbered out of total 16,818) new eye patients attended at out patients department (OPD) of Dristisheba O Gobeshona (private eye care centre), Jamalpur during 2003-2005.Main features are as follows:  The ocular disease pattern in Bangladesh was a top concern while developing this curriculum.The priority topics chosen for skill development by the respondents in round II given below is very much consistent with ocular disease pattern in Bangladesh.Though refractive error, retinoscopy and correction of refraction scored 20% in topic choice component in round-I and scored 18%, 17% & 20% respectively in skill component in round-II, although refractive error occupies the top of ocular diseases profile in patients attending in hospitals, both urban, suburban & rural eye centers, practice of refraction to develop skill for correction of refraction is not included in the current curriculum.But respondents opined in favor of it.In the existing undergraduate ophthalmology curriculum, topics included from topic concentrate community ophthalmology is school sight testing program.A good number of topics other than above one were proposed by respondents in Round-I Delphi to include in curriculum.Those are primary eye care, day to day eye care, vision-2020, The National Eye Care Plan of Bangladesh, magnitude of blindness, epidemiology of common eye diseases, strategies for prevention of blindness, community eye organization and eye health education.All these topics were chosen to add in Round-II Delphi by the respondents.In the study report by WHO in SEAR countries these topic are mentioned and urged to include with importance in curriculum.
In regard to the training hours for the under graduate medical course the task force of ICO strongly recommends that all medical schools include ophthalmology as a part of the essential curriculum and not exclusively as an elective.The task force estimates that the total educational commitment throughout medical school will require approximately 40-60 hours exposure.The same committee also recommended three teaching methods to achieve educational goal: didactic lectures, clinical demonstration: illustrative case method study and evidence based medical teaching to fulfill the learning.
In the present curriculum teaching methods and allocated teaching hours suggested is very much consistent with suggestion of ICO and is as follows: Lecture, tutorial (clinical demonstration), demonstration (in OT), case presentation, video, school sight testing But study reveals that in SEAR countries 10 48.74% of medical college has less than 30 lectures scheduled for ophthalmology, set with higher hours including Bangladesh.In 66% of medical colleges duration of OPD posting was less than 30 days.Similarly in eye words 58% with less than 30 days posting, exception in India with longer duration.In 68% of colleges a separate examination in ophthalmology was conducted as like ours though as part of Surgery.Over 95% of the colleges reported conducting some form of internal assessment during undergraduate medical education.Forty three percent institutions had no specific hours allocated for community ophthalmology training, only in few institution (mostly in India) were more than 10 hours devoted to community ophthalmology teaching.Over all more than 80% stated that community ophthalmology training in the region was inadequate.In our present curriculum there is no designated hours for community ophthalmology but respondents opined in favor.Respondents also opined to incorporate the learning domain attitude for each topic of the curriculum.

Conclusion:
Finally on the basis of the opinion of the respondents, reviewing literature, analyzing the ocular disease pattern in Bangladesh and also analyzing the present ophthalmology curriculum, a community and need based ophthalmology curriculum for undergraduate medical course in Bangladesh was developed.This research would help developing community and need based ophthalmology curriculum for undergraduate medical course in Bangladesh.

Table - I
: Distribution of participants in Delphi round-1

Table -
III: Topics arranged according to the priority based on the analyses of the all precious topics of round-I.

Table -
VI:The topics/diseases given weightage from 100% to 50% in round-I are rearranged according to priority under each topic concentrate heading.

Table -
VII: Main features of ocular disease pattern in rural Bangladesh

Table -
VIII: A comparative analyses of ocular disease pattern of urban and rural hospital of Bangladesh

Table - X
:Teaching hours allocated for ophthalmology: