The presentation of results is at two levels: PRECEDE results and PROCEED results. The first are mainly descriptive (to tell and analyse the facts). PROCEED results are more normative, leading to certain recommendations for practitioners and other actors.
PRECEDE results
To facilitate presentation of the results and understanding of this coherent, overall vision of the interrelated elements, it was considered pertinent to retranscribe the full model as it exists for the 6th Directorate of the DRC's Ministry of Health.
To structure the results' presentation, we shall follow the order in which the model's construction progressed. The table must be read from right to left, starting with the epidemiological and social diagnosis, then going on to the behavioural diagnosis and from there to the analysis of the educational and environmental determinants of these behaviours, and then to end with the analysis of the institutional diagnosis (see Additional file 1).
Epidemiological and social diagnosis
In the Ministry of Health, all the players are concerned by the mortality and morbidity indicators in the country. For health professionals, the lack of quality of the service provision and care provided by their health system is an obvious cause of the people's lack of confidence in their health system [8]. However, to produce a verifiable systemic analysis and then effective strategic synthesis within the directorate that interests us, the problem of the directorate in charge of health science education must first be clarified in connection with this broader problem. Thus the mismatch between health science teaching and the competence that health professionals are expected to have was seen as connected to the lack of quality in health care and services. All the players on their various organizational levels – ministry staff, teachers, basic supervisors, donors and project officers – took this diagnosis on board as a major concern.
Behavioural diagnosis
Who are these players and what behaviour can explain, through a direct link, the diagnosis of inadequacy? In answering these questions with the players themselves, we discover that there are groups of players that are never clearly identified yet are clearly related to this problem of inadequacy. This is the case, for example, of the donors and nongovernmental organizations (NGOs).
Revealing all the groups of players makes it possible to see more easily why importance should be given to a multisectoral approach, especially one that covers teachers and medical and paramedical professionals. If the population is considered a group of players that is separate from the problem at hand, it will not be possible to take it into account in setting up action strategies, to the extent that the aim of such work is to better define people's expectations in terms of the quality of care and arrive at a better understanding of their behaviour.
During the discussions, the teachers felt that priority had to be given to separating the group of teachers from that of intern supervisors in order to better highlight the particularities and role of the field training. The school managements revealed their specific role in this problem of mismatches. Indeed, the teachers' and supervisors' behaviour is strongly linked to their own behaviour in dealing with changes [9]. We have presented one or the other behaviour for each of these groups of players as examples only.
Environmental diagnosis
This diagnosis allows for the factors that are linked to the environment and are direct causes of the epidemiological and social diagnosis. In a context such as that of the DRC, geopolitical and socioeconomic factors head the list, along with the health structures' inaccessibility. To take a more constructive approach without denying reality, it is necessary to focus the analysis of this diagnosis on the more targeted problem of the inadequacies in the training sector. This reveals variables that are more controllable for the levels that are concerned and that everyone agrees are connected to the problem. These are: the learning environment, teaching environment, class hours that facilitate or hamper certain types of learning, etc.
Educational and motivational diagnosis
The educational diagnosis enables one to home in on the educational and motivational determinants, which must not be overlooked when one goes on to an interventional phase. To the extent that the systemic approach gives significance to each group of players (teachers, learners and others) as well, as is the case in the DRC, it is fully possible to set up a frame of analysis, assessment and action-research that presents the variables and determinants in a PRECEDE model that are specific to each specific group (action-research framework). This is what was done in the DRC to follow the changes in teaching practices, in conjunction with each intervention that was identified, that were made in the specific group of teachers. The results show that it is relatively easy to separate the educational determinants from each other in order to facilitate subsequent reflection about the strategic action to take.
The predisposing factors that concern knowledge, experience, attitudes, perceptions and representations have a key place in relation to the behaviours of the players of interest to the Directorate for Education. This construction shows clearly that the training given is usually concerned with knowledge only and generally does not make use of the learners' life experiences.
The other important result is to be able to visualize the place of representations in a conceptual framework that will likewise be used for the action. For example, there are the various representations of learning theories when it comes to teaching methods or unfounded beliefs about the quality of care. Specific models exist that enable one to delve much deeper into perceptions and beliefs [10, 11]. These are complementary research models. When we are seeking to develop a tool that can be used to construct an operational model for strategic choices of action to take on a high institutional level, the possibility of providing this place for representations and beliefs is already vital and elucidating.
The enabling factors in terms of actual competences (skilfulness, know-how and behaviour) are too often disregarded and underestimated in interventions. Incorporating them in this model thus enables the directorate in charge of this branch of education to check to what extent the projects, programmes and other support measures consider this priority strand in terms of development independence.
The reinforcing factors, which are sometimes also referred to as facilitating factors, are the determinants that act upon the positive feedback loops. The importance that all the players give to this type of variable in constructing the model confirmed the need that the directorate had already felt to find means to set up long-range monitoring mechanisms for the various activities engendered by the programme or by some more specific projects.
The model contains a certain number of variables. It is clear that it can be enriched in the course of the process through its use and the players' better discovery and gradual appropriation of its features.
Institutional diagnosis
In terms of results, the institutional diagnosis requires analysing the situation at the organizational level that corresponds to the level of the model's application. This is a national health science education programme under the Ministry of Health. As such, the institutional diagnosis stresses essential strategic variables if one wants to work on a well-knit, comprehensive set of changes. It thus entails the need to analyse the institutional standards when it comes to inspections and assessment, but also those governing health system management and health sector human resource quality management (for example, the existence or lack of a Nursing Board). This is also the level on which we shall discuss how the programme dovetails with other variables and determinants.
PROCEED results
Before strategic thinking can be put into place based on this situational analysis, it is possible to go on to a more dynamic reading of the relations between determinants and variables. So it is that the DRC's Ministry of Health directorate in charge of health science education foresees a certain number of strategic axes for action. The aim of the action is the problem's translation into an objective form. The directorate thus considered its main goal to be to improve the match between what is learnt in schools and health professionals' needs and the population's expectations.
To better understand how the reading of the conceptual model brought us to the action strategies, it is useful to stress an intermediate step that is summarized in Figure 2.
A natural adaptation of the PRECEDE model was to define the groups of players by their behaviour. In this way, we obtained a better picture of the division of responsibilities to achieve a common goal and evidence of the need for interdisciplinary work [12]. A comprehensive reading of the PRECEDE model points us towards a strategic choice that integrates an institutional and educational approach from education with an epidemiological and social approach from health and welfare. The players in their respective environments are located between the two. This model shows the need to find a common thread between education and health needs that allows for the place and role of each group of players in their context.
The results bring to the fore a number of behaviours that attest to a lack of independence, absenteeism, lack of collaboration, failure to connect theory and practice, a lack of communication, ignorance of the teacher's role, etc., depending on the group. Examination of these results prompts us to stress the importance that must be given to the learning environment and, when it comes to action strategies, the importance to give to a learning environment that is in tune with the strategic axes that are selected, in this part just as in the other parts of the situation's analysis.
Given this finding and the need to link the educational and institutional diagnosis with the health problem (seen as an appropriate form for education), one proposed strategic hypothesis is to favour learning techniques that are based on active teaching methods [13].
In going consistently through the various diagnoses and organizational levels, this choice led the education directorate to think about changing its programmes and standards so as to base them on novel teaching concepts such as skills-based learning [14] and setting a skills reference framework on the basis of in-depth research done with the entire set of clearly identified target populations.
The reading of these results in terms of strategic action reveals the need to bolster the analytical and planning process that already exists within the directorate to pay more attention to the educational and environmental determinants for all the target populations concerned. To our mind, the success of the expected changes in terms of narrowing the gap between the "supply" and the "demand" hinges on this.
The following diagram summarizes the strategic axes that the Directorate for Health Science Education chose to achieve this objective on the basis of the PRECEDE analysis (Figure 3).
This figure reveals four axes to be reinforced:
-
to reinforce communication and coordination in conjunction with the other reinforcing factors: the pilot schools' teaching method committees, teaching monitoring and feedback, the setting-up of networks, etc.;
-
to develop methods to enhance the learner's autonomy: active teaching, constructivist approach, interdisciplinary, critical spirit, etc.;
-
to foster a learning environment that enables the learners to acquire knowledge: library, teaching materials, computer learning, computerized documentation centre, etc.;
-
to provide institutional and structural support: standards and curricula in tune with teaching and organizational innovations and skills targets that fit health professionals' needs and meet the community's expectations.
The discussion will take place on two levels – the operational and the conceptual. On the operational level, we feel it is interesting not to dwell on the presentation of the model as it could have been applied, but on its actual application. The results are presented so as to allow the reader to understand how to organize the problems that are felt to exist in health science education in the DRC.
Even if the Directorate for Health Science Education is well aware of its problems, the systemic modelling of the interconnected variables and populations seems to give it a conceptual and operational tool that is useful on various levels, as follows:
-
tool for dynamic analysis of the situation with regular updates;
-
tool for systemic planning that also enables the directorate to put forward arguments in dealing with donors and NGOs in the sector;
-
assessment tool that gives more importance to assessment criteria such as cohesiveness, consistency, relevance, appropriation, and comprehensiveness, i.e., process criteria;
-
research and evaluation tool that can also promote a more quantitative approach to analysing the relations between variables and various diagnoses or within the same diagnosis;
-
a dialogue-enhancing tool, for it gives the groups of players involved a vision of the planned change and a common objective.
To sum up, this is a tool that provides a certain guarantee that the strategy development process is informed, meets the needs and is complete [15].
The list of these advantages is obviously based on some baseline conditions: a participatory process in which the model is developed and operates and the appropriation of the concepts that subtend the model [16]. Even though it was more difficult to describe how the intervention strategies are set, based on the construction of this model, we should like to stress that a complete analysis of the situation that is based on this systemic approach usually reveals the relevant strategic axes on its own and despite the protagonists' limited ability to synthesize the situation.
On the conceptual level, the discussion will revolve around Figure 4.
We observed through the PRECEDE analysis and then the PROCEED strategic reflection phase that many disciplines converged in order to lead us to this hypothesis and a common objective of needs-matching. Indeed, when action is carried out it will be a matter of achieving a gradual advance that occurs along the (horizontal and vertical) strategic axes defined earlier in this article. Moreover, we are confronted with strategic choices that involve at least three dimensions: a public health approach, an education approach and a sociological approach.
These three dimensions are part of the data collection process's success, as well as the success of the strategic choices that follow. This reinforces the fact that the PRECEDE PROCEED model comes from the development of an approach aimed at meeting the need for education and health promotion tools and methods. So it is that we see numerous applications of this process in technical health education establishments that spring from a true systemic analysis of the problems with full mastery of a structuring capacity, unlike some other models such as causal analysis (17).
Similarly, we can consider that defining a problem at an institutional and organizational level also requires the identification and involvement of all the parties concerned. We can also consider that the tools that help to understand the relations between elements and insist on a better search for behavioural determinants are prerequisites for organizational learning that has groups of players interact with each other. This is all the more true if the change that is ultimately expected (a match between two sides of the equation) is contingent on changes in the players' behaviour and practices, as is the case of health education.
In terms of limits of this research, it targets the analysis of an inadequacy within human resources' management in health, which is that of training of nurses from professional technical levels. Other levels of inadequacies are worthy to be analysed in a complementary way relating to other health professionals, the sectors of health and education planning. The Green model is complementary to the use of methodological dynamic references much as the management of the project cycle focuses on managing interventions or projects whose aim is to contribute to changing a situation from unsatisfactory to satisfactory. Its use within the framework of the project could obtain more means while enabling developments relating to action research. In this context, the contribution from other disciplines, such as psychology, could be reinforced.