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WPRO 6201
FIRST REnIONAL WORKSHOP ON THE TEACHING
OJ!' NU'lRITION IN SCHOOI.8 OJ!' MEDICINE
Sponsored by the
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WORlD HEAL'm ORlANIZATION REnICliAL OFFICE FOR
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WES'lERN PACIFIC
Manila, Philippines 24 to 30 September 1974
FINAL REFORI'
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Not for Sale Printed and Distributed by
the
Regional Offioe for the Western Pacific of the World Health Organization Manila. Philippines October 1974
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CONTENTS
• 1. 2. 'R:EX::~DATI ON S
•••••••••••••••••••••••••••••••••••••••••••••••••
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rnmoroCTIOO •.••..•••••••••.••.•••..••.•••••...••.•••.••••...•.• ~TlVES:
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ORGANIZATrON AND ADMINISTRATION ••••••••••••••••••••••••••••••••• 3 COtJN'lRY' Ql1E.STIO:NlJAIRE ••••••••••••••••••••••••••••••••••••••••••• DI::K:USSIONS •••••••••••••••••••••••••••••••••••••••••••••••••••••
5. 6. •
4 5 5
6.1
Teaching content (educational obJeotives) •••••••••••••••••
6.1.1 6.1.2 6.1.3 6.1.4 6.1.5 6.1.6 6.1.7 6.2
Approach •••••••••••••••••••••••••••••••••••••••••• Coordination •••••••••••••••••••••••••••••••••••••• Applioation ••••••••••••••••••••••••••••••••••••••• Scope ••••••••••••••••••••••••••••••••••••••••••••• Adaptat10n ••••••••••••••••••••••••••••••••••••••••
Breakdown Cheok list
·....................................... ......................................... 13 13
5 5 5 13 13
Teaching teohnique
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6.2.1 6.2.2 6.2.3 6.2.4
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6.2.5 6.2.6 6.2.7 6.2.8 6.2.9 6.2.10 6.2.11 6.2.12 6.2.13 6.2.14 6.2.15
Learning through doing •••••••••••••••••••••••••••• Community medicine survey and basic soience symposium Community health survey of the University of S1n8apore Problem-solving basic science and basio soienoe symposium Integrated teaching - the ind1 vis1blli ty of medicine Group assignments Small group teaching - interdepartmental cooperation
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·........................................ 17
·........................................ 18 ................................. 19
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The malnourished student •••••••••••••••••••••••••• 20
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................................. 19 20
Nutri tlon and pharmacology •••••••••••••••••.•.•.•• 21
...................................... 21 Introduction to medicine course .. ................. 21 . Teaching staff •..•..•.••.•••••.•••..•.•..•.•••.••• 21
The cost and content of foods - the food prescription
Educational support service ••••••••••••••••••••••• 22 Multimedia library •••••••••••••••••••••••••••••••• '22 Audio-visual aids made by students •••••••••••••••• 22
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• 6.3 Evaluation.......... . .... .. ......... ••.• •••.•.•. ................... .••. .... 22
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6.3.1 6.3.2
6.3.3 6.3.4 6.3.5
Instruments for evaluation •••••••••••••••••••••• Formative and surnmative evaluation •••••••••••••• Continuous assessment ••••••••••••••••••••••••••• Simulation ...............................................................
22 22 23 23
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6.3.6 6.4
Objective tests (multiple choice questions) ••••• Teaoh-test-mark-discuS8 •••••••••••••••••••••••••
23 23 23 29
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Example - instruction on vitamin A disease in olinical nutrition •••••••••••••••••••••••••••••••••••.••
7.
EVAWATION OF '!HE WORKSHOP ........................................................................
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ANNEX 1 - LIST OF PARTICIPANTS •••••••••••••••••••••••••••••••• 33 ANNEX 2 - LIST OF DOCUMENTS GIVEN TO PARTICIPANTS ••••••••••••• 39
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1.
RECOMMENDATIONS
• 1.1
To medical schools Although all schools teach some aspects of nutrition, much essential teaching is apt to be omitted and there is often unnecessary duplication and a lack of integration. It is therefore recommended that schools should take further steps to identify what their graduates should do in the field of nutrition when they qualify, and design the curriculum to achieve it. As some assistance towards doing this it is suggested that curriculum committees should examine the check list of educational objectives in Section 6.1.7. There should be at least one staff member with special training in nutrition on the staff of a faculty, and he should coordinate nutrition teaching. If such a staff member does not exist, a sui table person should be sent for training. Students should be made aware of the career opportunities available in nutrition. To WHO 1.4 At ~ earliest opportunity WHO should if possible, produce a . "nutrition learning system" for medical students with the following integrated components: (a) (b) (c) a fully specified set of educational objectives an 'action oriented' nutrition textbook for medical students a set of audio-visual aids a set of evaluation instruments, including a bank of multiple choice questions an instructor's guide containing suggestions for practical teaching
1.2
1.3
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(d) (e)
This set of components could be adapted to local circumstances and would assist understaffed schools to attain a minimum standard of nutrition teaching. Better staffed schools could develop their teaching from this foundation as their facilities permitted. 1.5 During the next three years WHO should write annually to participants in the Workshop to find out what change, if any, has occurred in the teaching of nutrition at their schools .
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• 2. INTROOOcrION
In Asia, excluding China and Japan, there are an estimated 70 million children aged 0-4 years suffering from severe or moderate protein calorie malnutrition. Iron deficiency anaemia affect.s more than 20% of Asian women, and 40% of those pregnant. In some areas as many as 9o,r; of children under two suffer from it. Studies in the Americas have shown that malnutrition is directly or indirectly responsible for over half the deaths in children under five. l Doctors have a great part to play in combatting such malnutr1t1on, but to do so they have to be adequately trained. There is evidence that the nutrition training presently given to many medical students could be improved, and with this in mind it was decided to hold a six-day workshop at the WHO Conference Hall in Manila to bring together 16 faculty members from schools of medicine in Australia, Fiji, Hong Kong, Japan, Laos, Malaysia, New Zealand, Papua New Guinea, Philippines, Republic of Korea, Republic of' Vietnam and Singapore. The Workshop was directed by Dr George Christakis, Adjunct Professor of Nutrition, Florida Atlantic University, Boca Raton, Florida, U.S.A. He was assisted by Dr Florentino Solon, Executive Director of the National Nutrition Council and Nutrition Oenter of the Philippines; Dr Maurice King, WHO Medical Officer, Interregional Project on Strengthening of Health Services, the Lembaga Kesehatan Nasional, Surabaya, Indonesia; Dr Corazon P. Gonzales, Professor of Physiology, College of Medicine, University of the Philippines. Dr L. He.sselvik, Director of Health Services, speaking on behalf of the Regional Director, said when he opened the Workshop that in the past, "Nutrition teaching in medical schools has usually been oriented towards biochemistry or physiology and was apt to reflect what the teacher felt was new or scientif1cally interesting. Fortunately, however, new winds are blowing through medical education. We have become conscious that it is impossible for any medical student to learn all the facts. Slowly we are discovering how to select the most relevant intellectual seeds and to refine our technique of planting and nurturing them." "It 1s my view", he said, "that those of use who train doctors to serve ,in this Region must first determine what applied skills our graduates will require. From this we can determine what ablli ties and knowledge they must be given and what basic scientific facts they require in order to understand, apply and adapt their knowledge. To me, the ability to act in a practical and effective way is paramount."
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• ~O Chronicle, 1974, 28, 3 - 7
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• 3. OBJEcrIVES
The objectives of the Workshop were: 3.1 3.2 to review the present content and methodology of teaching nutrition in medical schools in the Western Pacific Region; to consider the most appropriate ways of undertaking the teaching of nutrition in a medical school ; and to identify the main areas where improvements are needed and how best to implement these.
3.3
4.
ORGANIZATION AND ADMmISTRATION
Groups and committees. The participants were divided into three working groups, each group consisting of about five participants, and the consultants, advisers and observers attached to them. Save for the first day one group dealt with basic science, another with clinical and a third with community health components. Each group elected its own chairman and rapporteur. A steering committee was established to ensure the smooth running of the workshop and to adjust the programme from day to day. Tuesday, 24 September 1974. The Director of Health Services, Dr L. Hesselvik, gave a welcome address on behalf of the Regional Director; the Re'gional Adviser in Nutrition, Dr Leslie B.lrgess, then described the purpose of the workshop and the conclusions drawn from the participant's questionnaire replies, after which the Director of th~ Workshop, Dr George Christakis, outlined its scope and methodology. The partiCipants, consultants and secretariat then introduced themselves. Dr Maurice King then spoke on the general and specific objectives in the teaching of nutrition in medical schools. This was discussed by the working groups, who defined detailed educational objectives for one or other of three topics - protein-energy malnutrition, vitamin A deficiency and the hyperlipidaemias. On subsequent days, these same three topics were considered from the point of view of how they should be taught and evaluated. Wednesday, 25 September 1974. Working groups continued to diRcuss objectives during the morning and then presented their reports, which were discussed in plenary session during the afternoon. Dr George Christakis spoke on current trends in medical education and the strategy for inserting nutrition in the medical school curriculum. This was followed by Dr Florentino Solon on course designs in nutrition teaching.
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• Thursday, 26 September 1974. Working groups had discussions on the course design and on how the three subject areas, the educational objectives for which they had discussed the previous day, could be taught. They presented their conclusions during the afternoon, after which there was a panel discussion on teaching techniques and resources by Drs Christakis, Gonzales, King and Solon. Friday, '27 September 1974. Working groups discussed teaching techniques and resources during the morning. IXtring the afternoon, participants visited the University of the Philippines, Community Health Center, Bay, Laguna to obtain a feedback from senior students and new graduates. '!hey also visited Tagumpay Village, and the Inte rnational Rice Research Institute. Saturday, 28 September 1974. Working groups presented their reports on teaohing techniques to a plenary session after which Dr Corazon Gonzales and Dr Teoh Soon-Teong both spoke on evaluation methodologies for the teaching of nutrition in medical schools. IXtring the latter part of the morning this was discussed by the groups. Monday, 30 September 1974. Groups presented their discussions of the previous Saturday in a plenary session after whioh Dr Jose Cuyegkeng spoke on administrative strategy for the inclusion of nutrition in medical schools. The draft workshop report was then presented, discussed and amended. The Workshop was then closed by Dr Christakis and the Regional Director, Dr F.J. ny.
5.
COUNTRY QUESTIONNAIRE
Before coming to the Workshop each participant had completed a comprehensi ve questionnaire. Analysis revealed that the schools from which partiCipants came varied widely in terms of the number of hours devoted to nutrition teaching, both in the classroom and in the field, in the number of staff qualified in nutrition and in the number of books and journals in the library. FUrthermore, the tasks new graduates would undertake and the responsibilities they would assume varied widely with the level of development of their countries. These questionnaires have not been analysed further since much of the data they contain 1s not statistically comparable.
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6. 6.1
DISCUSSIONS
Teaching content (educational obJectives2
6.1.1 Approach The Workshop defined what a doctor should be able to do in the field of nutrition by listing the major objectives that a medical student should be able to achieve during his undergraduate course. These objectives are listed below and are derived from the role of a composite 'master perfonner' (Figure 1) who is both a general duty medical officer leading the health team of his district, and a clinician in his ward or health centre. They are defined as a single overall purpose which has been broken down into a number of lesser objectives ('goals' and 'purposes') (Figure 2). Al though much further analysis is required before these can be considered pedagogically adequate, they span the whole field of nutrition as members of the Worltshop felt it should be taught in an undergraduate curriculum.
6.1.2 Coordination Nutrition overlaps .several established disciplines in the medical school, and has in addition special concerns of its own which are often neglected. This relationship is shown in Figure " which also shows the overlap between physiology and biochemistry that is found in some schools. No attempt has been made to allocate objectives to departments of physiology, biochemistry, medicine, paediatrics, social medicine or nutrition, because the best way of handling them will differ so much from one school to another. Instead, it is recommended that the curriculum committee in each school should go through the objectives in the list below, allocate them to one department or another, and provide enough time for them to be achieved. The cOlllllWlity aspects of nutrition will probably require about 75 hours. In a large well staffed school it may be appropriate to have a special department of nutrition. Where this is not poSSible, it is recommended that nutrition teaching be coordinated by the department of community medicine. 6.1.3 Application The list of objectives may seem a long one, and on first sight it might appear much too extensive to be realistic. However, only limi ted competence in regard to some of them is necessary, and in a well designed course most could be achieved rapidly. If a similar analysis is made across the entire curriculum it will probably be found that substantial economies can be made in some subject areas where material is taught which is much less necessary than that relating to the objeotives listed here. It may also be possible to reduce some of the overlapping that is often found. When finally agreed to, it is ' hoped that students will be given the objectives as a guide to their studies.
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WHAT DOES THE
MASTER PERFORMER
II' ACTUALLY DO?
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HAVE TO CESIGN OUR CURRICULA SO iHAT STUOENTS ARE ABLE TO 00 CERTA'N CAREFUL.LV SPECIFIED THaNes WHEN THEY QUALI FV. WHAT THESE THINGS ARE CAN BE DERIVED FROM WHAT MASTER PERFORMER'S 00 IN A REAL L-IF"E SITUATION.
Figure 1
A HIERARCHY OF OBJECTIVES
PURPOSE
GOAL
GOAL ~ o
PERFORMANCE
PERFORMANCE
PERFORMANCE
PERFORMANCE
SKILL/ KNQWLEOe£
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SKILL/ KNOWLEDGE
II
SKILL/ KNOWLEDGE
II
SKIl.L/ KNOWLEDGE
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SKIl.l./ KNOWl.EDGE
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SKILL/ KNOWLEDGE
SKILL / KNOWLEDGE
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SKI l.L / KNOWLEDGE
Figure 2
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NUTRITION OF AT ~,)..~l NOT TA.UGHT
IS OFTEN ALL. IT HAS EITHER TO BE COVERED ey A efJECIAL oe~RTMENT OF NUTRIT
THIS PART
COMMONLY OMITTED INCLUDE ~~~~~~~~ TO ANY KNOWI..EDGE OF FOOD COMPOSITION • THE ABILITY DO A NUTR.ITlON SURVE ~~~~ Kfi<)WLE Y, AND DGE OF ",,'f"/"
..,,:,)1(;"
DEPARTMENTS.
OR BY ~ON. BJECTS
OTHER.
THE HYPERLIPIDAEMIAS
~"U'M
ME DIC INE 11111/1111111111111111111111111
M A DIA GRA ' W THE SHOTIN& RIT 'ON TO ;lC.I& OF NU" HIP O;!L ATI ONS IN A FtTM ENT S SCH OOL . Figur e
MeDICA~
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6.1.4
Scope
Unfortunately, it has not been possible to define the exact level of detail required by most objectives. For example, " •••• outline the synthesis of cholesterol •••• " might be interpreted as requiring half an hour or ten. The main purpose of the check list is to help to define a minimum level of competence across the entire field of nutrition by describing all the objectives that are to be achieved, at least in an elementary way. At the present time students too often graduate without knowing the composition of even the most important local foods, and sometimes without being able to recognize the common deficiency diseases. 6.1.5 Adaptation
These objectives are suggested as being suitable for schools which are moderately well financed, equipped and staffed. Some reduction may have to be made in schools which are less fortunate than this, or some extension in those which are more fortunate. Some obJectives will need particular emphasis in a developing country and others in an industrial one. Even so, students in either type of oountry should know something about the nutritional problems of the other. 6.1.6 Breakdown
The objectives are numbered here in a way whioh will enable them to be broken down further. Thus item 18, "(a) describe and (b) apply the principles of nutrition education" is & major objective and embraoes as one of its subsidiary objectives item 18.1, whioh is being able to "give nutrition education lessons •••• As used here, the word 'desoribe' means in effect .. to be 'able to answer multiple ohoice que.tions on' •••• " 6.1.7 Cheok list or objeative, Overall objective The student must be able to (a) prevent, (b) diagnose and (c) treat nutritional disease in the individual and the community. Subsidiary objeotives The student must be ABLE TO: (1) describe the general structure of the macro- and mioronutrients, and also their digestion, absorption and metabolism. (Detailed structural formulae are not required, and it is not considered necessary, for example, for a student to be able to draw the struotural formulae of the amino aoids.)
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(2)
describe the interrelationships between protein, fat and carbohydrate in the diet;
(3) list the essential amino acids; (4) describe the qualitative difference between food protein in terms of essential amino acid content, limiting amino acid, and NPU,
(5) state the approximate protein content of the major foods; (6) state the recommended protein and energy allowances for a child of two and for a reference man and woman, and also the additional allowances for pregnancy and lactation; list food sources for the more important micro-nutrients: (a) (b) (c) (d) (e) (f) recognize the structural formulae of the sterol nucleus: outline the pathway by which cholesterol is synthesized: describe its metabolic functions and catabolism; state the age specific normal levels for serum cholesterol and lipids; list the foods, drugs and other factors which influence serum lipid levels; and describe the relationship they have to arterial disease:
(7) (8)
(9) describe the metabolic abnormalities, pathology, epidemiology, diagnosis, prevention and treatment in the individual and the community of the diseases, both clinical and sub-clinical, caused by excess or deficiency of any of the macro-nutrients and of the more important micro-nutrients, including carotene and retinol, thiamine, nicotinic aCid, riboflavin, folic acid, pyridoxine, ascorbic aCid, cholecalciferol, Vitamin K, iron, iodine and fluorine. Besides protein-energy malnutrition, the major avitaminoses, hyperlipidaemia and arterial disease, the nutritional conditions covered by this objective include: the childhood determinants of obesity, anorexia nervosa and the dietary problems of ill-advised slimming, food zealotry (food fadism), drug abuse, alcoholism, the student life, old age and urbanization.
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(10)
(a) (b) (c) (d)
take a nutritional history; examine a patient; investigate him by locally available methods; and treat him for any of the diseases considered in objective 9;
(11) (12)
describe the global nutrition situation and its relation to population; describe the consequences of malnutrition to the individual and to society; (a) describe current views on the effect of malnutrition on mental and physical development;
(13)
describe the major social and economic factors responsible for malnutrition in his own community and some of the more important factors that operate in other parts of the world. together with some indication of the methods that can be used to alleviate them; (a) describe the interaction of nutrition and infection; describe the food habits. customs and practices of his own community; and distinguish those which are advantageous from those which are not;
(14)
(a) (b)
(15) (16) (17)
describe the local method of classifying food; conduct a simple nutrition survey using clinical and anthropometric methods; (a) (b) obtain; and interpret data on an individual or a family's income, food sources, food storage methods, cooking procedures, diet and ways of distributing food among its members; describe the advantages and disadvantages of the methods used to obtain such data; use tables to determine from such data the family's daily intake of macro- and micro-nutrients. The student should also be able to use tables toftnd out the family's intake of nutrients
(c) (d)
(e)
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and the percentage of its requirements that have been met. He should be able to (f) (g) (h) (i) (18) (a) (b) describe: and comment on any imbalances found: teach the family to use acceptable and easily available foods to correct these imbalances: and restate the corrected family's diet in terms of daily nutrient intake. describe: and apply the principles of nutrition education. (18.1) (18.2) (18.3) (19) (20) give nutrition education lessons to an individual or a group: prepare a food demonstration; prepare and use audio-visual aids including a flannelgraph.
describe the most significant improvements in agricultural methods by which poorer families can improve their diet; describe the important contaminants of food and their effects; (a) investigate an outbreak of food pOisoning; give examples of food standards; and be able to find out more about them:
(21)
(a) (b)
(22) (23)
examine a ki tchen and make any necessary recommendations on the improvement of its hygiene; describe the nutrition services of the country, including day care oentres, nutrition rehabilitation units and feeding programmes for schools and industries; describe the locally appropriate ways by which families can increase food production and improve its storage;
(24)
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(25)
<a) (b) (c)
lead; teach; and administer his junior staff and any other appropriate workers in the improvement of nutrition, especially nutritionists and social workers. list the national and international agencies concerned with nutrition; and deaoribe their major roles.
(26)
(a)
(b)
Obviously, these objectives differ in magnitude and importance and many of them will require breaking down into further subsidiary performance and skilljknowledge objectives. Their orientation towards and deviation from the "master performing" new graduate is obvious. 6.2 6.2.1 Teaching technique 'Learning through doing'
Nutrition can be taught by most of the traditional methods, but there are some which are particularly useful and there are many important details. The following pages describe some ot those which members of the Workshop had found useful. Most of them actively involve the student in learning through doing. However, in many countries. a student's earlier educational experiences have so accustomed him to 'spoon feeding' that he ini tially resents newer methods which teach him to teach himself. and to go on doing so. These methods are particularly important under such circumstances. but they need to be introduced patiently. A valuable way of improving stUdents' learning patterns is to have a short introductory course for all freshmen on 'learning in a university', which includes such matters as the use of a library. 6.2.2 'Community medicine survey' and 'basic science symposium'
These caught the imagination of the Workshop as being admirable vehicles for teaching nutrition, and are described in the next two sections; both integrate a variety of diaoiplines. 'lbe community medicine survey teaches this subject only and is based on a field survey. In the basic science symposium there is some community medicine, but the emphasiS is on basio science; there is also some olinical medicine.
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6.2.3
Community health survey of the University of Singapore
The survey takes place during the vacation between the third and fourth year. LUring the previous years the students have had courses in statistios, epidemiology, nutrition and environmental sanitation. The survey makes previous theoretical teaching a reality and achieves a variety of educational objectives besides those in nutrition. The objeoti ves of the survey include being able to interact with the community, to prepare and present a report and to use visual aids. It was enjoyed by 'the students and does much to promote staff-student relationships. 'Dle staff ot the department begin by discussing the survey of the previous year and modifying it if necessary. They then prepare doouments tor instruotion of the students whioh show the work to be done at various stages in the survey. Survey areas are then chosen and formal permission to work in them is obtained from the Ministry of Health. Contact is then made with government staff working in the survey areas, suoh as teachers, health inspectors, public health doctors and nurses.
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LUring the first week, the survey is introduced formally to the class of students who are to undertake the survey. It is presented to them as a job to be done. Meanwhile, the students are given an informal introduotion to the survey by the class of the previous year. Its success depends on a reputation of good organization built up over the years. Among the many matters with which the students have to become acquainted are the local terms for certain diseases. Students then divide into survey groups of about 20, supervised by a faculty member. They are given survey areas which oover all types of oommuni ty in Singapore and the neighbouring Malaysian peninsula and are allocated a room for their own use. They then visit the area with their supervisor. Some questions are set for all students to ask, and others they design themselves. The questionnaires used have three parts a personal part, a household part and a general part divided into about ten subsections. One of these is devoted to special investigations partioular to each group, such as dental care or haemoglobin levels. Each student group then elects its own chairman and rapporteur, completes its questionnaire, carries out a pilot survey and, if necessary, modifies its questionnaire. The second week is devoted to field work and includes visits to clinios, a school and a factory.
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The third week is spent in the medical school analyzing and interpreting the results of the survey, smaller groups devoting themselves to each subsection. Groups are encouraged to come to definite conolusions on the health of the population of the survey area and finally make a fonnal presentation of their findings, preceded by a dress rehearsal. The students giving the best presentation get the prize of a dinner. A final report is prepared after the presentation, which is the oombined effort of the entire group. Each student makes his own sUIIIDary in a thousand words. He presents this to his supervisor at the beginning of the next term and is questioned on it. He is evaluated on his entire perfonnanoe in the survey, his marks being counted in the examination in community medicine. 6.2.4 'Problem-solving basic soienoe' and 'basic science symposium'
It is now being said increasingly that biochemistry, and sometimes also molecular biology, have taken over the role, traditionally held by anatomy, of burdening the students' mind with a vast plethora of unnecessary detail. To counter this, the Biochemistry Department of the University of Queensland have replaced many of their leotures with teaching in which the student is required to solve problems while having access to any books he wishes. Thi. has been found to extend and develop his mental abilities to a much greater extent than the traditional system, and to send him better prepared into the clinioal years. At Queensland, this problem-oriented teaching method culminates in an snnual symposium the main aim of which is to demonstrate the clinical and social applications of basic science. A general topic is chosen such as 'Behaviour: environment or heredity', and the entire class of 250 students divides into groups of 15 and makes an intensive study of some aspect of i t. E~h student is required to do an individual assignment as a contribution to his group's topio. The group then elects its own chainnan and works out its topic in consultation with an expert tutor who is often recruited from outside the faculty. The topios chosen involve basic science as well as, for instance, studies of the family and the comnnmi ty. The topics may also include suoh subjects as the clinical assessment of children. The groups correlate their topics into a general theme under the guidanoe of a department chainnan. The symposium is then entirely presented by the students, giving the whole class a broad view of the subjeot. 6.2.5 Integrated teaching - the indiviSibility of medicine
Nutrition is well adapted to any kind of teaching which breaks down departmental barriers, since it is linked with the basiC sciences and a patient in any clinical department may have nutritional problems. Integrated teaching also makes it possible to introduce the student to malnourished children early in his pre-clinioal course and so enliven biochemistry,
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physiology and even anatomy with human interest. If integrated teaching is to be effective, oommunity medioine and olinical departments must be closely linked so that integrated and detailed 'patient-family studies' can be made of ohosen cases. 'lhese are partioularly effective if a patient's home can be visited or be illustrated with slides. If a particular kind of case cannot be found for a speoific occas1on, it oan be simulated with audio-visual material from a teaching collection. A useful approach to the integrated teaah1ng of nutrition is for the department of oommunity medicine (or nutrition) to define the content of nutrition teaching for certain oonditions, sq anaemia in pregnancy, and for this to become part of the teaching of another department - in this case, obstetrics. But integrated teaching haa its dangers and in some oountries, notably in North Amerioa, opinion i. now turning against it in favour of the traditional method of allocating departments 'block time'. Sometimes the students say that they have already heard the Slllle material four times in different situations and always in the same shallow manner. To avoid this some part of the subjeot should be covered in depth on each ocoasion, and the rest of 1 t be reviewed lightly. Consistenoy of this k1nd is muoh easier if the same subjeot, say biochemistry, is always taught by the same person. 6.2.6 Group asSignments
'lhis is a useful way of getting students to teach themselves on a more modest so ale than in the wide-ranging projeots desoribed earlier. If the subjeot studied is vit8lD1n A, for example, one group of students can be sent to look up data in the library, another can study its assay in the laboratory and a third oan see how dark adaptation is tested in the. ophthalmology department. All groups oan then present their findings to the olass. 6.2.7 Small group teaching - interdepartmental oooperation
One of the diffioul ties of small group teaching is the lack of teachers in anyone department ~o are suffioiently skilled in a partioular subjeot to be able to teach it. A good way to get round this is to cooperate with other departments, to hold an orientation meeting for the small group teachers before each session, and for teachers to use materials prepared by the 'best department'. 6.2.8 'The malnourished stUdent'
Pew things are quite so interesting to most of us as ourselves. Good use oan be made of this interest by estimating for instance. the serum iron and folate levels of the olass, and using this as the starting
- 21 -
point for discussion. Triglycerine and choles\erol levels Can be used to illustrate risk factors of another k1nd. 6.2.9 The cost and content of foods - the 'food prescription'
Few students or doctors can estimate from the appearance of a diet how much protein or how many Joules (calories) a patient is eating. Yet an appreciation of the weight. bulk, cost and nutrient content of a patient's diet is of great clinical value, and this matter needs to be introduced early in the course. '!his is easily done by asking a laboratory assistant to put lOOg portions of various foods in plastiC bags. Students can then be asked to identify each food (some fail to identify the foods of their own country), to estimate weight, cost and approximate nutrient content. He Can also be asked to state f'oods that are high or low in a particular nutrient. and to name pairs of' protein f'oods that complement each other'. amino acid deficiencies. The idea that the 'doses' of nutrients are as important as the doses of drugs is a useful one to leave in the student'. mind. A visual concept of' how much of any food is required to meet different circumstances is also vi tal in instructions to patients subsequently. 6.2.10 Nutrition and pharmacology
There are some important pharmacological aspects of nutrition, and an interesting lecture can be built around the interrelationships of food and drugs. Besides such obvious topics as atromid and hypercholesteraemia, there is the anorexic action of digitalis. aspirin and gastriC haemorrhage, and. the role of drugs in malabsorption syndromes. 6.2.11 'Introduction to medicine' course
Many schools have a special short course Mhich introduces the student to clinical medicine. '1h1s is good time to emphasize the importance of the nutritional history and introduce him to the concept of malnutrition as a background disease. 6.2.12 Teaching staff
Few SChools are as far sighted as the Uni verai ty of Malaya in giving ooramity medicine as much time as clinical medioine and surgery; and several participants stressed the difficulty often encountered of getting adequate staff and time in the curriculum for community medicine and. nutrition. Staff can sometimes be shared with other departments as described earlier in this section. Another method is for some staff members to have Joint appointments in two departments. an arrangement which also aerves to break down departmental barriers.
- 22 -
6.2.13
Eduoational support servioe
Few schools make as much use of audio-visual aids as they oould. A great help in doing this is to have all the visual aids in a sohool administered by a speoial department directed. by an academic staff member, u hu been done in the University of Mal~a. If the school 1s large enough and the staff of this department are appropriately trained, they can also act as advisers in teaching and evaluation methods to the 'oontent speoialists' of other departments and thus provide an I eduoational support service' to the faoul ty. 6.2.14 Multimedia library
Traditionally, libraries deal only in books; and it m~ require some persuasion to get them to fit their libraries with carrels oomplete with headphones and slide/tape sets tor self instruotion. '!here is. however. an inoreasing amount ot inexpensive audio-visual material available. suoh as for example the "Teaching Aids at Low Cost" provided by the Institute of Child Health. Great Ormond Street. London; so it is important that good use be made of this opportunity. 6.2.15 Audio-visual aids made by students
Students who do projects have to present the results of their work to the rest of the olass. cIt is useful experienoe for a student and helpful for the rest of the olus if he is expeoted to make visual aida. espeoially transparencies for an overhead projeotor. To make this possible. outfits containing pens and acetate sheets, etc., need to be made available. 6.3 6.3.1 Evaluation Instruments for eValuation
Several participants emphasized the importance of designing instruments for evaluation at the same time as the objeotives are defined. An inseparable part of an evaluating instrument isoareful speoifioation of the conditions under whioh it is to be used, such as limitation of time and acoess to books, and the oriteria for deciding whether or not a satisfaotory level of competence hu been achieved. 6.3.2 Formative *Dd aummative eValuation
Distinotions were also made between formative evaluation which the student uses to evaluate himself for his own use, and summative evaluation used. by the raoul ty to assesa him.
- 23 -
6.3.3
Continuous assessment
The usefulness of this was emphasized on many oooasions as also was its value in deoiding whether students were potentially fit for distinotions, or 'clear passes' or were possible failures. Where classes are large the labour of oonducting final examinations can be greatly reduoed by giving no further examinations to the students that oontinuous assessment has shown to merl t 'olear passes', and by examining only the oandidates for distinotion or failure. A tripartite evaluation regime of this kind not only reduoes the burden of evaluation, but also improves its quality. 6.3.4 Simulation
The evaluation of high level objectives requires an instrument that approaches the real life situation as closely as possible. Such si tuations are not easy to achieve for examination purposes or for teaching, and several partiCipants mentioned as alternatives in default of them the 'simulated patient' of the 'simulated situation'. The right visual aids oan make these very life-like. 6.3.5 Objective tests (multiple ohoioe questions)
The design of a sufficient number of high quality objective tests was considered diffioult by several participants; so it was with this in mind that reoommendation 1.4 was made, concerning the establishment of a bank of objective tests in nutrition. Until this oan be achieved it is hoped that sohools will exchange multiple choioe questions between themselves. 'Teaoh-test-mark-discuss' A useful teaching opportunity is lost if a test is not discussed wi th the students as soon as it has been done. For this purpose it is better to have more frequent Short evaluation tests, to mark them quiokly and to discuss them, rather than to have a smaller number of larger and more formal tests which are difficult to discuss adequately. 6.4 Example - instruction on vitamin A disease in clinioal nutrition
Further on, a teaching scheme for one small subject area, vitamin A, is set out in detail &9 this was prepared by one of the working groups. The first column lists the nine educational objectives relating to the subjeot. This is followed by columns listing the necessary prerequisites, the units of instruction, the teaching methods, the media resources required and the methods by which all these nine educational objectives oan be evaluated. This exercise is to some extent
- 24 -
artificial since it would on many occasions be convenient to teach students about vitamin A in oonJunction with other subJects. It does, however, give an indication of the kind of rigour with which the subject should be approached. Other groups dealt with protein energy malnutrition and the hyperlipidaemias in a similar way.
i
i
INSTRUCTIONAL DEVELOPMENT IN THE PLANNING OF A MODEL UNIT (VIT AMJN A DISEASE) IN THE TEACHING OF CLINICAL NUTRITION
(A)
(D)
(C)
(D)
(E)
(f)
Educational ObjeClives
Entry Pre-requisites
Units of Instruction
Teaching Methods
Media Resources Required
Evalualion
1) Should be able to obtain a complete clinical
1) Z)
history, and recognt&e and identify the symptoms of Vitamin A disease. 2)
Biochemistry of Vito A (85)Human requirements of Vito A (BS/CN)"
Sub-ulli[ 1a; Nutritional aspects of history taking Sub-unit Ib;
1)
Lecture on sub-units 1& and Ib Live cue demoostration C ate demonstration by s)ides
1) Live patient 2) 3)
Slide projector Islides CeTV camera!monitor!VTR Supplementary reading or lape
When given a live patient with Vitamin A disease, the student must be able to, in a period of 1-1/2 hours: 1)
2)
should be able to obc:a1D .. d1ccary hiltary from a patient illustratiol foodlcuffs consumed and recognize therefrom any deficiencies in Intake of foods rich in Vitamin A.
3)
Food sources of Vit. A (CN/BS)
3) 4)
4)
Obtain a complete clinical history and recognize the symptoms of VHamin A disease Obtain a dietary history from a patient illustrating foodstuffs consumed and recognize therefrom any
4) A billty to take a cUnleal hlstory 5)
Dietary habits of population
The dietary bistory (These can be combined with units relating to other diseases)
Case demoastration by Closed Circuit Television (CCTV) - (large grouP) 2)
deficiencies in the intake of foods rich in Vit. A 3) Perform a complete physical examination and recognize 1) 2)
3)
Should be able to do a pb)'5ical examination and recognize therefrom early and late signs of Vitamin A deficiency
1)
Ability to perform a general physical examination
Sub-unit 2: General review of symptoms and signs of Vii. A disease
5)
Lecture (1/2 hour) with slides preferably
Slide projector/slides Supplementary reading or tape/slide programme 4)
therefrom early and late signs of Vitamin A Select suitable laboratory tesl~
disea~e
from a given list to
of)
Should be able to telect witable laboratory tests required for coafinnaUon of Vitamin A deficiency and be able to interpret resulu obtained tberefrom.
1)
Biocheminry and physiology or Vitamin A
Sub-unit
s:
6)
Group awgnments - report on following day a) Dark adaptation test b) Biochemistry test c) Normal limits and
1)
Laboratory facilities
confirm his diagno~h and to interpret the results when supplied with them
Tests in Vitamin A
2) Library
deficiency
tiJ Arrive at a correct diagnosis of Vitamin A disease in the light of infonnation obtained from the above 6) Communicate this e1ialnous and give the basis for it orally to the examiner. 7)
interpretation 5) Should be able to arriTe at a correct diagnosis 1) Pathology of VUamin A
Formulate a regime of management and communicate tbis orally to the examiner. taking into consideration the following factors: available facilities. socio-economic factors, culture and inter-relationship between VJtamin A and other nutrients., according to the standards required by an examiner ming a scoring sheet (see Assessment Form 74/B/IO/WHO) for standard fating The student mu~t obtain at least a 'PASS' score in all sections evaluated
~: Reviews of pathogenesis of Vitamin A deficieocy Sub-unit 5: Differential 4iagnolis and diagnosis of Vj~. A deficiency'
7) 8)
Reading assignments
-'--1-1)
Slides. patients, projection
of Vitamin A disease in tbe light of information obtained from history, pbyslcal and laboratory examinatiOGs.
2) Pharmacology of Vitamin A 3) Pathogenesis of Vitamin A
Review tett and discussion 9) LeclUre with slides or Uve demorutraUoo
defideacy
"BS
= Basic Science
CN = Community NuUitlon
(AI
(8)
(e)
(D)
eE) Media Resources Required 1) Library Data on socio-economic variables 11
Educational Oojectives
EnlTy Pre-requisites
Units of Insuuction Sub-unit 6: Treatment of Vit A deficiency a) Dietotherapy b, Vitamin A as a drug Inter-relationship with other nutrients and drugs 10)
Teaching Mcthods Live or simulated case presentation by student(s)
•
IF)
Evaluation
6) To be able to describe the pathogenesis of Vii deficien~'y
A
and toxicity 10
2
When given a series of slides (35 mm. illustrating xerophthalmia, the student, after this unit of instruction, should be able to: 1) Recognize and write down his diagnosis within 2 minutes 2)
~)
Should be able
formulate a regime uf treatment
11 2)
All ofthe abow Therapeutics in relation to Vitamin A deficiency and toxicity
for Vitamin A defiCiency, taking into consideration the following factoni: available facilities, socioeconomic (actorn, culture and inter-relationship between Vitamin A and other nuniems.
Draw a schematiC diagramme to ~ow the pathogenesis of this deficiency state, including in his diagramme the following Which should be done in 20 minutes: environmental facton b) socio~cultural~economic facton c) pathological factors a)
8) Should be able to recognize early and emergency
1) All of the ahove i
~:
11) Discussions by a panel groop
1) Slides 2\
states In Vitamin A defiCiency (xerophthalmia and acute Vitamin A poisoning)
: Emergencies in Vitamin A disease
of the following may be valuable: a) Physician Medical nutritionist c) Dietician d) Social worker e) Pnarmacologist b)
Patients
In. Following (his unit of instruction, the student mould be able to write an essay on: 'The role. and contribution. of the following categories of penons in tbe management of Vitamin A deficiency. a) Physician b) Medical nutritiooilt c) Dietician d) Social worker'
Students g) Biochemist 9) Should be able to utilize when necesury related 1) All of the above
n
Thb mould be done within 25 miDutes.
non-medical personnel in the management of Vitamin A deficiency,
Sub-unit 8: Utilization of related nonmedical personnel in the management of Vitamin A disease.
12) As above
Other (acton meriting consideration: 1) Time restraints Flexibility of timetable
Other factors meriting consideration; Time required 2) Shortage of teachers 3) Repetition by small number of teachers availahle 4, Educational support services 5) Co-ordination among depanments 6) Clinical and social medicine inrerface possibilities 1)
Other facton meriting consideration: Tne above woold be difficult 10 terms of staff and time available. To permit an evaluatioo to be 40fte in practice, the 'sk1Us' component of the evaluation may be left to & formal swnmative evaluatioo session. At the ead of tbe unit, the 'knowledge' part might be assessed by CGIIftrtiog 1he ftnI: evaluatlon procedure into a written short-8I1IWeI aamlDaUoa using a simulated situati.on This would be expected to lilt only one hour for an students rather rhan ClUe aad a half boun for a single stUdent.
2) 3)
4)
Placement of emphasis according to national situation Practical training vs. theoretical concepts 6) Motivational problems 6) Passing of responsibility for dietotherapy to dieticians 7) Possibility of establishing a small 'Nutrition Unit' as well as wards for teaching use
Time teqllired for above units of instruction; About 3 hoon total teaching time.
- 29 -
7.
EVAWATION OF 'mE WORKSHOP
Answers to the questionnaire are set out below, and show that most participants considered that the workshop had achieved its objectives and that the topics discussed were helpfUl. Of particular interest is the desire of 11 out of 13 respondents to have "echo" workshops in their own countries.
Yes 1.
No
Partly
Has the workshop met its stated objectives? (a) to review the present content and methodology of teaching nutrition in medical schools in the Western Pacific Region; to consider the most appropriate ways of undertaking the teaching of nutrition in a medical school; to identify the main areas where improvements are needed and how best to implement these.
5
1
7
(b)
10
2
(c )
5
8
2.
Will the workshop topics and discussions be helpfUl and relevant to the teaching of nutrition in your Medical School? TOPIC I TOPIC II Objectives for the teaching of nutrition Current trends in medical education and course designs Teaching techniques and resources 11 2
9
4
TOPIC III
12
1
- 30 -
Yes 2.
No
Partly
(cont'd.) TOPIC IV TOPIC V Evaluation methodologies in nutrition courses Administrative strategy for the inclusion of nutrition 10
-
3
8
-
5
3.
Has the workshop provided you with adequate information to stimulate, io1 tiate, strengthen or expand a nutrition teaching programme in your school? Which of these workshop 'follow-up' activities would you support to advance nutrition teaching in Western Pacific Medioal Schools? ( a)
11
1
4.
Establish a Western Pacifio Nutrition Committee to act as a centre for acoumulation and distribution of ourrioular material, syllabi, teaching slides and other aids. Establish a visiting faculty or faculty exchange programme in nutrition to visit those schools requiring teaohing assistance.
12
-
1
(b)
10
2
1
(0 ) Establish a group of nutrition teaching oonsultants to advise in the teaching of nutrition to Medical Schools.
5
2
5
(d)
Creation of a Committee to formulate and write a nutrition textbook to best serve the needs of Western Pacifio Medical SChools.
7
1
3
- 31;32 -
Yes
No
Partly
4.
(cont'd.) (e) Have an "echo" workshop in the near future to report problems and progress in advancing nutrition teaching. Training programme to 'teach the teacher'. Develop a pool of obJective tests (multiple choice) questions to evaluate nutrition knowledge. Creation of a Western Pacific Board of Nutrition to establish rrutrition as a sub-specialty of medicine.
11
2
2
(f) (g)
9
2
7
-
5
(h)
6
2
3
- 33 -
ANNEX 1
LIST OF PARTICIPANTS 1.
PARTICIPANTS Professor Chev S. Kidson Head. Department of Biochemistry University of Queensland St. I11cia. Queensland 4067
AUSTRALIA
FIJI
Ms Savita D. Tikaram Lecturer. Department of Nutrition and Dietetics Fiji School of Medicine Suva Dr Michael J. Colbourne Head. Department of Preventive and Social Medicine University of Hong Kong Hong Kong
HONG KON:}
JAPAN
Dr Norimasa Hosoya Chairman and Professor of Nutrition School of Health Science Faculty of Medicine University of Tokyo 3-1. Hongo 7, Bunkyo-ku Tokyo Mr Yoshitomo Fujisawa
Specialist in Nutrition Administration Nutrition Division Public Health Bureau Ministry of Health and Welfare 1-2-2, Kasumigaseki Ch1yoda-ku, Tokyo LAOS
Dr Baccam Thuyene Charge du cours des maladies endocriniennes et metaboliques Ecole royale de Medicine Vientiane
- 34 Annex 1
MALAYSIA
Dr Kader SUltan Haji Ismail Heed, Biochemistry Department. Medical Faculty National Uni verai ty of Malaysia 124 Pahang Road Kuala IJ.unpur Dr Teoh Soon-'l'eong
Lecturer, Faculty of Medicine Uni verai ty of Malaya Kuala Wmpur NEW ZEAIAND Dr William Murphy Director Division of Publio Health Department of Health P.O. Box 5013 Wellington Dr Laupu Nageob Bussim
...
PAPUA NEW GUINEA
Senior Tutor in Child Health Faculty of Medicine P.O. Box 5623 Boroko PHILIPPINES Dr Nilda SUnico-Castro
Associate Professor and Chairman Nutrition Committee Manila Central University Medical College (concurrently Physician-in-Charge, Malnutrition Wards, MCU Hospital) Manila Dr Emerita Gutierrez
Associate Professor Department of Biochemistry and Nutrition Faculty of Medicine and SUrgery University of Santo Tomas Manila REPUBLIC OF KOREA Professor Kwang Wook Ko College of MediCine Seoul National University Seoul
- 35 -
Annex 1
REPUBLIC OF KOREA
REPUBLIC OF VIET-NAM
Professor Je Hyun Kim Department of Biochemistry College of Medicine Yonsei University Seoul
MIne Bui Boi Tien Pharmacienne/Assistante Chef du Laboratoire de Bio-Chimie Ecole de Medecine Hue Dr Nallamah Ruth Tan Senior U!cturer Department of Social Medicine and Public Health Faculty of Medicine University of Singapore Singapore 2.
SINGAPORE
CONSULTANTS George Christakis Adjunct Professor of Nutrition Department of Biology Florida Atlantic University Boca Raton, Florida United States of America Dr
Workshop Director
Consultants on Teaching of Nutrition
Dr Florentino S. Solon Executive Director National Nutrition Counail and the Nutrition Center of the Philippines Manila Dr Maurice King WHO Medical Officer Inter-regional Project on Strengthening of Health Services '!be U!mbaga Kesehatan Nasional Jalan Indrapura Surabaya, Indonesia
•
- 36 -
Armex 1
3.
TJ!lt1PORARY ADVISERS
Dr Corazon P. Gonzales
Professor of Physiology College of Medioine University of the Philippines Pedro Gil street Manila Dr Jose Cuyegkeng Executive Director AssOCiation of Philippine Medioal Colleges 547 Pedro Gil street Ermi ta, Manila
•
4.
SECRETARIAT
Dr H.J.L. Burgess Regional Adviser on Nutrition WHO Regional Offioe for the Western Pacifio Manila Dr E.G. Kapal Consultant Health Manpower DeveloJlDent WHO Regional Offioe for the Western Pacifio Manila
Mr J. Aboede
Publio Information Offioer WHO Regional Offioe for the Western Pacifio Manila Ms Muriel Bourne Nutritionist Family Health Field Advisory Servioes WHO Regional Offioe for the Western Pacifio Manila
•
- 37/J8 Annex 1
5.
OBSERVERS
Mr Peter Bailey
Programme Officer UNICEF
Manila Dr Angelina Bayan Medical and Applied Nutrition Division Food and Nutrition Research Center
•
Manila Dr So11 ta Camara-Besa Department of Biochemistry College of Medioine University of the Philippines Manila Dr Lourdes Sumabat
National Nutrition Service Department of Health Manila Dr Trinidad Gomez Direotor National Nutrition Service Department of Health Manila
• •
J
- 39 -
• ANNEX 2
LIST OF OOCUMENTS GIVEN TO PARTICIPANTS
1. 2.
Shirley Perlmutter:
The dynamics of a learning group (WHO/EOOC/73.l6l)
Christine H. McGuire: The evaluation of teachers and teachil1§i effectiveness (WHO/EDUC/73.l65) Allan W. Walldren: (WHO/EDUC/73.l62) George Miller: Curriculum theory and currioulum practioe
3.
•
4. 5.
Eduoational obJeotives (WHOjEruC/7l.l45) Organizing short-term teacher training progr~s
Karen J. Connell: (WHOjEDUC/7l.l4l)
6.
M.D. Kovrigina: Advanoed medioal studies with the help of television (WHOjEooC/7l.l46) Frank Penta &: Thomas Telder: (WHO/EOOC/7l.l48) Christine McGuire: (WHO/EDUCj72.l5l) Agnes Rezler: Eileen Bughman: Riohard Foley: Audio-visual aids to learning
7.
8.
Diagnostio examinations in medioal education
9. 10.
The assessment of attitudes (WHO/EWC/72.152) The leoture method of instruotion (WHOjEruC/72.l57) Microteachlng for teacher training (WHq/EDUC/72.l59) The problem-oriented medioal reoord
•
11. 12.
Albany Medical Centre (POMR): (WHO/HS/NAT. COM/72.283) James Bobula: George Miller:
13. 14. 15.
Examinations and deoision making (WHO/EruC/73.l70) Teaching large groups (WHOjEruC/74.l73)
World Health Organization (1973): '!he training and preparation of teachers for schools of medicine and of the allied health services, (Wld Hlth Org. teohn. Rep. Ser., No. 521) Segall. A.J •• ed.: Harvard Sohool of Publio Health oourse book on systematio ourrioulum design
• •
16.
- 40 17. Christakis, G.: The speoial eduoational advantages and problems of nutrition teaching in medioal sohools Solon, F.: King, M.: Developing a strategy for the teaohing of nutrition Behavioural objeotives for nutrition
18. 19. 20. 21. 22. 23.
List of' books and journals in nutrition Gonzales, Corazon: Christakis, G.: Ways of solving problems
A summary of the hyperlipidaemias
•
World Health Organization (1972): Health aspeots of food and nutrition: a manual for developing oountries in the Western Pacifio Region I)ltra de Ol1verim, T.R. (1974): Teaching nutrition in medioal schools: some problems and preferred solutions, ~. ~., .§, 49-51. Bligh, D. (1972): Some oommon teaching methods and instruotional media and appropriate objectives, Penguin, 150-154. Frank1e, R.T.; Williams, E.R. c!: Christalds, G. (1972): Nutrition eduoation in the medical school: experience with an eleoti ve oourse for first-year medical stUdents. Amer. J. c1in. Nutr •• 25. 709-719 Christakis, G.; Frankle, R.; Brown, R.E.; Jeffers, R.; Walter, J. c!: Deusohle, K. (1972): Nutrition teaching at the Mount Sinai Sohool of Medioine: a three-year experienoe, Amer. :I.. olin. ~., 25, 997-1009. Nutrition teaching in medical schools, ~. med. ~., 1963. 955-959. Teaching nutrition in paediatrios in developing oountries, Paediatrics. 1966. 38. 671-689. Rao, K.S. (1971): A method for improvement of nutrition teaching in medioal sohools Proc. 6th symp. Nutr. Health near East) Amerioan University of Beirut. 1 -202.
•
24.
25.
26.
27.
•
28. 29.
30.
•
•