1 BACKGROUND

There is a global consensus that primary health care (PHC) is the foundation of the health system for delivering effective, equitable, and sustainable health services [1, 2]. This need is particularly acute in low- and middle-income countries (LMICs). However, the primary care training system in LMICs is often weak, leading to a lack of educational resources for PHC professional development, a shortage of qualified PHC health workers and general practitioners (GPs), a lack of trust in PHC sectors, and an ineffective primary care system [3, 4].

While an increasing number of LMICs have recognized the important role of primary care training in developing a sustainable healthcare system, there are very few successful examples of international collaboration in primary care training between high-income countries (HICs) and LMICs [4-7]. International partnerships in medical education have traditionally been characterized by HIC institutions owning and controlling the process, with little meaningful involvement from LMIC medical institutions [8-10]. Without long-term reciprocal collaborative partnerships in primary care training, it is difficult to understand training priorities in the LMIC primary healthcare context and maximize the long-term training impact. In addition, the implementation of international training programs has raised many questions about the institution's capacity to deliver and manage these programs, including differences in language, challenges in information technology infrastructure, and time zones [11].

In 2020–2021, the Department of Family Medicine at McGill University (McGill DFM, Montreal, Canada) and Tongji University School of Medicine (TUSM, Shanghai, China) jointly implemented the McGill-Tongji Blended Education Program for Teacher Leaders in General Practice (also known as “Tongji blended learning program” or “Tongji program”) at Tongji University, Shanghai. This is a collaborative primary care education project tailored to improve the teaching capacity of GP teachers in China. Both McGill DFM and TUSM made great efforts to adapt this PHC training project into a practical international educational collaboration. In this paper, we discuss the evaluation of the implementation and the perceived impact of the Tongji blended learning program to highlight the experiences and lessons learned in this collaborative PHC training project.

2 METHODS

3 RESULTS

4 DISCUSSION

In this mixed methods study, we evaluated the implementation and the perceived impact of the Tongji blended learning program. Our evaluation results shown that the Tongji program addressed many of the challenges facing the academic medicine community, such as providing high-quality primary care training in LMICs, developing meaningful medical education partnerships between HIC institutions and LMIC institutions, and navigating the language and technical barriers of cross-country initiatives. To our knowledge, this is the first study to evaluate a multi-institutional and longitudinal blended learning program in primary care between HICs and LMICs to enhance the leadership and teaching capacity of primary care faculty.

Primary care has been an evolving field worldwide over the past three decades [22-24] and international collaboration in medical education is no longer a novel concept [25, 26]. However, the literature on the experiences of international collaboration in primary care education in LMIC remains limited. To the best of our knowledge, the only two examples of HIC-LMIC collaboration in the primary care education literature are the initiatives between the University of Calgary and the National University of Laos [4, 6], and the University of Toronto's Brazilian and Chilean PHC training [7]. Although both projects mentioned the importance of adaptation or partnership, neither of them provided a rigorous evaluation of how these practices enhanced the impact of their training. In their comprehensive report in 2018 [2], Rouleau et al. [23] examined the development of family medicine in seven countries around the world. They identified four “meta-enablers” in the development of primary care in all seven countries: (1) effective champions; (2) committed partnerships; (3) political will; (4) adaptability of primary care in a given setting. Our evaluation results supported Rouleau et al.'s [23] second and fourth “meta-enablers” findings. Given the resonance observed between our findings and the broader literature [2, 24], the following two lessons that emerged from the evaluation of the McGill-Tongji Blended Education Program may be applicable to other institutions seeking to improve their primary care training capacity.

This study provided important insights into the implementation of international collaboration in primary care education. The first lesson learned from the Tongji program and a number of collaborations between McGill and other Chinese medical institutions is the significance of partnership [27]. Before the launch of the Tongji program, McGill DFM had already collaborated with Chinese medical institutions on several blended training initiatives, which served as a foundation for initiating a more comprehensive partnership. From January 2017 to December 2017, six community health centers and 31 learners in Shenzhen participated in a similar distance learning program based on the partnership between Shenzhen Community Health Association and McGill DFM [28]. The evaluation of the Shenzhen Program provided valuable insights and lessons that helped McGill DFM to revise and redesign subsequent programs in China, including the three-city program in 2019 (Wuhan, Zhengzhou, and Xining), and the Tongji program in 2020. TUSM also valued the opportunity to co-deliver the learning program instead of solely procuring external training, which ensured the successful implementation of the Tongji program. During the development of Tongji program, a Joint Education Committee (five members from Tongji and five members from McGill) met monthly to discuss the objectives and implementation of the training. TUSM organizers also established various communication channels for the learners, including online questionnaires, WeChat groups, and FGDs to provide feedback, raise concerns, report technical issues, and send notices to prepare for discussions.

Adapting the international training program to the local context is another important lesson. The Shenzhen blended learning program was delivered in English because local leaders believed that English training would improve the learners' English language skills. The program used the learning management system of McGill (MyCourses), and all instructors, facilitators, and organizational staff were professors and staff from McGill DFM. However, the evaluation revealed that participants encountered numerous technical and connectivity issues. Teaching in English also created barriers for many participants to understand the lecture and express their opinions during discussions. The Tongji Project has implemented the following strategies to remove these barriers. First, to eliminate language barriers, all teaching materials were translated into Chinese. Mandarin-speaking professors and residents from McGill DFM were recruited to facilitate virtual face-to-face meetings with Chinese GP learners. Second, to eliminate the technology barriers, McGill DFM replaced the MyCourses system with a Moodle learning system designed by a Chinese company with servers in China, which greatly improved access for Chinese learners. Third, the evaluation and continuous improvement of training content is crucial for success. Since the beginning of the series of blended learning programs in China, McGill DFM developed rigorous assessment plans for these programs. These evaluations enable educators and learners to learn from each other and further customize the program with additional topics based on the learners' requirements (e.g., the pedagogy of critical thinking, clinical reasoning and communication skills). Nevertheless, 27% of our participants still found some content incompatible with their practice context in China (e.g., well-developed primary care teams, student complaint policy). We recognize that achieving real change in primary care in China will require a long-term commitment to learning. The development of Tongji program itself is an example of this learning process. It is encouraging that the participants of Tongji program also agree that this training has altered their attitudes towards primary care, and they are willing to facilitate this process of change.

The evaluation has several limitations. First, our evaluation focuses on the participants' perceptions of program content and organization, to explore program implementation. It does not explicitly assess learning outside the context of the program, such as enhancements in teaching skills or behavioral changes in teaching. Second, the number of participants in these trainings is relatively small and all of these trainings so far were conducted in larger cities in China. Since the digital literacy of GPs and the practice of community health centers may vary across different regions of China, our conclusion may not be applied to the entire country. Third, our self-administered survey may cause recall bias or social desirability bias (given the fact that these participants were active teachers). More in-depth training and evaluation in larger and more diverse primary care settings are needed in the future to modify the practices or test the effects of training programs. Fourth, it is worth noting that our study only includes one male participant. While it is true that females constitute over 75% of health workers at community health centers in China [29], future studies should aim to attract more male participants in training programs. In the end, it should be noted that cultural difference is still an important barrier in our training. Further research could focus on overcoming cultural differences in educational cooperation.

5 CONCLUSIONS

In conclusion, our study shows that it is feasible and useful to implement a primary care education program to improve the leadership and teaching capacity of GP teachers through international collaboration by developing committed partnerships and an adaptive teaching model. Future research should focus on how international primary care education programs affect learners' long-term behavior in their practice settings, and explore barriers and facilitators to change.

AUTHOR CONTRIBUTIONS

Ziyue Wang: Conceptualization; formal analysis; data curation; investigation; software; visualization; writing—original draft; writing—review and editing. Xinxin Zhao: Conceptualization; investigation; resources; validation; project administration; writing—review and editing. Huixia Shen: Conceptualization; investigation; resources; validation; project administration; writing—review and editing. Hao Wang: Validation; project administration; writing—review and editing. Gemma Cheng: Validation; project administration; writing—review and editing. Ya Ning Gao: Validation; investigation; project administration; writing—review and editing. Wenzhen Zuo: Validation; project administration; writing—review and editing. Zhuyin Xu: Validation; project administration; writing—review and editing. Francesco Avallone: Methodology; investigation; software; formal analysis; validation; writing—review and editing. Anish K. Arora: Methodology; investigation; formal analysis; validation; writing—review and editing. Manxi Guo: Validation; project administration; writing—review and editing. Rachel Simmons: Validation; project administration; writing—review and editing. David Lessard: Methodology; formal analysis; validation; visualization; writing—review and editing. Theresa Beesley: Methodology; validation; writing—review and editing. Jialin C. Zheng: Conceptualization; resources; validation; project administration; writing—review and editing. Bertrand Lebouché: Methodology; validation; visualization; writing—review and editing. Howard Bergman: Conceptualization; resources; funding acquisition; validation; project administration; supervision; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

Bertrand Lebouché has received research support and consulting fees from ViiV Healthcare, Merck, and Gilead. The remaining authors declare no conflict of interest. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.

ETHICS STATEMENT

The Research Ethics Office of the Faculty of Medicine and Health Sciences at McGill University (Approval Number: A04-E16-21A (21-04-043)) and the Medical and Biological Research Ethics Committee at Tongji University (Approval Number: 2021tjdx051) provided ethical approval for this evaluation.

INFORMED CONSENT

Informed consent was obtained from all individual participants included in the study. Verbal informed consent was obtained before the interview.