Medical ethics in Faculdades Integradas do Norte de Minas: student perception

Abstract

It is increasingly evident that reflection on humanities and deontology is necessary for a more comprehensive training of medical students, aimed at preparing professionals that are not only technically qualified, but also humanized. For this reason and also to follow the current national curriculum guidelines, Faculdades Integradas do Norte de Minas introduced a new module in the sixth period: “Humanities, Bioethics and Medical Anthropology.” Aiming to evaluate student perception about the teaching of ethics in the institution, this research applied a questionnaire to the students (seventh to tenth period) of the medical course. The instrument comprised questions on the module’s structure and the teaching of ethics. Results show the importance of including medical ethics in the medical curriculum for a more humanized formation of doctors.

Ethical theory; Bioethics; Education, medical; Humanization of care; Anthropology

Resumo

Está cada vez mais evidente que a reflexão sobre ciências humanas e deontologia é necessária para a formação mais abrangente do estudante de medicina, visando preparar não apenas profissionais tecnicamente capacitados, mas também humanizados. Diante disso, e a fim de seguir as diretrizes curriculares nacionais atuais, as Faculdades Integradas do Norte de Minas instituíram módulo no sexto período de medicina chamado “Humanidades, Bioética e Antropologia Médica”. Objetivando avaliar a percepção de alunos sobre o ensino de ética nessa instituição, esta pesquisa aplicou questionário a estudantes do sétimo ao décimo períodos do curso de medicina. O instrumento contava com perguntas sobre a estruturação do módulo e o ensino de ética. Os resultados evidenciaram a proposta inovadora do módulo e a importância da ética médica na grade curricular no sentido de contribuir para a formação de médicos mais humanos.

Teoria ética; Bioética; Educação médica; Humanização da assistência; Antropologia

Resumen

Cada vez es más evidente que la reflexión sobre humanidades y deontología es necesaria para la formación integral del estudiante de medicina, con el objetivo de preparar no solo profesionales técnicamente calificados, sino también humanizados. Por lo tanto, y con el fin de seguir las actuales directrices curriculares nacionales, las Facultades Integradas del Norte de Minas establecieron un módulo en el sexto período de medicina denominado “Humanidades, Bioética y Antropología Médica”. Con el fin de evaluar la percepción de los estudiantes sobre la enseñanza de la ética en esta institución, esta investigación aplicó un cuestionario a estudiantes del séptimo al décimo período de la carrera de medicina. El instrumento tenía preguntas sobre la estructuración del módulo y la enseñanza de la ética. Los resultados mostraron la propuesta innovadora del módulo y la importancia de la ética médica en el plan de estudios para contribuir a la formación de futuros médicos más humanos.

Teoría ética; Bioética; Educación médica; Humanización de la atención; Antropología

Can you tell me, Socrates, is virtue the sort of thing you can teach someone? Or is it the sort of thing no one can teach you, but you pick it up by practicing it? Or maybe it’s neither: virtue is something people are born with, or something they get some other way?¹. The words of Meno, a character who questions Socrates in a dialogue about virtue, show that the interest in teaching the behaviors and norms that govern human life dates back to ancient philosophy.

The teaching of ethics in medical schools has made this dialogue a permanent fixture. In view of the many events that threaten life and human dignity during the exercise of the profession, and considering that contemporary education is based on competitiveness and on the search for personal success, it is increasingly evident that reflections on the human sciences and deontology (moral rules that professionals must follow) are necessary to provide health professionals a more comprehensive formative training² , ³ .

Throughout the centuries, medicine has accumulated knowledge that does not necessarily correspond to ethical/moral progress⁴. This is due to the predominance of fragmented knowledge, generated by the classic Flexnerian model of curricula, which made unfeasible the perception of the integrality of human beings – inseparably biological, psychological, cultural, social and spiritual⁵. Ever more accentuated, this mismatch has a negative impact on different spheres of life, and on educational activities in particular.

According to Neves⁶, a report prepared in 1985 by the Medical Education Commission of the Federal Council of Medicine (CFM) emphasized the Federal Council of Education’s determination to include deontology in medical courses’ curricula. The goal of such an inclusion was to bridge the gap between medical technique and ethics; the document, however, did not provide details on class hours, syllabuses or target academic periods⁶. Since then, Brazilian medical courses have pursued the inclusion of ethics as an actual teaching subject.

In 2014, the National Board of Education⁷adjusted the national curriculum guidelines (DCN) for undergraduate medicine programs, determining that courses should include the ethical and humanistic dimension, contributing to students’ development of attitudes and values oriented towards active, multicultural citizenship as well as human rights. Thus, the teaching of ethics should not only consider as its only model the Code of Medical Ethics⁸, which merely establishes rules and prescribes penalties for not complying with them. Ethics stands above coercive forces, and therefore must be discussed and thought to reassess the values of health professionals⁹.

In this context, to comply with these new curricular definitions, during the first academic period of 2018, Faculdades Integradas do Norte de Minas (Funorte) established the “Humanities, Bioethics and Medical Anthropology” module (MHBA), offered in the undergraduate course’s sixth period. Since problem-based learning is the course’s methodology, the module’s tutorial sessions mirrored the procedures of other modules while approaching ethical, bioethical, humanistic, anthropological and spiritual topics to address issues regarding the biopsychosocial being and the doctor-patient relationship. These sessions included groups of 8 to 10 students with a professor (tutor). Moreover, the course’s evaluation methods (dissertation, discussion of ethical dilemmas based on movies, development of plays by students) differed from those employed by other modules.

In view of the importance of ethics for medicine – as recognized by the National Board of Education⁷in its curricular guidelines, by the CFM⁸, and by the public health system itself –, this article aims to evaluate, from the students’ point of view, how ethical teaching can be developed during undergraduate studies. More specifically, from student perception, this research characterizes the teaching of medical ethics at Funorte, mainly in the MHBA.

Method

The study’s sample included students enrolled in the seventh to the tenth periods of Furnorte’s medical course, that is, students who had already attended the MHBA. The participants received a questionnaire (Appendix) prepared by the researchers and made available online via Google Forms. The instrument had 28 questions, referring to demographic characteristics and ethics-related experiences. Data were collected in 2020.

The form included the following demographic variables: gender, age, skin color, whether the respondent had already completed another degree, and in which academic period the respondent was enrolled. Regarding student perception of the teaching of medical ethics in the undergraduate course, the following parameters were considered: general satisfaction; academic periods and teaching methods in which medical ethics were approached; and attitude of preceptors and tutors in practical terms. As for the MHBA, student satisfaction regarding both the module’s approach to the topics and its evaluation methods was assessed, as well as the importance that the interviewees attributed to the module itself and to the possible behavioral changes resulting from it.

Student satisfaction levels were categorized as excellent (“very satisfactory”), good (“satisfactory”), fair (“neither satisfactory, nor unsatisfactory”), poor (“unsatisfactory”) or very poor (“very unsatisfactory”). For purposes of discussion, on the basis of student perception the course’s approaches were categorized as “satisfactory” (excellent or good), “indifferent” (fair) or “unsatisfactory” (poor or very poor).

At the end of the questionnaire, the students could make criticisms and suggestions regarding the structure of ethics teaching in the undergraduate course. Results were analyzed by descriptive statistical analysis, with simple percentage calculations provided by the Google Forms system. Questions with written answers were analyzed by categorizing the answers.

Results

Among the 234 students enrolled in the seventh to the tenth periods, 119 (50.8%) answered the questionnaire. Most participants were female (69.7%), self-declared brown (55.5%) or white (37.8%), with mean age of 24.8 years. Only 6.7% had already completed another degree (nursing, biomedicine or nutrition). Data on the demographic profile of the participants is shown in Table 1 .

Table 1
Demographic profile of participants

Variables	n	%
Gender
Female	83	69.7
Male	36	30.3
Age group
20-24 years	85	71.4
25-29 years	25	21.0
30-40 years	9	7.6
Skin color
White	45	37.8
Yellow	2	1.7
Black	5	4.2
Brown	66	55.5
Not informed	1	0.8
Has another degree
No	111	93.3
Yes	8	6.7
Course period
7th	28	23.5
8th	30	25.2
9th	20	16.8
10th	41	34.5

All 119 students answered that the teaching of medical ethics was present in the curriculum; 95% replied that this content was mostly taught in the sixth period, and no one replied that the topic had been present in all past periods. According to the respondents, medical teaching is mainly covered in tutorial sessions, and 97% consider the subject important.

Regarding MHBA’s structure, most of the respondents answered that the most frequent methods used to approach the contents were debates during tutorial sessions, plays and movies. The least frequent method was discussion during practical activities.

The following topics ranked higher in terms of how satisfactorily they were addressed, according to the students: doctor-patient relationship (99.2%), euthanasia (85.8%), and brain death (74%). The themes with the lowest satisfaction rates were assisted reproduction (28.5%), animal testing (33.6%), and ecology and bioethics (35.3%) ( Table 2 ).

Table 2
Student satisfaction regarding topics covered by the “Humanities, Bioethics and Medical Anthropology” module

				Evaluation
Topic	Excellent		Good			Fair			Poor/Very poor
	n	%	n		%	n	%		n	%
Euthanasia	31	26.1	71		59.7	14	11.8		3	2.5
Abortion	20	16.8	58		48.7	30	25.2		11	9.2
Organ transplantation	22	18.5	48		40.3	25	21.0		24	20.2
Genetics and health	14	11.8	42		35.3	35	29.4		28	23.5
Ecology and bioethics	12	10.1	30		25.2	41	34.5		36	30.2
Assisted reproduction	11	9.2	23		19.3	35	29.4		50	42.0
Animal testing	11	9.2	29		24.4	31	26.1		48	40.3
Brain death	34	28.6	54		45.4	23	19.3		8	6.7
Doctor-patient relationship	82	68.9	36		30.3	0	0.0		1	0.8
Public health	29	24.4	57		47.9	24	20.2		9	7.5

Regarding evaluation methods, tutorial sessions were considered satisfactory by 67.3% of them, and dissertations by 53.7%. The ethical attitude of preceptors was assessed as satisfactory by 82.3% of the interviewees in regards to relationship with other professionals; 67.2% concerning relationship with students; and 80.7% with patients. Meanwhile, the MHBA tutors’ ethical stance was considered satisfactory by 75.6% of students ( Table 3 ).

Table 3
Student satisfaction with the “Humanities, Bioethics and Medical Anthropology” module

	Evaluation
Variable	Excellent		Good		Fair		Poor/Very poor
	n	%	n	%	n	%	n	%
Tutorial sessions as an evaluation method	29	24.4	51	42.9	18	15.1	21	17.6
Dissertations as an evaluation method	21	17.6	43	36.1	24	20.2	31	26.1
Preceptors’ ethical stance in relation to
Other professionals	13	10.9	85	71.4	19	16.0	2	1.7
Academics	7	5.9	73	61.3	30	25.2	9	7.6
Patients	12	10.1	84	70.6	19	16.0	4	3.4
Ethical behavior of the module’s tutors	32	26.9	58	48.7	22	18.5	7	5.9
Discussions on medical ethics in practice	8	6.7	51	42.9	41	34.5	19	15.9
Change of behavior at the end of the module	39	32.8	51	42.9	25	21.0	4	3.4
Importance of the module	48	40.3	41	34.5	20	16.8	10	8.4

For 49.6% of students, ethical aspects were usually addressed satisfactorily in discussions about medical practice in hospitals and outpatient clinics. Regarding changes in ethical stance after completing the MHBA, 75.7% consider themselves satisfied, while 21% consider themselves indifferent to these changes. The MHBA was rated as important by 74.8% of the students ( Table 3 ).

Only five (4.2%) respondents left suggestions, stating that the module should focus on discussing topics with more practical relevance for their professional practice, and that the contents should be distributed throughout the course itself, with no need for a separate module. Furthermore, students criticized the tutorial-session method, suggesting that the subject should be dealt with in a more dynamic way – for example, in roundtables – and that these discussions should address real cases of ethical dilemmas.

Discussion

As observed in this research sample, most medical students enter college while still young. Medicine is generally their first higher education course, and they reach the course’s final years when they are 23 to 26 years old. There is a major predominance of females (about 70%), a finding that corroborates the ongoing change in the profile of Brazilian medical students. Although it is still a predominantly male profession, a 2013 study showed that there were more women than men entering undergraduate courses and registering themselves with medical boards¹⁰.

Most students consider themselves brown, but the number of self-declared blacks was very low (4.2%). Data from the Higher Education Census 2018¹¹show that only 7% of the undergraduate students were black. The data reflects this population’s difficult access to higher education, especially in courses regarded as typical choices for people of higher social strata, such as medicine.

Regarding academic periods in which medical ethics and related subjects were addressed, students point out that these were predominant in the first and sixth academic periods, and appeared mainly in the form of tutorial sessions. In the ninth and tenth periods, when they have to carry out their medical internships and activities become exclusively practical, the topic is not discussed.

In another study, an analysis of the curricular syllabuses of public universities in Ceará pointed out that specific topics related to ethics and bioethics are taught from the first to the fourth year of the undergraduate course, meaning that students explore these issues long before the curriculum’s exclusively practical activities, which often take place during the course’s final years¹². A factor that may explain the concentration of ethics teaching in the first academic periods is the student’s somewhat more idealistic view at the beginning of the course, which makes them more receptive to the learning of the medical practice in its all dimensions. In the last years, student interest appears to shift towards strictly technical knowledge¹³.

The participants pointed out that MHBA contents were taught mainly through tutorial sessions, plays and movies, in addition to the reading of specific books for subsequent evaluation in the form of a dissertation. These approaches differ from the ones adopted by other curriculum modules, in which the contents are also taught in tutorial sessions, but objective examinations are used as an evaluation method. Among the interviewees, 47.3% were disatisfied with the MHBA evaluation model. In the module, each tutor is assigned a group of students and becomes responsible for correcting their dissertations (a class is divided into seven to ten groups). As several professionals are responsible for correcting the texts, personal interpretation differences may influence the results. This issue could be solved by making a single professional responsible for correcting all dissertations.

According to the interviewees, the doctor-patient relationship topic was among the most adequately addressed in the MHBA. This is important content, since, in order to remain solid and long-lasting, the doctor-patient relationship must have exchanges of experience, mutual trust, and responsibility. Moreover, patients should collaborate with doctors, getting involved in the process, exposing their opinions, questions and decisions, in a shared practice¹⁴.

On the other hand, our results show that essential topics, such as ecology, remains insufficiently discussed, despite the fact that the national curricular guidelines for medical courses recommend the study of ecological determinants, whether individual or collective, in the health-disease process, considering that interactions between the environment and living beings determine the process of adaptation⁷. Furthermore, ecology contributes to reflect on how technological processes and systems of social organization can bring about changes in human life⁷. Finally, there is also the topic “sustainable development,” a subject whose discussion should be further emphasized in the undergraduate course.

Certain themes should be better explored during the module, considering that in the space reserved for opinions at the end of the questionnaire some students argued that the topics covered by the module have little relevance for professional practice. There were also complaints about the repetition of contents that were addressed at more than one point throughout the course. However, only five of the 119 interviewed students expressed their opinion in that section, which limits the relevance of this finding.

The approach to ethical aspects of clinical cases in hospitals and outpatient clinics was considered satisfactory by 49.6% of the students, that is, less than half of the participants. This finding demonstrates that it is necessary to connect the MHBA’s theoretical framework with the students’ practical experience. In fact, as pointed out by a study conducted at Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro, in the absence of ethical guidance by their preceptors, future professionals often find themselves alone in difficult situations¹⁵.

Still concerning the practical applicability of medical ethics, most students considered the stance assumed by preceptors in relation to other professionals, professors and patients as well as the stance posited by MHBA tutors to be satisfactory. However, the number of students dissatisfied with or indifferent to their tutors’ ethical stance was significant (24.4%). This finding inspires caution, since students may learn more from practical examples than from theory. Thus, professors must be aware that their attitudes are closely observed by their students and regarded as a parameter for dealing with ethical dilemmas. Some researchers argue that learning only consolidates itself when students can assign meaning to contents, linking it to situations that occur during their professional practice¹⁶.

The separation between technical knowledge and humanistic qualities often leads students to treat the latter as less important. This attitude affects the so-called “hidden” or informal curriculum, which extrapolates the national curriculum guidelines and is built in the professor-student relantionship, which may indirectly influence professional practices¹⁷. The importance of good professional models for medical students has been emphasized in the literature, since knowing and not doing is not truly knowing ¹⁸.

Most of the interviewees noticed changes in their attitudes during the internship after attending the MHBA. However, even though they represent a minority, the 21% who were indifferent and the 3.4% who reported no changes show that the module may not have been able to effectively change the doctor-patient relationship dimension. The absence of change, in any case, could also be explained by the fact that young people who choose this profession may have associated their personal motivations and values with medicine long before entering a medical school. During their training, these values are not necessarily forgotten, and may influence their professional practice¹⁹.

Among the participants, 74.8% evaluated the module as important for the medical curriculum, which demonstrates the effectiveness of its implementation as a way of complying with national curricular guidelines. The inclusion of more questions about ethics and bioethics in medical residency admission tests – since 2006, the presence of ethics in all programs as well as specialist-degree examinations has become a requirement – may also have contributed to awaken students’ interest in this theme²⁰.

Bioethical disciplines should focus on ethical issues, creating a space for institutional and personal reflection on values, life goals and professional practice, in order to promote social responsibility among doctors and medical schools²¹. However, these schools still have structural limitations that prevent this from happening, such as restricted class hours, professors who lack humanistic background, syllabuses with topics that have little pertinence, absence of practical classes addressing the contents, and evaluation methods incompatible with the disciplines’ proposals³.

A possible solution may be found at Universidade Federal de Pernambuco, for example, where the module “Medicine, Society and Ethics”, in the third period, is an integral component of the personal-development axis of the medicine course²². To further improve the covered subjects and student performance, many of the module’s activities led to scientific articles, work for congresses, manuals, regulations and social work with patients and the community²². By adopting similar initiatives, Funorte could make MHBA a space for consultation, especially concerning ethical dilemmas and conflicts. With such a model, students may begin to see MHBA under a new light, making it more visible in the other modules.

Given its importance, Funorte’s decision to develop MHBA as a module meant specifically for addressing humanistic issues enriches the institution’s formal curriculum. Curricular reforms are necessary to adapt higher education courses to the evolution of knowledge, and can improve the training of doctors. The teaching of bioethics encourages student participation in debates and highlights the need to deepen their perception of the patient as an agent endowed with rights and prerogatives, thus strengthening the doctor-patient relationship²³.

Final considerations

This study shows that the ethics-related activities of the course are mainly concentrated in the first and sixth periods (in MHBA, in this case). These activities are carried out by tutorial sessions, theater and cinema. Students are evaluated mainly by dissertations, which were considered unsatisfactory as an evaluation method by a significant portion of the respondents. The use of such an evaluation method should be revised, in contrast to tutorial sessions, which were considered a satisfactory form of examination.

Another relevant finding was that the approach to some of the module’s topics was considered ineffective. In view of the importance of these subjects, it is necessary to make them a more tangible part of the daily routine of doctors, bringing theory and practice closer together and making preceptors more present in discussions regarding ethical dilemmas.

Most students reported changing their ethical view after attending the module. Therefore, the teaching of ethics as a factor of transformation in the medical field stands out, expanding the view of professionals beyond technical contents. In this sense, the perception of both preceptors and tutors was also mostly satisfactory.

Despite some students’ criticisms of the MHBA’s structure, the study clarified that the contribution of the module for the formation of more humane doctors whose knowledge goes beyond their specialties. This directly reflects upon the doctor-patient interaction, substantially strengthening it.

Questionnaire Sociodemographic questions

1. What is your age? _____________

2. What academic period are you enrolled in? ( ) 8th ( ) 9th ( ) 10th

3. Gender: ( ) female ( ) male

4. Color: ________________

5. Do you have another degree? ( ) Yes ( ) No

If so, which one? _____________________

Questions 6 to 8 refer to the teaching of ethics in medical school:

6. Do you consider the subject of medical ethics to be:

( ) very important ( ) important ( ) fairly important ( ) slightly important ( ) not important

7. Does the curriculum have a subject dedicated to bioethics?

( ) Yes. In which academic period(s)? ( ) 1st ( ) 2nd ( ) 3rd ( ) 4th ( ) 5th ( ) 6t ( ) 7th ( ) 8th ( ) 9th ( ) 10th ( ) No

8. Between the 1st and 5th periods, the topics “medical ethics,” “humanities” and “anthropology” were addressed in:

( ) they were not addressed ( ) theoretical classes ( ) case discussions ( ) tutorial sessions ( ) reading of specific books ( ) discussions during practical activities in outpatient clinics ( ) theatrical and cinema sessions ( ) others: _________________________

The following questions refer to the Humanities, Bioethics and Medical Anthropology (MHBA) module:

9. At the MHBA, content was delivered through:

( ) theoretical classes ( ) case discussions ( ) tutorial sessions

( ) reading of specific books ( ) discussions during practical activities in outpatient clinics

( ) theatrical and cinema sessions ( ) others: _________________________

Questions 10 to 19 refer to the MHBA’s themes:

10. The approach to the theme of “euthanasia” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

11. The approach to the theme of “abortion” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

12. The approach to the theme of “genetics and health” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

13. The approach to the theme of “ecology and bioethics” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

14. The approach to the theme of “brain death” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

15. The approach to the theme of “transplantation” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

16. The approach to the theme of “assisted reproduction” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

17. The approach to the theme of “doctor-patient relationship” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

18. The approach to the theme of “public health” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

19. The approach to the theme of “animal testing” was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

20. During case discussions in hospitals and outpatient clinics, ethical aspects are usually addressed in a way that you consider:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

Questions 21 and 22 refer to evaluation methods:

21. The use of tutorial sessions as a method of evaluation was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

22. The use of dissertations as an evaluation method was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

Questions 23 to 26 refer to professors’ ethical relationship:

23. Throughout the course, your preceptors’ attitude concerning ethical issues arising from their relationships with other professionals was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

24. Your preceptors’ attitude regarding ethical issues arising from their relationships with academics was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

25. Your preceptors’ attitude regarding ethical issues arising from their relationships with patients was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

26. Your MHBA tutors’ attitude regarding ethical issues was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

27. Your assessment of changes in your own ethical attitude after undergoing the MHBA module was:

( ) very satisfactory ( ) satisfactory ( ) neither satisfactory nor unsatisfactory ( ) unsatisfactory ( ) very unsatisfactory

28. The MHBA was:

( ) very important ( ) important ( ) fairly important ( ) slightly important ( ) not important Why? ___________________________________

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Publication Dates

• Publication in this collection
  21 May 2021
• Date of issue
  Jan-Mar 2021

History

• Received
  16 July 2020
• Reviewed
  4 Feb 2021
• Accepted
  8 Feb 2021