Validation of a didactic sequence for teaching pulmonary tuberculosis management in medical educationABSTRACT
Introduction: Direct intervention in tuberculosis (TB) education in medical schools has been proposed as an important strategy for disease control in low- and middle-income countries.
Objective: To develop and validate a didactic sequence for teaching the clinical management of pulmonary and laryngeal tuberculosis in adults, aimed at undergraduate medical students and medical residents in Family and Community Medicine.
Method: Methodological research focused on the development, evaluation, and improvement of intervention tools and strategies, involving three processes: 1) development of the didactic sequence; 2) validation of tools; 3) evaluation and/or application of tools. A literature review was conducted on the knowledge presented by medical students regarding TB, followed by the development, construction, and validation of the didactic sequence as an active intervention methodology.
Results: The validation scores assigned by 26 experts to the didactic sequence, considering the aspects of objectives, structure/presentation, and relevance, showed high content validity indices (CVI), with most items presenting CVI equal to or greater than 96.1%, and some reaching 100%, indicating strong agreement among evaluators regarding the pedagogical quality of the sequence. The item referring to the possibility of adding or eliminating activities presented a lower CVI (88.4%), indicating room for adjustments and flexibility according to the application context.
Conclusion: The proposed didactic sequence was, in general, considered by the evaluators to be well-structured and relevant for enhancing the pedagogical quality of TB teaching.
Keywords:
Education, Medical; Tuberculosis, Pulmonary; Clinical Competence
RESUMO
Introdução: A intervenção direta do ensino sobre a tuberculose (TB) nas escolas médicas tem sido proposta como importante estratégia para o controle da doença em países de baixa e média rendas.
Objetivo: Este estudo teve como objetivo descrever o desenvolvimento e a validação de uma sequência didática para o ensino do manejo clínico da TB pulmonar na graduação em Medicina e na residência médica em medicina de família e comunidade.
Método: Trata-se de uma pesquisa metodológica com foco na elaboração, na avaliação e no aperfeiçoamento de instrumentos e estratégias de intervenção, envolvendo três processos: 1. desenvolvimento da sequência didática; 2. validação de ferramentas; 3. avaliação e/ou aplicação de ferramentas. Foi realizada revisão da literatura sobre os conhecimentos apresentados por graduandos em Medicina sobre a temática da TB, seguida do desenvolvimento, da construção e da validação da sequência didática como metodologia ativa de intervenção.
Resultado: Os escores de validação atribuídos por 26 especialistas à sequência didática, considerando os aspectos de objetivos, estrutura/apresentação e relevância, evidenciaram elevados Índices de Validade de Conteúdo (IVC), com a maioria dos itens apresentando IVC igual ou superior a 96,1%, e alguns alcançando 100%, o que indicou forte concordância entre os avaliadores quanto à qualidade pedagógica da sequência. O item referente à possibilidade de acrescentar ou eliminar atividades apresentou menor IVC (88,4%), indicando espaço para ajustes e flexibilizações conforme o contexto de aplicação.
Conclusão: A sequência didática proposta foi, de maneira geral, considerada pelos avaliadores bem estruturada e pertinente para potencializar a qualidade pedagógica do ensino da TB.
Palavras-chave:
Educação Médica; Tuberculose Pulmonar; Competência Clínica
INTRODUCTION
The National Education Council/Chamber of Higher Education, in CNE/CES Resolution No. 3 of 20 June 2014, which establishes the National Curriculum Guidelines for the Undergraduate Medical Programme, stipulates in Article 7(VII) that undergraduate students must “link, through the integration of teaching and clinical practice, their academic medical training to social health needs, with an emphasis on the Unified Health System (SUS)”1.
Within the competency matrix for the Family and Community Medicine (FCM) residency programme, CNRM Resolution No. 9 of 30 December 2020 stipulates that, within the healthcare provision strand, with regard to the management of infectious diseases, the following are required: the management of the most common infectious diseases relevant to public health; a thorough understanding of the local prevalence of infectious diseases; proficiency in the diagnosis and correct inclusion in the differential diagnosis of infectious diseases prevalent throughout the country; proficiency in the prophylaxis of the most common and relevant infectious diseases; coordination of active contact tracing; a thorough understanding of the management of patients with pulmonary, laryngeal and extrapulmonary tuberculosis under their care; the ability to assess and identify issues relating to adherence to treatment for infectious diseases such as HIV/AIDS and TB, including supervised dosing2.
The National Tuberculosis Control Programme (PNCT), now known as the General Coordination for the Surveillance of Respiratory and Chronic Diseases (CGDR/SVS/MS), has as one of its cornerstones health education and the strengthening of Primary Health Care (PHC), which should be the main point of entry into the health system3. Nonetheless, studies show that a significant proportion of TB cases are still diagnosed in medium- or high-complexity facilities, such as hospitals and A&E departments, highlighting weaknesses in the capacity for early detection within primary healthcare and the need to strengthen this level of care4.
Direct educational intervention on TB in medical schools has been proposed as an important strategy for controlling the disease in low- and middle-income countries5. Effective coordination between the various sectors of the health system involved in the management of TB, including universities, would ensure that healthcare professionals follow the recommendations of the National Tuberculosis Control Programme (PNCT). Consequently, the Ministry of Health’s guidelines on the care and management of people with respiratory symptoms or confirmed tuberculosis need to be discussed as part of the medical education curriculum, and the assessment of the acquisition of this knowledge needs to be strengthened, given the major public health problem posed by this clinical condition and the recommendations of the National Curriculum Guidelines for medical degree programmes6.
Patients with tuberculosis may present with non-specific symptoms, and healthcare professionals unfamiliar with the disease may fail to recognise the link between the combination of clinical, radiological and epidemiological findings which, taken together, would suggest the diagnosis, thereby compromising the quality of care for people with TB7. These shortcomings in the quality of care can stem from several sources, including knowledge gaps, the inappropriate use of technology, and the inability of organisations to monitor and support standardised care8.
In undergraduate medical programmes, a large proportion of assessments are still based on conceptual knowledge, and the use of oral and written multiple-choice tests remains a frequently used assessment tool9. In most contexts, teaching is still based on the transfer of knowledge from teacher to student in a top-down manner, limited to a process centred on lecture-study-exercise-exams10. This creates a false impression of what practice entails in terms of developing practical skills, whilst ignoring the specific circumstances of each student’s real-life situations11.
In education, competency is a combination of components, including social and behavioural aspects, together with knowledge, values, ethics and attitudes, which can collectively be drawn upon to generate effective action in a given context, whilst remaining transferable to other contexts12. A competency-based approach to teaching and learning encourages problem-based learning, in which students are expected to engage with and take an active interest in their learning, whilst the teacher’s role is to organise the learning process, guide the learning pathways and encourage projects13.
The proposed teaching programme is aimed at an adult audience (undergraduate medical students in their clinical training and medical residents), which means that the principles of andragogy must be considered as a guiding framework for pedagogical choices. Proposed by Malcolm Knowles in the second half of the twentieth century, andragogy is based on the assumption that adults learn in a qualitatively different way from children: they bring prior experience which serves as a resource for new learning, are guided by concrete problems, are predominantly internally motivated, and need to understand the practical relevance of what they are learning in order to engage with the learning process14.
In the context of certain healthcare practices, such as basic life support (BLS) training for teachers, this approach promotes autonomy and intrinsic motivation, thereby increasing the effectiveness of knowledge retention and readiness to act in critical situations15. This example therefore demonstrates that the integration of andragogical principles enables educational interventions to go beyond the mere transmission of information, facilitating voluntary behavioural changes and the adoption of habits and values that lead to better health outcomes16”.
When designing healthcare curricula, competency should be understood as the ability to mobilise, coordinate and put into practice the knowledge, skills and attitudes that are desirable for the effective performance of the tasks required in the workplace17. Competency-based curricula should incorporate teaching and learning methodologies, pedagogical practices, different contexts, learning scenarios, and assessment and research methods in line with this principle18. This curriculum includes a number of features, such as: specifying skills in a way that allows them to be measured; emphasising pupils’ independent progression; activity-based assessment; instruction designed to foster the acquisition of skills; a focus on real-world experiences and problems; and support for the use of multimedia technologies19.
The learning outcomes to be achieved in this curriculum are first defined, followed by the processes required to achieve them, with a focus on what the learner should learn rather than what is taught, with educational sessions centred on the application of knowledge to real-world contexts20. Among the pedagogical principles underpinning the competency-based curriculum is training focused on solving the most relevant practical problems, presenting essential content defined on an epidemiological basis, with teaching tailored to the local healthcare context19.
The adoption of teaching sequences as pedagogical tools for the teaching-learning process offers an innovative perspective on curriculum design, emphasising a research-based educational approach21. This involves using real-life, everyday situations, beginning with questions that encourage students to compare their prior understandings with the new information introduced during the educational process22. Thus, they are encouraged to internalise novel concepts, explore different research methodologies and create objects and procedures23.
The way in which different types of activities are combined is one of the distinguishing features that define the specific nature of many teaching approaches24. The first element that identifies a method is the order in which the activities that make it up take place, as well as the relationships established between them25. The teaching sequence makes use of intervention units, in which pupils’ participation varies in degree, as well as the interrelation of different content areas and the way in which they are approached, as well as different methodological approaches to teaching and learning, characterised by an ordered and coherent series of activities9.
In light of the above, the aim of this study is to describe the development and validation of a teaching programme on the clinical management of pulmonary tuberculosis, designed for medical undergraduates and medical trainees in Family and Community Medicine.
METHOD
This is a methodological study focusing on the validation of a teaching sequence for the clinical management of pulmonary tuberculosis, developed for medical undergraduates and medical trainees in Family and Community Medicine. The study was organised into three sequential stages: 1) development of the teaching sequence, based on a review of the literature and the drafting of content items; 2) validation of content by experts, using a tool based on the Content Validity Index (CVI); 3) implementation, analysis and refinement of the teaching sequence based on the evaluators’ recommendations.
The research was approved by the Research Ethics Committee of the State University of Pará and the Federal University of Pará, under CAAE registration numbers 83829024.5.0000.5174, opinion no. 7,247,473, and 83829024.5.3001.0018, opinion no. 7,423,420, respectively.
Study Location
The Faculty of Medicine at a public university in the state of Pará, Brazil, and at a university hospital which is a centre of excellence for infectious diseases in the same state.
Aim of the Teaching Sequence
To develop specific skills for the clinical management of pulmonary and laryngeal tuberculosis in adults, using a range of learning strategies that combine theory and practice.
Development of the teaching sequence elements
Although cooperation between universities and state health authorities a measure recommended by the World Health Organisation (WHO) as a strategy for controlling and eradicating tuberculosis, an integrative literature review demonstrated gaps in medical undergraduates’ knowledge regarding key areas for the management of TB, highlighting the need to reinforce the recommendations set out in the Ministry of Health’s Manual of Recommendations on Tuberculosis26.
With regard to the conceptual and procedural knowledge acquired by medical undergraduates in areas relevant to the management of the disease, a scoping review revealed weaknesses in the discussion and assessment of this content, thereby compromising the establishment of learning objectives and methodological teaching strategies to achieve them27.
With regard to skills development, an integrative review of the literature and documentary research proposed an essential competency matrix for medical undergraduates following a generalist training programme, including comprehensive care and medical knowledge28. Consequently, the teaching sequence developed and presented to the experts outlined the validated skills and competencies relating to the content identified by the literature review as areas of weakness in terms of knowledge of the management of pulmonary TB.
Based on a literature review and the researcher’s clinical experience within the context of specialist practice, the phases of the general teaching sequence were defined and summarised in Chart 1, which is adapted from the model proposed by Zabala (2010).
The structure of the content in the general teaching sequence provided to the research participants is summarised in Chart 2.
Criteria for the selection of experts
Experts in the field of clinical practice and/or teaching in pulmonology and phthisiology from public medical universities in the state of Pará, with more than five years’ teaching experience, were invited to participate, regardless of whether they are involved in research groups or projects on the subject of tuberculosis, or who have experience as supervisors of theses, dissertations, Final Course Projects (TCC) or Final Residency Projects (TCR) on the same theme, or who have published papers in journals on the subject of TB; lecturers on the Family and Community Medicine modules; pneumologists who are members of the local society of pneumology and phthisiology; graduates of the postgraduate programme in Amazonian health education at a public university in the state of Pará, with published teaching sequences as technical-educational resources, in the field of teaching or management; lecturers with pedagogical training from public university medical schools in the state of Pará, working in undergraduate or postgraduate programmes at these institutions; specialist nurses in public health pulmonology who had been practising in wards or outpatient clinics specialising in Pulmonology and Phthisiology for more than 5 years.
The selection criteria for the experts were intentionally geared toward their experience and interest in the field of TB. Teachers with teaching qualifications were selected using the snowball sampling technique, in which the initial participants recommend others with a similar profile, thereby enabling the network of specialists to be expanded progressively. No specific mathematical model was used to determine in advance the number of experts to be selected - the final result was based on convenience sampling.
Validation tool and data collection process
For content validation, the experts completed a structured questionnaire comprising 18 items, organised into the domains of objectives, structure/presentation and relevance, using a three-point scale: Appropriate (A), Partially appropriate (PA) and Inappropriate (I). The questionnaire was administered via the Google Forms platform. The Content Validity Index (CVI) was calculated for each item using the formula (A + PA) × 100 / n, where n is the total number of assessors; a CVI of ≥ 80% was considered satisfactory36.
Application and assessment
The teaching programme was delivered in the form of a refresher course structured around face-to-face workshops, with a total duration of 12 hours, comprising 4 hours of face-to-face sessions and 8 hours of prior independent study. The material for self-study was made available to participants in advance and consisted of short videos and a guidance booklet on the clinical management of pulmonary tuberculosis, drawn up and validated by specialists in the field (who did not take part in the evaluation phase of the teaching sequence, this being an exclusion criterion adopted in the selection of assessors). Seven workshops were held between 6 March and 16 June 2026, attended by medical undergraduates and residents in Family and Community Medicine.
At the end of the final workshop, participants were invited to evaluate the teaching sequence via a self-administered online questionnaire, made available via Google Forms, consisting exclusively of closed-ended questions organised on a five-point Likert scale (Strongly Disagree, Partially Disagree, Neither Agree nor Disagree, Partially Agree, Strongly Agree), divided into two domains: Objectives and Content; and Motivation and Relevance. The data collected were tabulated and analysed descriptively, with absolute and relative frequencies presented by item and by domain.
RESULTS
Evaluation by workshop participants
A total of 111 students, including medical undergraduates and Family and Community Medicine residents, took part in the seven workshops held between March and June 2026. Of these, 53 completed the questionnaire evaluating the teaching sequence (response rate: 47.7% Table 1 shows the distribution of responses by item and by domain. In both areas assessed (Objectives and Content; and Motivation and Relevance), ‘Strongly Agree’ responses predominated, particularly for items 1 (96.2%), 10 (94.3%) and 8 (92.5%). The item with the lowest proportion of ‘Strongly Agree’ responses was item 6, concerning the appropriateness of the total workload (69.8%), which also accounted for the highest percentage of ‘Partially Disagree’ responses (7.5%).
Validation by the experts
Table 2 shows the validation scores awarded by 26 experts to the teaching sequence, taking into account the domains of objectives, structure/presentation and relevance. The overall CVI was 96.5%, with ‘Appropriate’ ratings predominating (87.6%), followed by ‘Partially appropriate’ (8.9%) and a low proportion of ‘Inappropriate’ ratings (3.5%). The item relating to the possibility of adding or removing activities had the lowest agreement rate (CVI = 88.4%).
Qualitative considerations from the expert assessors
In addition to the quantitative scores, the assessors recorded qualitative comments on the teaching sequence. Among the positive aspects, they highlighted that the sequential organisation of the activities helps to identify the instrument’s strengths and weaknesses, lends coherence and a progressive structure to the teaching and learning process, and adopts an active methodology consistent with the principles of competency-based education. As a recommendation for its use, the experts suggested that the sequence should preferably be used at the start of the Family and Community Medicine internships. The experts proposed the following suggestions for improvement: a review of the Fishbowl method, clarifying the point at which participants switch between the inner and outer circles; greater detail on strategies for assessing prior knowledge; summarising the volume of content to facilitate its assimilation by students; clarifying assessment criteria, rubrics and strategies for formative feedback; and future expansion of the scope to include tuberculosis in children and extrapulmonary forms.
DISCUSSION
Profile of the assessors and their relevance to the assessment
The composition of the panel of experts involved in content validation is a key factor in the credibility of the assessment process. In the literature, it is recommended that the panel should comprise professionals with experience both in the subject area being assessed and in the pedagogical domains relevant to the instrument, in order to ensure technically sound judgements regarding the relevance, clarity and appropriateness of the items20),(37. In this study, the panel consisted of 26 experts, bringing together professionals working in clinical practice and/or teaching in pulmonology and phthisiology, who were responsible for assessing the clinical accuracy and epidemiological relevance of the content, and academics with training in pedagogy, capable of assessing the methodological coherence and the suitability of the proposed teaching and learning strategies.
This mixed composition has been adopted in studies validating health education materials, as it facilitates a comprehensive assessment that integrates clinical and educational perspectives38. The minimum requirement of five years’ experience as an inclusion criterion for clinical experts is in line with the recommendations for establishing panels with consistent evaluation capacity regarding tools designed for professional training in healthcare37.
The validation process: CVI and its interpretation
The overall CVI score obtained in the expert evaluation demonstrates that the teaching sequence meets the criteria for content validity established in the literature, which recommends values of 0.80 or higher for educational instruments36. The item with the lowest agreement index (CVI = 88.4%) related to the possibility of adding or removing activities from the sequence; whilst this is still within the acceptable range, it indicates a need for greater clarity regarding the criteria guiding any adaptations. In this regard, the sequence can be adapted to suit the setting in which it is used. For example, in situations where there is less time available for face-to-face teaching, Fishbowl activities can be replaced by discussions in smaller groups followed by a plenary report; in contexts where students are already more familiar with the subject matter, the time allocated to individual study can be reallocated to practical clinical simulation activities.
Expected impact: active methodologies and training in tuberculosis
The high level of acceptance of the teaching sequence by participants, as evidenced by the predominance of ‘Strongly Agree’ responses across all items assessed - particularly regarding the workshop’s contribution to understanding the importance of TB (96.2%), the clarity of the information (92.5%) and the engaging nature of the proposed discussions (94.3%), is consistent with accumulated evidence regarding the positive impact of active learning methodologies on the motivation and academic performance of medical students11. Recent studies have shown that flipped classroom strategies lead to significant improvements in both cognitive performance and student engagement and satisfaction, compared with the traditional lecture-based model39),(40.
In the specific context of teaching infectious diseases, a field that shares similarities with TB in terms of the need to integrate epidemiological knowledge, diagnosis and clinical management, approaches based on team-based learning have demonstrated high levels of acceptance and a perceived gain in knowledge amongst medical students, including for topics of greater clinical complexity41. These findings take on added significance given the poor state of TB education in Brazilian medical schools, as documented by Trajman et al.5, and the persistent gaps in knowledge about the disease amongst medical and nursing undergraduates, as identified in a recent integrative review26.
Capacity-building for the diagnosis and management of TB should begin early on in general medical training, given that healthcare professionals unfamiliar with the clinical presentation of the disease tend to delay diagnosis, with consequences for epidemiological control28. In this regard, the workshop format - involving prior individual study and face-to-face activities centred on problem-based learning and group discussion - proved to be well-suited to the andragogical principles that guide adult education in healthcare contexts, encouraging active participation and critical reflection on clinical practice22.
Study limitations
This study has some limitations that should be taken into account when interpreting the results. The response rate to the evaluation questionnaire amongst participants (47.7%) may have introduced response bias, with greater participation from students who were more engaged or satisfied with the experience. Furthermore, the tool used assesses participants’ perceptions and satisfaction, but does not provide a direct measure of knowledge acquisition or changes in clinical behaviour (outcomes that would require a longitudinal study with pre- and post-intervention assessments). The unicentric nature of the study, which was carried out at a single public institution, also limits the generalisability of the findings to other institutional and regional contexts. Future multicentre studies with objective learning outcomes are needed to consolidate the evidence on the training impact of the programme.
CONCLUSIONS
The teaching sequence for the clinical management of pulmonary tuberculosis was developed on the basis of a review of the literature and validated by a panel of 26 experts with clinical and teaching experience, achieving an overall Content Validity Index (CVI) of 96.5%, which is above the recommended minimum threshold of 80% for educational tools. All items assessed in the areas of objectives, structure/presentation and relevance exceeded this threshold. The only item which, although approved, received the lowest agreement rate (CVI = 88.4%) was the one concerning the possibility of adapting the sequence by adding or omitting activities, suggesting a need for greater clarification of the criteria guiding any adjustments to different contexts of application.
The implementation of the programme across seven face-to-face workshops, held between March and June 2026 with medical undergraduates and residents in Family and Community Medicine, revealed a high level of acceptance amongst participants in both areas assessed (Objectives and Content; and Motivation and Relevance), with a predominance of ‘Strongly Agree’ responses across all items in the questionnaire. These results suggest that the teaching sequence constitutes a viable educational strategy that is structurally sound and well received by the target audience for which it was designed.
Given the epidemiological situation regarding tuberculosis in Brazil and the persistent gaps in the teaching of the disease in undergraduate medical education, this validated curriculum represents a concrete contribution to the training of professionals capable of the early diagnosis and appropriate management of TB in primary healthcare. Future pre-post, multi-centre studies are needed to assess the educational impact of the programme on participants’ knowledge, attitudes and clinical practices.
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