Impact of a pre-clinical skills course with Peer Assisted Learning (PAL) on preparedness and confidence levels of medical students in Africa

  • Cheryl Snyder MA, DO, San Diego Christian College
  • Rose Chisenga MB ChB, University of Zambia
Keywords: peer assisted learning, PAL, medical education, Africa, africa, confidence levels, Zambia, clinical skills


Background: Many benefits of pre-clinical medical skills training have been documented in more technologically advanced nations, and in the past decade, these courses have been introduced to developing countries. Curriculum that can prepare and build confidence in medical students must be cost effective, evidence-based and culturally sensitive in places where there are severe resource limitations.  In 2013, an initial pre-clinical skills course without assessments was introduced to medical students in Zambia. Later that year, a more developed course was launched to a second cohort integrating Peer Assisted Learning (PAL) and assessments. These trainers were prepared in advance with instruction in standardized skills, learning theory, effective feedback techniques and use of rubrics to insure good inter-rater reliability in teaching and assessments.

Methods: A quantitative study surveyed 108 students utilizing convenience sampling and a written questionnaire. Data collected compared preparedness and confidence in performing clinical skills of the intervention cohorts with the control group (medical students who preceded pre-clinical skills training).

Results: Preparedness responses increased from 36.1% of the students in the control group to 90.9% in the intervention group who had been exposed to the PAL course with assessments (p value <0.001). Student confidence levels in history taking, physical exam skills, procedures and the application of critical thinking skills diagnostically also showed improvement from 11.5-29.5% range in the control group to 77.3-86.4% range in the PAL cohort (p value <0.001).

Conclusions:Exposure to pre-clinical training program especially utilizing PAL with assesments had a positive impact on the sense of preparedness and confidence levels for medical students beginning their clinical training years at the University of Zambia.  Integration of PAP influenced academic development, clinical procedural standardization, appropriate curriculum additions, transitional support and program sustainability. PAL may have beneficial application extending to basic science lab instruction in resource limited environments. Recommendation for future research would be integration of qualitative triangulation and reduction of variables in confidence data reporting. 

Author Biographies

Cheryl Snyder, MA, DO, San Diego Christian College

MA, DO, Associate professor at San Diego Christian College and Chair of the science department

Rose Chisenga, MB ChB, University of Zambia
Rose Chisenga is a Junior Resident Medical Officer currently doing her internship at the University Teaching Hospital in Zambia.She received her Bachelor of Medicine and Bachelor of Surgery degrees from the University of Zambia, School of Medicine.She is interested in teaching and carrying out research that can help improve the standard of health care in developing countries like Zambia.She hopes to get specialized training in infectious diseases.  


Ali, L., Nisar, S., Ghassan, A., Khan, S. Impact of clinical skill lab on students’ learning in preclinical years. Journal Ayub Medical College Abbottabad. (Oct –Dec 2011); 23 (4). 114-7. DOI not available PMID: 23472431

Fromme, H, Karani, R., Downing, S. Direct observation in medical education: a review of the literature and evidence for validity. Mount Sinai Journal of Medicine; (August 2009); 76 (4), 365-71. DOI: 10.1002/msj.20123

Small, R., Soriano, R., Chietero, M. Easing the transition: medical students' perceptions of critical skills required for the clerkships. Education Health, (December 2008); 21 (3), 192. DOI not available PMID: 19967639

Chumley, H., Olney, C., Usatine, R., Dobbie, A. A short transitional course can help medical students prepare for clinical learning, Family Medicine, (July-August 2005); 37 (7), 496-501, Retrieved October 25, 2013 from ProQuest database. DOI 10.1007/978-90-481-3937-8_4

Remmen, R. Effectiveness of basic clinical skills training programmes: A cross sectional comparison of four medical schools. Medical Education, (2001); 35 (2), 121-128. DOI: 10.1111/j.1365-2923.2001.00835.x

Hao, J. The clinical skills laboratory: A cost effective venue for teaching clinical skills to third year medical students, Academic Medicine, (2002); (77) 2, 152. DOI not available

Manyana, M., Mshana, S.E. Shortage of faculty in medical schools in Tanzania: A case study at the Catholic University of Health and Allied Health Sciences, African Journal of Health Professional Educators, (November 2013); (5)2, 95-97. DOI not available 354-2157-1-PB.pdf

Shahid, H. How to Develop a Core Curriculum in Clinical Skills for Malaysia?, The Malaysian Journal of Medical Sciences, (July 2007); 14 (2), 4-10. No DOI available PMID: 22993486 PMCID: PMC3442621 internet retrieval Jan 6,2016 internet retrieval January 6, 2016

Stark, P., Fortune, F. Teaching Clinical Skills in Developing Countries: Are Clinical Skills Centres the Answer? Education for Health, (2003); 16 (3), 298-306. DOI: 10.1080/13576280310001607433

Widyandana, D., Maioor, G.,Scherpbier, A. Transfer of medical students’ clinical skills learned in a clinical laboratory to the care of real patients in the clinical setting: the challenges and suggestions of students in a developing country. Education for Health. (2010); 23(3)

Falk, G., Robb, W., Khan, W. Hill, A. Student-selected components in surgery: providing practical experience and increasing student confidence IRISH J MED SCI , vol. 178, no. 3, pp. 267-272, 2009. 10.1007/s11845-009-0306-8

Blohm M, Krautter M, Lauter J, Huber J, Weyrich P, Herzog W, Jünger J, Nikendei C. Voluntary undergraduate technical skills training course to prepare students for clerkship assignment: tutees' and tutors' perspectives. BMC Med Educ. 2014 Apr 4; 14:71.

Bugaj T., Nikendei C. Practical Clinical Training in Skills Labs: Theory and Practice. GMS J Med Educ. 2016 Aug 15;33(4):Doc63.

Wenrich, M., Jackson, M., Maestas,R. From cheerleader to coach: The developmental progression of bedside teachers in giving feedback to early learners. Academic Medicine. 2015. Nov 90(11).S91-S97.

doi: 10.1097/ACM.0000000000000901

Plack, M., Goldman, E.,Wesner, M., Manikoth, N.,Haywood,Y. How Learning Transfers: A Study of How Graduates of a Faculty Education Fellowship Influenced the Behaviors and Practices of Their Peers and Organizations.Academic Medicine.2015 March 90 (3).372-378.

doi: 10.1097/ACM.0000000000000440

Sammaraiee, Y., Mistry R., Lim J., Wittner L., Deepak S., Lim G. Peer-assisted learning: filling the gaps in basic science education for preclinical medical students. Physiol Educ. 2016 Sep;40(3):297-303.

Shiozawa, T., Hirt, B., Lammerding-Koeppel, M. The influence of tutor training for peer tutors in the dissection course on the learning behavior of students. Ann Anat. 2016 Jul 28; S0940-9602(16)30127-3.