Availability and use of hepatitis B vaccine in laboratory and nursing schools in the United States.

Roush SW, Hadler SC, Shapiro CN, Schatz GC. Source Division of Viral and Rickettsial Diseases, Centers for Disease Control, Atlanta, GA 30333. Abstract Hepatitis B is a well-documented occupational hazard for health care workers, including both laboratory and nursing personnel. Since the development of effective hepatitis B vaccines, the Immunization Practices Advisory Committee (ACIP) has recommended that health care workers receive the vaccine. In this study, 78 laboratory training programs and 83 nursing training programs were surveyed regarding availability and usage of hepatitis B vaccine. The hepatitis B vaccine was made available to students in 81 percent of the laboratory programs and 23 percent of the nursing programs. In those programs making the vaccine available, only 59 percent of the laboratory programs and 5 percent of the nursing programs reported a high (greater than 75 percent) use by students. Concern about cost and payment for the vaccine was the most common reason (80 percent) noted by laboratory schools that did not have hepatitis B vaccination programs for students. Of the nursing schools that did not have vaccine programs, 58 percent had not yet considered a program. At laboratory schools with vaccination programs, who paid for the vaccine (hospital or school versus student) was among the most important determinants for vaccine usage by students. These findings point out that some laboratory schools and many nursing schools have not applied the ACIP recommendations to their own programs. Educational efforts and creative payment plans for the vaccine are needed to increase the availability and use of hepatitis B vaccine among laboratory and nursing students. PMID:
Free PMC Article

Hepatitis B and hepatitis B vaccine requirements in schools of nursing in the United States: a national survey.
Goetz A, Yu VL.
Veterans Administration Medical Center, Pittsburgh, PA 15240.

Abstract
To ascertain use of the hepatitis B vaccine and occurrence of hepatitis B infection in nursing students, 1152 U.S. nursing schools were surveyed; 54.3% responded. The vaccine was required by 4.2% and recommended by 7.7%. Baccalaureate programs tended to require the vaccine more than the associate degree or diploma programs (p = 0.062). The occurrence of exposure of nursing students to blood and body fluids in the past 5 years was reported by 89.7%. Students in the diploma program had significantly more exposures (98.6%) than those in the associate degree (92.8%) and baccalaureate programs (82.7%; p less than 0.0005). At least one case of hepatitis B in the past 5 years was reported by 6.8%. Development of positive serologic markers in students after exposure to blood was reported by 7.1%. Seropositivity tended to occur in the Southeast and West (p = 0.035) and in cities with a relatively higher incidence of acquired immunodeficiency syndrome (p = 0.075). Diploma programs were 1

significantly more likely to institute appropriate follow-up for students after exposure to blood of patients who were known or unknown carriers of hepatitis B virus (p less than 0.0001). For students exposed to blood of patients whose hepatitis B status was unknown and patients who were known hepatitis B carriers, 19.2% and 8.9%, respectively, reported they performed no follow-up whatsoever. U.S. nursing students are inadequately protected against hepatitis B. Nursing school administrators and faculty should be educated on the risks of hepatitis B infection and the indications and use of the hepatitis B vaccine. PMID:
J Adv Nurs. 1992 Apr;17(4):507-13.

Preferred sources of information on AIDS among high school students from selected schools in Zimbabwe.
Ndlovu RJ, Sihlangu RH.
Source

Department of Nursing Science, Faculty of Medicine, University of Zimbabwe. Abstract Following various national HIV and AIDS awareness campaign activities under the auspices of the Ministries of Health and Education, Zimbabwe, an AIDS KABP survey was undertaken. The study sample comprised 478 high school students randomly selected and stratified to represent sex and Forms 1 through to 6. The study instrument was a 31-item questionnaire designed to assess the students' knowledge, attitudes, practices and sources of information in relation to HIVsyndrome. This report reviews only that part of the study dealing with sources of information. Newspapers, television, radio and magazine were the most frequently cited sources of first information. Classmates were cited by 20% to over 30% of respondents as first sources of information. Authority figures like health workers, parents, teachers, the Church did not emerge as significant sources of first information. Doctors were identified as the most preferred source of information in future. Sources of first information were related to age, form level, sex and location of school attended. There were notable differences between boarding school respondents and day scholars. No regional differences were noted. 478 students from 4 sub-urban coeducational schools from Mashonaland region and Matabeleland region, Zimbabwe, were surveyed on their knowledge, attitudes, and behavior related to AIDs in OctoberDecember, 1990. The sample was randomly selected and stratified by sex and grade level. Information was obtained on their first source of sources of information on HIV infection and AIDs, the most informative source, and the most preferred source. A national awareness campaign, begun in 1987, informed the general population and distributed 3 booklets on HIV infection and AIDs to high school students. Differences were reflected by sex, grade level, school location, and geographical region in the use of newspaper, television, and booklets. The findings were that health care providers were of minimal significance in providing information, although 20% cited these professions as preferred sources of information. 49% of the students cited the newspaper as their first source of information. Following newspapers in order of preference were television, radio, and magazines which were identified as the first source by 36-45% of the students. Only 25% gave booklets as the first source of information. 20% cited classmates as the first source of information. First sources may not always be the most informative. Higher grade levels more frequently cited newspapers as their first source, but television was the most frequently cited as the first source in grades 1-3. Higher grade levels (5-6) also cited classmates as an

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important first source. Girls tended to cite as first sources classmates and radio, while boys cited newspapers and magazines. Sources of first information followed a school location pattern and socioeconomic setting. Classmates were the higher first source in the boarding school, while television and magazines had the lowest scores in the school with mostly low income families. Magazines were considered the most informative source for 17% and newspapers and magazines for 32%. Nurses and relatives were considered the least informative. Only 12.2 cited parents as the first source and only 3% cited them as a good source. 10% preferred booklets. Several proposals for thenursing practice are given. The rural population and appropriate networks needs to be examined.

Factual knowledge about AIDS and dating practices among high school students from selected schools.
Nyachuru-Sihlangu RH, Ndlovu J.
Source

Department of Nursing Science, Faculty of Medicine, University of Zimbabwe, Avondale, Harare. Abstract Following various educational strategies by governmental and non-governmental organisations to educate youths and school teachers about HIV infection and prevention, this KABP survey was one attempt to evaluate the results. The study sample of 478 high school students was drawn from four randomly selected schools in Mashonaland and Matabeleland including high and low density, government and mission co-educational schools. The sample was randomly selected and stratified to represent sex and grade level. The KABP self administered questionnaire was used. The paper analyses the relationship between the knowledge and dating patterns. Generally, respondents demonstrated a 50pc to 80pc accuracy of factual knowledge. Of the 66pc Forms I through IV pupils who dated, 30pc preferred only sexually involved relationships and a small number considered the possibility of HIV/AIDS infection. A theoretically based tripartite coalition involving the school, the family health care services for education, guidance and support to promote responsible behaviour throughout childhood was suggested. Educating at risk populations about HIV transmission in hopes of encouraging the adoption of low-risk behavior is one of the few options presently available to potentially reduce the rate of HIV infection and its prevalence. To communicate with and educate youths, one must first understand the social and sexuality issues of their existence and development. A survey of 478 high school students from 4 randomly selected school in Mashonaland and Matabeleland, Zimbabwe, was therefore conducted to evaluate the results of government and nongovernment organization educational strategies to educate youth and school teachers about HIV infection and prevention. The sample included students from high and low density, government and mission coeducational schools, and was stratified to represent sex and grade level. Respondents were 50-85% accurate on factual knowledge about HIV infections and AIDS, yet only 2-9% of those who date think that their present partners may be infected with HIV. 3

Accordingly, many sexually active students are most likely having sexual intercourse without condoms. 66% of Forms I-IV dated, of whom 30% preferred only sexually involved relationships. 48-55% of boys and girls dated, with 30% claiming they had had more than 1 boy/girlfriend over the past 12 months. More than 30% of those who were sexually active stated that they would not continue their relationship if sex were no longer a component. Overall, sampled students seemed relatively knowledgeable about HIV and AIDS, but were slow to properly assess the level of risk to which they may be exposed. While informational booklets were spread throughout the schools and left in student reading rooms or libraries, teachers were unprepared to talk about HIV infection and AIDS with students. Schools do not help youths reduce their vulnerability to HIV infection. A coalition of health services, schools, and families offering education and guidance is therefore recommended. Efforts must be made to change the faculty assumption that adolescents are generally healthy and not at risk of diseases, and steps taken to reach out to meet their great unmet need for health and education service

Results of a model AIDS prevention program for high school students in the Philippines.
Aplasca MR, Siegel D, Mandel JS, Santana-Arciaga RT, Paul J, Hudes ES, Monzon OT, Hearst N.
Source Research Institute for Tropical Medicine, Department of Health, Alabang, Muntinlupa, Metro Manila, Philippines.

Abstract
OBJECTIVES: To describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes andAIDS-preventive behaviors. SUBJECTS AND METHODS: A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in four demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. INTERVENTION: An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists and health educators. The teacher-led AIDS program was designed to provide students with accurate information about AIDS, particularly in dispelling misconceptions about casual contagion, to foster positive attitudes towards people with AIDS and to develop skills aimed at clarifying values and assessing intended behavior. RESULTS: At baseline, 11% of students (20% of males and 4% of females) reported ever having had sexual intercourse (mean age 14 years). Among these, condom use was low (24%). After implementation of the AIDS prevention program, statistically significant effects favoring the intervention group were observed in knowledge and attitudes towards people withAIDS. While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. 4

CONCLUSIONS: A sizable number of Filipino high school students are sexually active but condom use is low. School-basedAIDS prevention programs can be developed and implemented in developing countries with the assistance of school personnel to address sexual issues. Our program was successful in increasing AIDS-related knowledge and improving attitudes towards people with AIDS. Supplementation with other preventive activities may be needed to achieve lasting changes in students' risk-taking behavior. The objectives were to describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors by means of self-administered questionnaires. A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in 4 demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. An AIDS prevention program was developed by public high school teachers together with localAIDS experts, social scientists, and health educators to provide students with accurate information about AIDS, dispel misconceptions about casual contagion, to foster positive attitudes towards people with AIDS, and to develop skills aimed at assessing intended behavior. At baseline, 80 (11%) of 804 students reported ever having had sexual intercourse (mean age 14 years). 66 were male and 14 were female (p 0.001). Among these, condom use was low (24%). Reasons for failure to use condoms were: use of other method (26%) and loss of sensitivity (25%). After implementation of the AIDS prevention program, the intervention group was more likely to answer correctly that HIV cannot be transmitted by mosquito bites (p 0.01), through a cough or sneeze (p 0.01), or by shaking hands with an infected person (p 0.01). Students who had attended the AIDSeducation program were less likely to avoid people with AIDS and were more compassionate toward them (p = 0.01). Changes in knowledge about modes of HIV transmission were associated with improvements in preventive knowledge (p 0.001). While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. The program was successful in increasing AIDS-related knowledge and improving attitudes toward people with AIDS.
Indian J Med Res. 2009 Sep;130(3):327-33.

HPV & HPV vaccination: issues in developing countries.
Bharadwaj M, Hussain S, Nasare V, Das BC.
Source Division of Molecular Genetics & Biochemistry, Institute of Cytology & Preventive Oncology (ICMR), NOIDA, Uttar Pradesh, India.

Abstract
Cervical cancer is the second-most common cancer in women worldwide causing most cancer related deaths in women indeveloping countries including India. The most predominant etiological factor for cervical cancer is persistent infection of certain high-risk types of human papillomaviruses (HR-HPVs), while low-risk types are associated with benign cervical lesions and genital warts. In India, the most common (98%) oncogenic types are HPV types 16 and 18 5

with HPV 16 exclusively (80-90%) prevalent. Two recently developed virus-like particle (VLP) based prophylactic HPV vaccines, quadrivalent Gardasil (HPV 16/18/6/11) and Cervarix (HPV 16/18) offer great promise. Several other therapeutic vaccines are also in clinical trials and are yet to establish their efficacy. The use of already developed VLP vaccines in resource-poor regions is limited by several factors, most importantly the high cost of the vaccine. Therefore efforts are being made in India to develop cost-effective second-generation vaccines. Besides cost, there are several socio-cultural and ethical issues involved with the implementation of already developed vaccines including the acceptability of HPV vaccination by preadolescent girls and their parents in India

Effect of portfolio assessment on student learning in prenatal training for midwives.
Kariman N, Moafi F.
Source Department of Midwifery, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

Abstract
The tendency to use portfolios for evaluation has been developed with the aim of optimizing the culture of assessment. The present study was carried out to determine the effect of using portfolios as an evaluation method on midwifery students' learning and satisfaction in prenatal practical training. In this prospective cohort study, all midwifery students in semester four (n=40), were randomly allocated to portfolio and routine evaluation groups. Based on their educational goals, the portfolio groups prepared packages which consisted of a complete report of the history, physical examinations, and methods of patient management (as evaluated by a checklist) for women who visited a prenatal clinic. During the last day of their course, a posttest, clinical exam, and student satisfaction form were completed. The two groups' mean age, mean pretest scores, and their prerequisite course that they should have taken in the previous semester were similar. The mean difference in the pre and post test scores for the two groups' knowledge and comprehension levels did not differ significantly (P>0.05). The average scores on questions in Bloom's taxonomy 2 and 3 of the portfolio group were significantly greater than those of the routine evaluation group (P=0.002, P=0.03, respectively). The mean of the two groups' clinical exam scores was significantly different. The portfolio group's mean scores on generating diagnostic and therapeutic solutions and the ability to apply theory in practice were higher than those of the routine group. Overall, students' satisfaction scores in the two evaluation methods were relatively similar. Portfolio evaluation provides the opportunity for more learning by increasing the student's participation in the learning process and helping them to apply theory in practice.

Portfolios as a learning tool in obstetrics and gynaecology undergraduate training.
Lonka K, Slotte V, Halttunen M, Kurki T, Tiitinen A, Vaara L, Paavonen J.

Source 6

Development and Research Unit, Faculty of Medicine, University of Helsinki, Finland. kirsti.lonka@helsinki.fi Abstract CONTEXT: We developed a structured portfolio for medical students to use during their obstetrics and gynaecology undergraduate training. The main objective was to support the learning process of the students. We also wanted feedback information to enhance teaching. METHODS: The study population consisted of 91 medical students who completed the portfolio during their training course. The portfolio consisted of a 28-page A5-size booklet. The students entered all the clinical procedures they had performed and all the deliveries they had attended. After each group session, they answered questions about what they had learned and evaluated the performance of the teacher. They also indicated their general evaluation of the course and the portfolio itself. The teachers listed the 13 most important skills to be learned during the course. The students were asked to evaluate their own development on a scale of 0-5 before and after the course. A content analysis was performed on all the texts the studentsproduced, and all quantitative variables were coded. RESULTS: The amount of text written in the portfolio correlated (P < 0.001, F-value 4.2) with success in the final exam. In addition to acting as a logbook, use of the portfolio enhanced the learning process during the course. Students' attitudes towards the portfolio were mainly positive. Students appreciated the departmental interest in their learning process. CONCLUSION: Portfolios support the personal and professional development of medical students. A portfolio clarifies the learning goals and helps students to monitor how these goals are achieved. A portfolio encourages constant self-reflection.

Undergraduate medical students' views about a reflective portfolio assessment of their communication skills learning.
Rees C, Sheard C. Source Institute of Clinical Education, Peninsula Medical School, Room F10, St Lukes Campus, University of Exeter, Heavitree Road, Plymouth, Exeter EX1 2LU, UK. charlotte.rees@pms.ac.uk Abstract INTRODUCTION: To date, no studies have examined preclinical medical students' views about portfolios. Since portfolios are becoming increasingly valued in medical education, this study explores secondyear medical students' views about a reflective portfolio assessment of their communication skills. METHODS: 178 second-year medical students at the University of Nottingham completed the 18-item reflective portfolio questionnaire (RPQ) (alpha = 0.716) and a personal details questionnaire 7

three days before submitting their portfolio assessment for communication skills. Data were analysed using univariate and multivariate statistics on SPSS Version 10.0. RESULTS: Total scores on the RPQ ranged from 40 to 75 (mean 58.28, SD 7.08). Significant relationships existed between RPQ total scores and students' ratings of their reflection skills (rs = 0.322, P < 0.001), RPQ total scores and students' confidence building another portfolio (T = 4.381, d.f. = 176, P < 0.001), and RPQ total scores and students' marks for their reflective portfolio assessment (rs = 0.167, P = 0.029). Students with more positive views about reflective portfolios were more likely to rate their reflection skills as good, receive better marks for their portfolio assessment, and be more confident building another portfolio. DISCUSSION: This study begins to highlight preclinical medical students' views about reflective portfolios. However, further research is required using qualitative studies to explore students' views in depth. Medical educators should be encouraged to consider introducing portfolios as a method of formative and summative assessment earlier in the medical curriculum.

Conditions for successful reflective use of portfolios in undergraduate medical education.
Driessen EW, van Tartwijk J, Overeem K, Vermunt JD, van der Vleuten CP.
Source Department of Educational Development and Research, Faculty of Medicine, University of Maastricht, Maastricht, The Netherlands. e.driessen@edu.unimaas.nl

Abstract
AIM:

Portfolios are often used as an instrument with which to stimulate students to reflect on their experiences. Research has shown that working with portfolios does not automatically stimulate reflection. In this study we addressed the question: What are the conditions for successful reflective use of portfolios in undergraduate medical education? METHODOLOGY/RESEARCH DESIGN: We designed a portfolio that was aimed at stimulating reflection in early undergraduate medical education, using experiences described in the medical education literature and elsewhere. Conditions for reflective portfolio use were identified through interviews with 13 teachers (mentors), who were experienced in mentoring students in the process of developing their portfolios. The interviews were analysed according to the principles of grounded theory. RESULTS: The conditions for successful reflective use of portfolios that emerged from the interviews fell into 4 categories: coaching; portfolio structure and guidelines; relevant experiences and materials, and summative assessment. According to the mentors, working with a portfolio designed to meet these conditions will stimulate students' reflective abilities.

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CONCLUSION: This study shows that portfolios are a potentially valuable method of assessing and developing students' reflective skills in undergraduate medical training, provided certain conditions for effective portfolios are recognised and met. Portfolios have a strong potential for enhancing learning and assessment but they are very vulnerable and may easily lead to disappointment. Before implementing portfolios in education, one should first consider whether the necessary conditions can be fulfilled, including an appropriate portfolio structure, an appropriate assessment procedure, the provision of enough new experiences and materials, and sufficient teacher capacity for adequate coaching and assessment.

Effect of portfolio assessment on student learning in prenatal training for midwives
Nourossadat Kariman and Farnoosh Moafi
Department of Midwifery, Shaheed Beheshti University of Medical Sciences, Tehran, Iran. Corresponding author. Corresponding email: n_kariman@sbmu.ac.ir Received January 17, 2011; Accepted March 22, 2011. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Other Sections

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Abstract
The tendency to use portfolios for evaluation has been developed with the aim of optimizing the culture of assessment. The present study was carried out to determine the effect of using portfolios as an evaluation method on midwifery students' learning and satisfaction in prenatal practical training. In this prospective cohort study, all midwifery students in semester four (n=40), were randomly allocated to portfolio and routine evaluation groups. Based on their educational goals, the portfolio groups prepared packages which consisted of a complete report of the history, physical examinations, and methods of patient management (as evaluated by a checklist) for women who visited a prenatal clinic. During the last day of their course, a posttest, clinical exam, and student satisfaction form were completed. The two groups' mean age, mean pretest scores, and their prerequisite course that they should have taken in the previous semester were similar. The mean difference in the pre and post test scores for the two groups' knowledge and comprehension levels did not differ significantly (P>0.05). The average scores on questions in Bloom's taxonomy 2 and 3 of the portfolio group were significantly greater than those of the routine evaluation group (P=0.002, P=0.03, respectively). The mean of the two groups' clinical exam scores was significantly different. The portfolio group's mean scores on generating diagnostic and therapeutic solutions and the ability to apply theory in practice were higher than those of the routine group. Overall, students' satisfaction scores in the two evaluation methods were relatively similar. Portfolio evaluation provides the opportunity for more learning by

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increasing the student's participation in the learning process and helping them to apply theory in practice. Keywords: Evaluation, Portfolio, Learning, Satisfaction
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INTRODUCTION
In recent decades, numerous innovations have occurred in the field of educational theory and practice. Traditional teacher-centered educational methods have been replaced with student-centered methods. Parallel with this trend, the evaluation system has also been changed from methods that evaluate knowledge to those that evaluate ability and competence. A wide variety of evaluation methods have been developed in this context [1]. A portfolio is a planned and purposeful collection of all kinds of documents that gives an impression of how tasks are fulfilled and how competence is developed [2, 3]. Interest in use of portfolios for assessment in the health-care professions has developed as a part of the move away from traditional testing towards the use of broader assessment approaches. This method provides a closer link between learning and assessment. The use of portfolios improves learning outcomes through the provision of feedback and attempts to assess students in areas difficult to assess by traditional methods (attitudes and personal attributes) [4, 5]. Portfolio collection requires the joint efforts of teacher and student in taking decisions, developing the portfolio's content, and establishing its assessment criteria [6]. Portfolios may include case-reports, a list of methods used, video tapes from consultations carried out, explanations of learning experiences in the clinical environment, reports on books or journals and report on research projects [7-10]. Portfolio advantages are as follows: it can assess areas that are difficult to test traditionally, attitude can be assessed, curriculum outcomes can be emphasized, it reflects a student-centered approach to learning, it helps to create critical thinking, and the breadth as well as depth of students' learning can be assessed [3, 4, 10, 11]. This method makes innumerable contributions to such issues as providing practice with equipment, being flexible, identifying the positive and negative environmental factors influential in the learning process, encouraging students' willingness to participate in activities, and orienting the activities accordingly [12, 13]. Several studies have shown that this method promotes learning [14, 15]. On the other hand, in some educational texts and articles in this area, lack of sufficient research in portfolios' reliability and validity for undergraduate students' assessment has been suggested as one of the weaknesses of this method [7, 8, 10]. The introduction of course work using portfolios as an assessment tool is rather new to educational research in Iran. Due to the lack of studies in this field in our country, the present study was performed to determine the effect of the portfolio evaluation method on learning and satisfaction of midwifery students of Shaheed Beheshti Medical University in prenatal practical training in 2008-09.
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MATERIALS AND METHODS
In this prospective study, all of the fourth semester midwifery students of two courses (n=40) were studied for 4 semesters from their first academic semester of 2007-08 to their second semester of 2008-09. Using the portfolio evaluation method in the apprenticeship and training of midwifery students was approved by the Education Development Organization of the nursing-midwifery faculty of Shaheed Beheshti Medical University and the Department of Midwifery. Student groups were allocated to the portfolio and routine evaluation groups by a simple random sampling method. Each group was composed of 20 students and there was no attrition during the research period. The pre-test was taken on the first day of training. Both groups were then trained by a midwifery instructor in a prenatal clinic. Finally, a post-test was administered on the last day of the training course. These tests contained 40 questions, which included 16 multiple choice questions (MCQs) on knowledge and comprehension levels. There were also two cases, with 16 MCQs for the first case focusing on the application and analysis levels, as well as two open-ended questions about the second case in which the students were asked to judge the management of a diagnosis suggested by the exam. The questions content validity was verified by the Shahid Beheshti Midwifery faculties. The practical exams were carried out for the routine group based on practical training routine method evaluation on the last day of the training course. The portfolio group prepared their package based on the educational goals after being introduced to the portfolio evaluation method, performance of making the portfolio, portfolio contents, and a portfolio evaluation checklist. Their portfolios consisted of five complete reports on women who visited the prenatal clinic during the first nine days of the course, including for each, a history, physical exam, and method of patient management. The different groups of five women were selected by each student based on educational goals and the midwifery students' job description. The portfolio evaluation checklist utilized in our study was developed and first used by Davis et al. [16]. In this study, the validity of the checklist was calculated through content validity and its reliability was controlled again through the KuderRichardson test (coefficient KR=0.81). The checklist included six criteria; each criterion had minimum and maximum scores of 1 and 4, respectively. The checklist's criteria included the following: portfolio content presentation, discussion about the portfolio, patient management, the ability to apply theory in clinical practice, use of educational resources, and scientific behavior (student learning from dealing with patients). During the last week of the training, the portfolios were presented and evaluated with the portfolio evaluation checklist while individual students were present with the teacher at the
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oral exam session. During the last day of their course, the post-test and clinical exams were administered to both groups. Students' satisfaction was assessed through the evaluation form. It included five phrases with five alternatives based on a Likert scale that was presented as follows: 1 for "completely dissatisfied," 2 for "dissatisfied," 3 for "no comment," 4 for "satisfied," and 5 for completely satisfied. The post-test and clinical exams were taken by routine evaluation methods without any intervention and the test scores were compared at the end of the next semester. This was carried out to determine the maintenance of evaluation method effects in prenatal practical training. The data analysis was performed using SPSS ver. 15.0 (SPSS Inc., Chicago, IL, USA). The differences between pre-test and post-test scores were conducted by a paired sample ttest. The differences between the two groups were determined by t-test for numerical variables with a normal distribution. Moreover, the following methods were also utilized: a chi-square test for qualitative variables and a Mann-Whitney test for ordinal variables. Also, numerical variables with a non-normal distribution were employed and P<0.05 was chosen as the level of significance.
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RESULTS
As mentioned, two groups were considered. Both groups had similar mean ages, pretest scores, prerequisite course grades that they should have taken in the previous semester. The mean±SD of the ages of the portfolio group members was 20.25±0.55 while the routine evaluation group were similar, at 20.10±0.30. These characteristics were not statistically different (P>0.05). Fifty five % of the portfolio group students and 60% of the routine group students lived in the dormitory; the 2statistic did not show a significant difference between the two groups (P>0.05). Also, the t-test did not show a significant difference between the portfolio and routine groups' pre-test scores, which were 8.97±1.54 and 9.55±1.84, respectively (P>0.05). The portfolio group's scores on prerequisites lessons i.e., the pregnancy and child bearing theory, had a mean±SD of 16.30±2.10. This was not significantly different from the routine group (16.70±1.89). The post-test scores are presented in Table 1 for both groups. It is noted that 11 portfolio group students (55%) and 6 (30%) routine group students had post-test scores of between 15 to 20 out of a total of 20. The mean post-test score of the portfolio group was 15.10±1.35, which was greater than the routine group (13.87±1.57). A t-test showed a difference between the two groups (P=0.01). The post-test scores were classified according to the questions' taxonomy as provided in Table 2. These classifications were taxonomy 1, knowledge and comprehension level questions; taxonomy 2, application, analysis, and
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synthesis level questions; taxonomy 3, evaluation and judgment level questions. There were not any statistically significant differences in the mean knowledge and comprehension level question scores on post-test between the two group (P>0.05). However, the mean scores on questions 2 and 3 in the taxonomy were higher for the portfolio group than the routine evaluation group.
Table 1 Post-test scores of prenatal practical training in the two groups

Table 2 Pre-test scores according to the taxonomy questions in the two groups

The practical test score in the portfolio group was greater than that of the routine evaluation group (17.70±1.02 and 16.94±0.84, respectively). A t-test revealed that the difference was statistically significant (P=0.01). The mean scores of the two groups are presented in Fig. 1 for the pretest, posttest, practical and prenatal externship test scores. Moreover, the test scores were higher in the portfolio group than the routine group for the post, practical, and prenatal externship. Table 3 presents the frequency distribution of diagnostic and therapeutic management and communication between the theoretical and clinical leanings in the clinical exam. 10 students in the portfolio group (50%) and 5 students in routine group (25%) suggested at least one acceptable method of patient management and they were able to defend it. The difference between the two groups was statistically significant using Fisher's exact test (P<0.001). The 14 students of the portfolio group (60%) and 9 students (45%) of the routine group were satisfied (i.e., completely satisfied or satisfied) with the evaluation method. The Mann-Whitney test did not show a statistical difference between the two groups (P=0.13) as it is shown in Fig. 2.
Fig. 1 Pre-test, post-test, practical test, and prenatal externship test scores in the two groups.

Table 3 Patient management in the prenatal practical training in the two groups Fig. 2 Students' satisfaction with the portfolio and routine evaluation methods.

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DISCUSSION
This study indicated that the portfolio evaluation method increases the students' learning level in prenatal practical training. Sahu et al. [3] performed a study in the Jawaharlal Institute of Postgraduate Medical Education and Research. They showed that students' learning and ability of self-assessment increased significantly for the portfolio group. Likewise, Tasdemir et al. [4] showed that the group for which portfolio evaluation along with cooperative learning was applied became more successful in passing the course than the other groups. Lambdin and Walker [17] concluded that the portfolio evaluation method increases self-assessment ability in students and makes them more independent in comparison to their classmates. In this research, scores on higher cognitive level question (analysis and judgment) were significantly greater for the portfolio group than the routine evaluation group. Scores for knowledge and comprehension did not show a significant difference between the two groups. The reason for this might be due to the fact that learning at these levels, i.e., knowledge and comprehension, is mainly acquired in theoretical classes. Thus, the portfolio method did not have any significant influence on the learning scores in comparison with the routine group. It should be noted that the portfolio evaluation method requires more time and sufficient training to involve teachers. Therefore, the routine method is more beneficial when the goal of training is for students to acquire knowledge and comprehension. On the other hand, the portfolio is more suitable if the goals to be achieved include higher cognitive skills. There are many important factors which determine whether to use the portfolio method. The most important one is to match this method with educational goals and course contents [2, 18]. This evaluation method provides more reliable results by taking information and assessing students from different perspectives during the learning process [19]. Portfolios provide more information about teacher and student activities. This information would be an appropriate source for the educational planning of each group by identifying the strengths and weaknesses of students [13, 16, 20]. Apple believes portfolios make an important contribution to providing information, evaluating facilities, having flexible goals, making educational plans, and identifying negative as well as positive environmental factors in the student evaluation process [12]. Using portfolios, teachers' biases are lowered [21, 22]. In the present study, student members of each group were already selected by the midwifery committee of the university. Thus, the selection process was not carried out randomly. To prevent this from affecting the quality of the study design, groups of students were randomly allocated into the two groups: portfolio and routine. Furthermore, the pre-test scores were not significantly different between these two groups (P>0.05).

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Portfolio evaluation expands learning opportunities by increasing the students' participation in the learning process and helping them to apply theory in practice. Moreover, portfolios help students to develop three basic self-directed learning skills, assessing the quality of their own performance, formulating learning needs, and selecting future learning tasks.

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