Curriculum mapping evaluation of a Tyler model designed physiotherapy curriculum of the Baptist institute of health science in Cameroon

Abstract

The shortage of rehabilitation health personnel in Cameroon is a limiting factor to attaining full health coverage under Sustainable Development Goal 3 of ensuring healthy lives and promoting well-being for all ages. This problem has been accentuated by the low level and quality of training of rehabilitation workers such as physiotherapists. This was partly due to the poor understanding of the profession of physiotherapy. The profession had also been devaluated to massage therapy or just a paramedical practice, requiring training programs of 2 years or less. This has caused a huge rehabilitation personnel gap which the Baptist Institute of Health Sciences is aimed at addressing with the Bachelor of Sciences in Physiotherapy curriculum and training. The paper aims to evaluate the aptness of the Tyler-designed curriculum in addressing the rehabilitation skill gap. The Baptist Institute of Health Sciences developed a 4-year Bachelor of Sciences curriculum designed using the Tyler Model as a training intervention to address this problem. This curriculum mapping tool is used to evaluate the designed curriculum for vertical, horizontal, interdisciplinary, and subject-area coherence and redundancy. This is to assess the structure of the curriculum in preparing physiotherapists to operate in full physiotherapists competencies in integrating rehabilitation between primary, secondary, and tertiary healthcare systems as defined World Health Organization. It was found that the curriculum has zero vertical redundancy (coherent with no content overlap) as it systematically covers 16 curriculum tracks. The zero vertical redundancy reveals the aptness of the curriculum as it includes all 8 domains provided by the Physiotherapists Educational framework and more. These 16 curriculum tracks are pedagogically grouped into three broad levels of competencies namely the fundamental, core, and specialty expertise competencies levels. They are progressively fashioned to train the habits of the mind and develop the appropriate skills proficiency outcomes (SPOs) in the physiotherapists in training. The curriculum has horizontal redundancy (skill repetition development cycle) created by the spiral curriculum approach used in reinforcing the skills proficiency Outcomes (SPOs) across the three competencies categories. This is because the physiotherapist in training grows in the 6 skills proficiency outcomes (SPOs) from comprehensive examination and assessment through to recommendation and patient self-management skills at all three levels.

Keywords:

• Rehabilitation medicine education
• physiotherapy curriculum
• Tyler’s Model
• curriculum mapping
• curriculum coherence
• redundancy

REVIEWING EDITOR:

• Stephen Darwin, Universidad Alberto Hurtado, Chile

SUBJECTS:

• Allied Health
• Health & Society
• Medicine
• Allied Health
• Rehabilitation Medicine
• Physiotherapy

1. Introduction

Physiotherapy as part of rehabilitation is a neglected service in the healthcare system in Cameroon. Studies have highlighted the significant lack of adequately trained rehabilitation personnel and high-quality rehabilitation services provided by physiotherapists in Cameroon (Foti et al., 2017). This is a growing concern as physiotherapy services are increasingly becoming important to the rehabilitation and healthcare system of Cameroon. Physiotherapy services are limited in coverage due to limited human resources and low levels of training. Statistically, the number of practicing physiotherapists per 10,000 population in Cameroon was estimated at 0.16 in 2021 (Physiotherapy, 2021). The training of physiotherapists in entry-level educational programs stood at 1.19 per 5,000,000 population in 2021 (Physiotherapy, 2021). In 2022, the practicing number of physiotherapists stood at 0.9 per 10,000 population compared to the African statistics of 0.23 per 10,000 population. Europe has an average of 11.7 practicing physiotherapists per 10,000 population with Central Europe having more than 20 practicing physiotherapists per 10,000. The World Confederation of Physiotherapy reports that Africa continues to have the lowest ratio of physiotherapy workforce in the healthcare team and health system. Cameroon’s statistics are significantly lower than the African statistics. This statistic corroborates the claim of limited human resources and the level of training of physiotherapists within the rehabilitation framework in the health system. This is making it difficult for Cameroon to attain Sustainable Development Goals (SDGs) 3 and 4.

In aligning Cameroon’s national healthcare agenda to attain Sustainable Development Goal 3 of ensuring healthy lives and promoting well-being for all ages, the Ministry of Public Health of Cameroon developed a strategic paper called the Health Sector Strategy 2016–2027. This policy document charts the healthcare implementation framework (Ministry of Public Health Technical Committee, 2016). The Health Sector Strategy 2016–2027 still has a minimal provision of rehabilitation services resources despite the incidence and burden of stroke, physical disability diseases, and/or treatment-related disabilities such as amputation. These healthcare issues are major sources of disability and rehabilitation needs in Cameroon. The prevalence of disability in Cameroon was estimated to range from 12.9% to 71.0% using the wide threshold of the Washington Group Tool Full Extended Set of functioning. This prevalence was estimated from a sample of 1,617 adults aged 18 years and above (Foti et al., 2017). Several other studies have confirmed the increase in the demand for disability rehabilitation services in Cameroon (Cannata et al., 2022; Mactaggart et al., 2016).

Due to the lack of comprehensive disability statistics in Cameroon, most disability prevalence studies have been done by regions or health areas. A study carried out in the Northwest Region to estimate the prevalence of disability (excluding impairments in sight and hearing), had the following estimates. A survey of 3933 households with total sample individuals of 18,878 estimated that the prevalence of physical disability in the upper limb was 0.7%, the lower limb was 2.3%, pain was 2.8%, and physical disability conditions at 6.9% prevalence (Cockburn et al., 2014). This study made use of the International Classification of Functioning, Disability, and Health (ICF) standard in a multistage household survey method in the estimation of the prevalence as presented in the Northwest Region (Cockburn et al., 2014). Furthermore, disabilities can be seen to be sparsely distributed across ages from 0 to above 70 years in Cameroon. The cohort 15–49 has the highest prevalence estimated at 31.7% followed by the age cohort above 70 years with a prevalence rate of 29.7%, followed by the age cohort of 50–69 with a prevalence of 27.0%. The age cohorts 0–14 years have a joint prevalence of 11.6%, dominantly with motor disability resulting from cerebral palsy and congenital abnormalities such as clubfoot. From the disability statistics, many of the rehabilitation conditions arise from cardiopulmonary problems, neurological disorders, musculoskeletal disorders, injuries, and post-treatment conditions such as surgery or amputation.

Given the complexity of rehabilitation cases, some scholars argue that it is vital to reconsider the training of rehabilitation professionals to optimize the quality of care in physical and rehabilitation medicine in Cameroon (Cannata et al., 2022). This argument is sustained by the fact that the disability prevalence in Cameroon is still estimated to be high irrespective of the tool of assessment as seen below. Using the standard threshold and the wide threshold of the Washington Group tool, disability prevalence is estimated to range between 6.1% to 66.3% respectively (Cannata et al., 2022). When the Washington Group tool Full Extended Set on Functioning is used, the prevalence is estimated between 12.9% to 71.0% using both the standard threshold and the wide threshold respectively (Cannata et al., 2022).

Based on the prevalence and complexity of disability (as presented above), a comprehensive healthcare system (McMahon, 2023) is hypothesized as the prerequisite for the achievement of Sustainable Development Goal 3 in a country like Cameroon. A comprehensive healthcare system functions beyond just a complementary system of the community healthcare system and the public health system. It requires a holistic approach to healthcare. In Cameroon, the public healthcare system over the years has been dominated by public health issues such as AIDS and cancer given that they rank amongst the top causes of mortality in Cameroon. Community healthcare has been limited largely to vaccination programs and community health education with the neglect of rehabilitation need assessment (World Health Organization-African Health Observatory, 2016). Figure 1 presents an overview of the health system in Cameroon. It shows that Cameroon has moved from a medical approach to healthcare through to a health service approach and finally to a community development approach with the goals of attaining the Sustainable Development Goals. The framework for attaining the Sustainable Development Goals in the health sector is the Health Sector Strategy 2016–2027. Despite this framework, there is a huge gap as there is no significant consideration of rehabilitation and physiotherapy services despite the widespread need for these services in Cameroon.

Figure 1. Synthetic representation of the evolution of national health policies in Cameroon (World Health Organization-African Health Observatory, 2016).

In 2019 the top 10 causes of death in Cameroon were malaria accounting for 6.6%, neonatal disorders accounting for 7.6%, lower respiratory infection accounting for 8.3%, tuberculosis accounting for 14.1%, road injuries accounting for 19.0%, stroke accounting for 21.7%, diarrheal diseases accounting for 30.2%, ischemic heart disease accounting for 32.8%, HIV/AID accounting for 33.8%, and diabetes accounting for 34.8% (Institute for Health Metrics and Evaluation (IHME), 2017). Of these top 10 causes, the ones that cause the most death and physical disability combined are Diabetes, Ischemic heart diseases, Neonatal disorders, HIV/AIDS, Stroke, Road injuries, and Congenital defects (Institute for Health Metrics and Evaluation \(IHME\), 2017). For instance, a prospective cross-sectional study in America reveals that those with diabetes had 50–90% risks of several domains of disabilities. Some of the domains are mobility loss, work disability, and even basic activities of daily living (ADL) disability (Gregg & Menke, 2018). Most of these diseases would require physiotherapy services for treatment and management. Due to the required collaboration of different health specialties in the treatment and management of such patients, appropriate physiotherapy training should be in broad clinical and healthcare team collaboration settings during training to permit the physiotherapist to operate effectively in an integrated manner within the healthcare system and team. It is this consideration that reinforces the argument for a comprehensive healthcare system. This is because the comprehensive healthcare system focuses on providing care for all patient needs at all stages of life (McMahon, 2023).

The claim of a comprehensive healthcare system is the quest to create an enabling environment to permit physiotherapists to provide rehabilitation services across the healthcare chain from primary healthcare through secondary to tertiary healthcare in Cameroon. The World Health Organization’s agenda for the integration of rehabilitation services between all levels of healthcare, from primary through to tertiary care makes the comprehensive healthcare system the ideal training and work environment for Physiotherapists (World Health Organization, 2017). The World Health Organization sees rehabilitation services as an integral part of healthcare that should link up the fragmented healthcare systems into a comprehensive healthcare system that provides healthcare across the lifetime of a nation or community. Thus, the importance of rehabilitation in the health system is its potential to provide an important link to integrate the healthcare system. Therefore, the training of the physiotherapist within a possible comprehensive healthcare system-type setting and healthcare facility would be a major strategy for the attainment of Sustainable Development Goal 3. This system requires the integration of community healthcare and public health with well-trained rehabilitation workers, especially physiotherapists, to provide quality care for all age groups including persons living with disabilities (World Health Organization, 2017).

Before stating the research questions, it is important to understand the current training environmental characteristics of Cameroon’s rehabilitation medicine education landscape. The quality of rehabilitation medicine education remains a major challenge as it is characterized by problems such as limited highly trained personnel to serve as faculty members (World Physiotherapy, 2022; 2022). These limited faculty usually have a heavy workload as most of them are Bachelor of Science Physiotherapists. There are fewer and almost no Doctorate in Physiotherapy who can serve as faculty members. Due to this, most of the training programs witness high levels of absenteeism from faculty members due to their pursuit of several teaching opportunities in the 2 years Higher National Diploma Programs and the few Bachelor of Science in Physiotherapy programs to supplement their primary income sources (World Physiotherapy, 2022).

In terms of the training model, there is heavy dependence on the traditional method of teaching, characterized by lectures by a teacher and note-taking by students. This teaching method is not the most effective way to teach. Based on the Cone of Learning or learning pyramid, the traditional teaching method focuses on just the visual and auditory elements of learning, and it is greatly passive. This method leaves out a great amount of learning channels that are kinesthetic and makes learning active (Baptist Institute of Health Sciences, 2021). It does not facilitate the development of the competencies of the learners by challenging their Higher Order thinking skills, (HOTS) or Autonomy and authority. Clinical and experiential teaching and learning strategies are crucial in the training of healthcare and healthcare-related personnel in the 21st Century. This justifies the weakness of rehabilitation medicine training in Cameroon as most lack an appropriate inclusion of clinical and experiential learning activities. This further elaborates on the weaknesses of the traditional teaching method. In developing the Bachelor of Science in Physiotherapy curriculum, significant consideration was given to the clinical and experiential learning activities. The inclusion of these artifacts in the curriculum makes the learning process to be focused on active learning. The active learning artifacts of the curriculum are practicum, clinical practicums, internships, and specialty rotations.

With an understanding of the current rehabilitation education landscape and the importance of a comprehensive healthcare-type setting for training with the focus of integrating rehabilitation in healthcare, the research question of this study is, what structure should a Bachelor of Science curriculum for the training of physiotherapists have to enable graduates to function effectively within the comprehensive healthcare system? The objective of this paper is to highlight the pedagogic structure for the design of an apt Bachelor of Science in Physiotherapy Curriculum, by evaluating the Bachelor of Science Curriculum of the Baptist Institute of Health Sciences (BIHS). The specific sub-objectives will include:

1. Assess the vertical and horizontal coherence of the curriculum.

2. Assess the comprehensiveness of the curriculum based on the interdisciplinary and subject-area alignment.

2. Methods

To answer the research question, the curriculum mapping tool is used to assess the aptness of the curriculum in training Physiotherapists who can fully operate in integrating the healthcare system in Cameroon. This tool has been used as a tool in the guidance for developing a curriculum for physiotherapist entry-level education programs for other physiotherapy programs (World Physiotherapy, 2022). The Curriculum Map tool is used in this study to evaluate the curriculum for the following specific aspects of its compactness: Vertical and horizontal coherence, subject area, and interdisciplinary coherence. The vertical coherence will be used to assess the alignment of the curriculum track or domains provided by physiotherapist educational frameworks. The horizontal alignment will be assessed by the degree of skill proficiency and the rate of overlaps of the skill competencies across the curriculum.

3. Setting for the design of the curriculum

The problem of the quality of rehabilitation services in Cameroon, especially for children living with disabilities, has always been of interest to the Liliane Foundation (Fonds, 2023) and other scholars (Cockburn et al., 2014; Foti et al., 2017). Due to the interest of the Liliane Foundation in rehabilitation services for children with disabilities, they have always drawn the attention of their partner organizations in Cameroon to this problem (Fonds, 2023). To effectively participate in the development of the appropriate intervention, the Liliane Foundation, and her strategic partner organization, the Cameroon Baptist Convention Health Service through the Empowerment and Disability Inclusive Development (EDID) Program, embarked on the analysis phase of the ‘Analyze, Design, Develop, Implement and Elevate Method’ (ADDIE) model to find a lasting solution (Vulpen, 2022). The ADDIE Model has become an effective method for the assessment and development of learning interventions tailored to meet specific job and skill requirements (Vulpen, 2022). The ADDIE Model is summarized in Figure 2 and highlights all the elements in each of the phases. The ADDIE Model has five phases as presented in Figure 2

Figure 2. The ADDIE Model (Vulpen, 2022).

In the Analyze phase of the ADDIE model, the following was achieved: identification of the problem of poor rehabilitation services due to low level and poor quality of training, some crucial training needs were identified such as the lack of proficient clinical skills and the lack of a strong science foundation to inform evidence-based practices of rehabilitation workers. To the Liliane Foundation, the target audience was primarily children living with disabilities, but the bigger audience in Cameroon today is the growing number of persons living with rehabilitation and disability needs. In assessing the stakeholders charged with the responsibility of providing training for rehabilitation workers like physiotherapists, it was found that the state and Private Higher Education Institutes (PHEIs) provided low-level training called the Higher National Diploma (HND) in Physiotherapy. Some healthcare providers like the Cameroon Baptist Convention Health Services provide in-service training for 1 year and 2 years to be classified as Physiotherapy Assistants. The HND is largely test-based with little attention to skill proficiency development during training. This description of the level and nature of training in rehabilitation medicine in Cameroon supports the claim that the quality and level of the training of physiotherapists is the cause of the low and poor quality of rehabilitation services. This also accounts for the lack of skilled clinical proficiency outcomes due to the low level of attention attached to clinical skills during the training process. To address the weakness in clinical training the BIHS curriculum adopted the Global Active Learning model in training healthcare and healthcare-related professionals in the 21^st century (Cannata et al., 2022).

Rehabilitation training in Cameroon can be described as presented below. Higher-level training programs in Physiotherapy did not exist until 2010 when the Public University of Dschang started a master’s program in Physiotherapy without an appropriate feeder Bachelor of Sciences in Physiotherapy program. The few Bachelor of Science programs had either an Advanced level certificate as an entry requirement which need not necessarily be in the sciences. Others were top-up Bachelor of Science programs with the common entrance requirement being the Higher National Diploma (HND) program which is test-based and certificate-focused. These post-high school diplomas are offered by Higher National Diploma-approved institutions by the Ministry of Higher Education in Cameroon. The downside of these programs is that most institutions running the programs do not have a teaching hospital or an outpatient clinical site. The responsibility for clinical skills development is usually passed down to the learners, parents, or guardians to identify and find internship placement sites. This among other reasons can account for the skill deficiency in the training process of Physiotherapists in Cameroon. In conclusion in the analysis phase of the ADDIE model, all key resources needed for an effective training program, especially a strong clinical site with the integration of clinical training in the curriculum were identified.

The second phase of the ADDIE model is the Design phase. In this phase, the goal is to develop or select a training intervention that would address the problem identified in the analysis phase. The outcome of this phase was to decide on the structure and the level of the training invention. There were three options to select from which included designing and implementing a master’s training program, sponsoring outside training of master-level physiotherapists, and developing and implementing a double major Bachelor of Science program in physiotherapy and Occupational therapy with elements of speech therapy. To better appreciate the background of the rehabilitation education landscape in Cameroon, the Analysis phase, revealed that there were a limited number of schools providing basic training in physiotherapy and rehabilitation education in Cameroon (Ministry of Higher Education., 2020). Most of the public and private schools lack expertise and are training at low levels such as the Higher National Diploma (HND) or lower levels (Ministry of Higher Education., 2020). The St. Louis University Institute of Health and Biomedical Sciences, Bamenda, was the lone English University Institute offering a Bachelor of Science in Physiotherapy. The State University of Dschang was training at the Master’s level (Ministry of Higher Education in Cameron., 2020). Due to a lack of qualified teaching staff in Cameroon, St Louis University Institute of Health and Biomedical Sciences depended on expertise from India, while the University of Dschang depended on expertise from Italy. Most practicing Cameroonian physiotherapists were either bachelor’s level trained in Nigeria for the English-speaking part and Doctor in Physiotherapy trained around the Central African sub-region or France for the French part. This leaves the country with the challenge of limited qualified physiotherapists to serve as faculty members to train at the higher levels of a Master’s, or Doctorate (World Physiotherapy, 2022). This background justified why the option of training developing and training at the master’s level could not be the choice. The second option of sponsoring the training of master’s level physiotherapists out of Cameroon was rejected on the grounds of the cost of training and the desire to improve the quality of patient care simultaneously with the training. The last option left was that of developing and implementing a double-major Bachelor of Science program in physiotherapy and Occupational therapy with elements of speech therapy. These options were assessed to be possible but with modifications informed by the present rehabilitation medicine training landscape. Understanding the limited clinical and high-level trained physiotherapist challenge, the Bachelor of Science level training was delimited just to a Bachelor of Science in Physiotherapy program built on a Clinical Cognitive Apprenticeship (CCA) Model (Collins, 2006). This decision was made with strong consideration of using the blended learning model. This is going the make it possible to have a broader pool of national and international faculty to provide lesson scientific content in an asynchronous or synchronous mode. This provided a diverse range of faculty both nationally and internationally. This significantly contributed to overcoming the limited pool of national faculty members. In addition, the pool of faculty was diverse to include key members of the healthcare team such as doctors, internists, surgeons, nurses, physiotherapists, anthropologists, psychologists, and educationists. The blended model provided the possibility of using the skills and knowledge of qualified international faculty at an affordable cost and the local physiotherapists leading the clinical practicum session. These diverse personnel provided a solid scientific foundation that would be supplemented with onsite national and international visiting faculty clinical apprenticeship sessions as Practicum, and clinical practicum.

The third phase of the ADDIE model is the Development phase. In the development phase, the Baptist Institute of Health Sciences (BIHS) was selected for the development and implementation of the Bachelor of Science in Physiotherapy curriculum. A critical resource identified in the Analysis phase of the ADDIE model was the cruciality of including a clinical site for clinical skills proficiency development. Given that BIHS has the Mbingo Baptist Hospital as the teaching hospital, this made the BIHS facility the most suitable implementation site. The Baptist Institute of Health Sciences is also running two residency programs in internal medicine and surgery. These programs added value to BIHS as the best fit to simulate the integration scenario of rehabilitation between primary, secondary, and tertiary healthcare services in the training process.

4. Design of the bachelor of science in physiotherapy curriculum

In developing the curriculum, the Baptist Institute of Health Sciences adopted Tyler’s curriculum model as the framework for the curriculum design. The development process of the Bachelor of Science in Physiotherapy curriculum was headed by Dr Nancy Palmer, Registrar of BIHS who served as Chairperson of the Curriculum Committee. The curriculum committee was an inclusive committee with members from the Cameroon Society of Physiotherapy (CASP), Supervisors of Physiotherapy services at the Cameroon Baptist Convention Health Services (both past and present), an inclusive educationist, a curriculum adviser, an e-learning expert, the Dean of the Baptist Institute of Health Sciences, a representative from the Ministry of Social Affairs, and senior practicing rehabilitation and physiotherapists in Cameroon, African and American professors who are either retired or chairs of physiotherapy department. Three senior physiotherapy faculty with curriculum development expertise were also included in the development process. Finally, the curriculum was reviewed by a physiotherapy curriculum development expert from Malawi.

The curriculum committee was guided and informed by Tyler’s curriculum design model summarized in Figure 3. Despite criticisms of Tyler’s curriculum model as being too linear, the model provides a helpful framework of the critical elements to be considered in the development process of an effective curriculum (Cruickshank, 2018). The steps of Tyler’s Model were used as the framework that guided the development process of the curriculum. In augmenting Tyler’s Model based on the critique of its linearity, the curriculum map was used for the evaluation phase of Tyler’s framework. This modified the process from a linear to a circular model process that is continuous through the life of the curriculum.

Figure 3. Tyler’s Model (1949) (World Health Organization, 1946).

The first phase of Tyler’s Model is to consider the contemporary life/society needs, the learner’s needs and interests, and the subject matter (specialist) in defining the program competencies and skills outcomes. From the contemporary life/society perspective, the key physiotherapist needs in Cameroon were considered in developing the expected competencies for the curriculum. The complexity and interrelatedness of sources of rehabilitation needs presented in the introduction were used to inform the development of a solid foundation through a systems approach to the human anatomy, physiology, and pathophysiology for a holistic approach and interdependence to healthcare and patient care planning. It also informed the subject-area diversity of the training team. The limitation of skilled nationally trained physiotherapists validated the necessity to adopt a blended learning model over the traditional teaching approach. From the subject matter (specialist) perspective, the physiotherapist education framework was used to identify necessary areas of competencies and the skills proficiency outcomes (Cruickshank, 2018). With these considerations, there is no doubt that the curriculum is significantly informed by society and the learner’s interest and subject matter specialists. The society in this phase refers to the contemporary statistics on the need for rehabilitation services in Cameroon. The statistics presented in the introduction and advice from practicing physiotherapists nationally and internationally guided the identification of the core competence areas to include musculoskeletal, neurological, and cardiopulmonary sciences. These areas have been identified as the foundation of a strong rehabilitation medicine program. In addition, these areas happen to be the key body system that physiotherapy practice revolves around as they are the major source of rehabilitation needs in Cameroon and the world. These areas were also used to inform the curriculum tracks that were developed from the fundamental science level of the anatomy, physiology, and pathophysiology of the human body. It also informs the core level of physiotherapy physical assessment, diagnosis, and the development of an appropriate treatment plan. Lastly, it informs the physiotherapist boundary and areas of collaboration with other clinicians for appropriate specialty-related competencies. This is supported by the fact that most of the sources of disabilities and rehabilitation required services are associated with the top 10 diseases in Cameroon (Cannata et al., 2022). Empirically, it can be seen from the statistics of Cameroon on rehabilitation and disability burden estimates that most of the rehabilitation service needs are focused on cardiopulmonary problems, neurological disorders, musculoskeletal disorders, injuries, congenital disorders, and post-treatment conditions such as surgery or amputation. The duration and structure of the curriculum had been suggested by an earlier study that had advocated the development of a physical and rehabilitation medicine training program with the following specifications (Cannata et al., 2022). The program should be a 4-year higher specialty training program with recognition from the Ministry of Higher Education in Cameroon, with competence in research on rehabilitation. The program should provide the possibility of acquiring a broad spectrum of functionality competence necessary to operate as a physical and rehabilitation medicine alongside the entire medical team of holistic healthcare (Cannata et al., 2022). The four-year designed Bachelor of Sciences Curriculum in Physiotherapy developed by the Baptist Institute of Health Sciences is seen to conform with the suggestion of this earlier study of rehabilitation medicine education in Cameroon.

The educational purpose of the curriculum was presented in two artifacts: the philosophy of education and the philosophy of learning. The philosophy of education of the Baptist Institute of Health Sciences highlights the key elements of the student’s learning experience. The three major elements of the philosophy of education are the culture of Holistic Healthcare, Evidence-based practice, and clinical research. The central element is that of Holistic health. This gives the big picture perspective of viewing health from the perspective of the entire functions of the human body. This is to ensure that the physiotherapists in training perceive their role in healthcare as health promoters for the complete functions of the body defined as a state of holistic health and not the absence of infirmity (Tenore et al., 2017; World Health Organization., 2007). The philosophy of education is summarized as a holistic pursuit in healthcare and promotion that includes a person’s physical, spiritual, psychological, social, and environmental well-being. This will be the professional training culture for faculty members to model for students when teaching so then to better understand holistic care for their patients. In modeling this holistic approach, competence development will be centered around the sciences of the human body in three major realms, scientific academic knowledge, clinical skills, and clinical research. The second artifact under the purpose of education is the teaching and learning model. The teaching model for the program is a customized version of the Global Active-Learning Curriculum: a new approach to teaching medicine in the 21st Century (Bury & Holey, 2018). The philosophy of learning adopted from the Global Active-Learning (GAL) model was integrated with a spiral curriculum concept to ensure that the learners develop proficiency from the level of a solid understanding of scientific theoretical knowledge on rehabilitation, to clinical skills, and finally, clinical research based on evidence. With the understanding of the source of the curriculum, the curriculum structure is informed by the eight domains of physiotherapist practice competence and the thirteen skills competencies. These eight domains of practice competence and the thirteen skills competencies define the scope of the curriculum in terms of program outcomes as presented by the Physiotherapist Education Framework developed by the World Confederation of Physiotherapists (WCPT) (World Physio, 2018). This implies that the competencies of the curriculum and the program outcomes are developed based on the prescription from the physiotherapist education framework, the society, and the learner’s interest as has been presented in this section of the paper. These skills competencies are developed across six proficiency levels and endeavor to capture the breadth of the program outcomes (Cruickshank, 2018). The summarized depth of the competencies is presented in Table A1 in the appendix entitled Program Outcome Matrix.

The breadth of the program outcome will be present right after the program outcome matrix and the level of proficiency of the students. The breadth of the learning outcomes is measured by the level of skills proficiencies developed by the students across the different competencies. These levels of skill proficiency are defined as the skills proficiency outcomes (POs). These proficiency outcomes are provided by the physiotherapist education framework (World Physio, 2018). The proficiency outcomes are presented as listed below.

• SPO1: Undertake a comprehensive examination and assessment of the patient/client or the needs of a client/population group.

• SPO2: Formulate a diagnosis, prognosis, and plan of treatment.

• SPO3: Provide consultation within their expertise and determine when patients need to be referred to another health professional.

• SPO4: Implement therapy intervention/treatment program.

• SPO5: Assess the outcomes of any interventions/treatments.

• SPO6: Make recommendations and teach the patient self-management.

5. Analysis of the curriculum

Tyler’s model of curriculum development has been criticized for being technical and robbing teachers of their creativity. Despite this criticism, the model provides a strong framework for curriculum development (Taylor et al., 1990). In completing the last phase of Tyler’s model, the curriculum map is used. The curriculum map is a tool that converts the linear process of Tyler’s model to a circular process of continuously evaluating and improving the curriculum. This is the value added that has validated the use of the curriculum map in the last phase of Tyler’s Model (Arnold, 1988; Dyjur et al., 2019). It is also a dynamic tool that can be used for both macro analysis of the program as a whole and microanalysis for a syllabus or course outline analysis. In this current analysis, the curriculum map is used for the macro analysis of the Bachelor of Sciences in Physiotherapy curriculum of the Baptist Institute of Health Sciences. It is used to develop a two-dimension matrix-analysis framework. These dimensions are the depth of the curriculum (competencies to be developed) on the vertical axis and the breadth of the skills developed (Skills Proficiency Outcome) on the horizontal axis of the framework. The objective is to determine what structure a Bachelor of Science curriculum for the training of physiotherapists should have to enable trained physiotherapists to function effectively within the comprehensive healthcare system.

From this analysis, the following specific objectives will be to determine the vertical and horizontal coherence of the curriculum and assess the comprehensiveness of the curriculum based on the interdisciplinary and subject area alignment. To attain these specific objectives, the curriculum map is built on a two-dimensional matrix with the vertical dimensions capturing the competencies to be developed across the curriculum. The horizontal dimension captures the skills proficiency outcomes that will permit the physiotherapist to operate within the healthcare team and system having the appropriate clinical authority to work independently and interdependently. The Curriculum Map is presented in Figure 4. From the curriculum map, the compactness and vertical alignment can be assessed by the 16 curriculum tracks or competencies covered within the four years of the curriculum. These competencies are broadly categorized into 4 major categories which are fundamental competencies, core competencies, specialty expertise, and language competencies. The fundamental competencies are musculoskeletal & and kinesiology, cardiopulmonary, neurological, and exercise therapy foundational knowledge set. In this category, the focus in terms of skill proficiency outcomes (SPO) is to be able to master SPO1, SPO2, and SPO3 as described above, in p.12 and p.13. At the core competencies category, the students transitioned from the Lower Order Thinking Skills (LOTS) to the Higher Order Thinking Skills (HOTS) of clinical facts memorization to the mastering and manipulation level. At this level, the students develop skills in physio-rehabilitation, patient & and holistic healthcare, clinical concepts, and physiotherapy clinical practice. The students at this point are expected to operate fully within all skill proficiency outcome levels ranging from SPO1, SPO2, SPO3, SPO4, and SPO5 to SPO6. It is worth noting that these competencies and skills proficient levels are within years 1 through 3 of their training. The specialty expertise categories cover the following competencies: obstetrics and gynecology, pediatrics therapy, prosthetics and orthotics, orthopedics, research, leadership, and administration as well as community rehabilitation. The students at this point are still expected to operate fully within all skill proficiency outcome levels ranging from SPO1, SPO2, SPO3, SPO4, SPO5 to SPO6. It is worth noting that these competencies and skills proficient levels are within years 2 through 4 years of their training. At this point, the physiotherapists in training can better integrate effectively into primary care and tertiary care as expected in the rehabilitation in the Health System (Hall, 2022).

Figure 4. Students’ Experiences Design by the Curriculum Map (Harden & Stamper, 1999).

Key.

⏺ Advanced skill level.

◑ Intermediate skill level.

○ Basic skill level.

Full or effective level of operation.

Moderate level of operation.

Basic or information-only level of operation.

Moderate level of operation in collaboration.

Horizontally, the curriculum integrates the spiral curriculum approach resulting in horizontal redundancy in the curriculum. Horizontal redundancy in a curriculum has been argued to have a positive effect on learning as it can be used to reinforce learning behavior development (Jacobs, 2010). In this case, it is used to reinforce the professional skill proficiency behavior outcome in the physiotherapist as they go through the training from the fundamental through the specialty competencies levels of the curriculum.

The second specific objective is to assess the relevance of the curriculum to the rehabilitation needs of the Cameroon health system. This curriculum is seen to cover 16 curriculum tracks, key of which are musculoskeletal & and kinesiology, cardiopulmonary, neurological and exercise therapy, physio-rehabilitation, patient and holistic healthcare, pediatrics therapy, prosthetics and Orthotics, orthopedics, research, leadership, and administration as well as community rehabilitation. Of these competencies, the students are progressively grounded in the core physiotherapy competencies, clinical research, and leadership skills to drive change with community rehabilitation. These competencies equip the graduates to operate effectively across the primary, secondary, and tertiary healthcare levels (for example, from primary healthcare and community-based rehabilitation to working in tertiary teaching and specialized hospital care).

Consequently, the efficiency of this curriculum analyzed by the diagrammatic curriculum map shows that the curriculum has no vertical, misalignment, or redundancy. It however provides a framework to build a culture of continuous improvement in the curriculum by constantly evaluating the alignment to the rehabilitation needs of Cameroon. Furthermore, from the curriculum map, four major outcomes can be deduced: there is vertical coherence with zero redundancy, there is horizontal redundancy, there is subject area coherence covering all necessary subject areas, and finally, there is interdisciplinary coherence as there is a good mix of basic sciences, physiotherapy, patient care, leadership OB/GYN, pediatrics, orthopedics, research, and languages. Language competency is a functional competency that should permit the students to function with patients in both the French and English languages. One of the major outcomes of using the curriculum map as a tool to complete the evaluation of Tyler’s Model is that it has converted the linear process of Tyler’s Model of curriculum design into a continuous and circular process.

6. Results

From the curriculum map, the curriculum has zero vertical redundancy. This is due to the proper sequencing of courses and competencies through the curriculum tracks, reinforced with a good mix of interdisciplinary competencies in all three competence categories. This interdisciplinary combination refers to the system approach to the basic sciences, nursing care, rehabilitation social sciences plus the theoretical foundation of clinical and evidence-based practice (Royal et al., 2014). The advantage of horizontal redundancy is that it provides horizontal connectivity that permits the learners to have broad and essential skills across the SPOs (Jacobs, 2010). This horizontal redundancy is common across the curriculum from through the first, second, third, and finally the fourth years of the program. This complementary structure of the courses allows for broad-based competencies and efficiencies through reinforcing teaching and learning activities.

The subject-area coherence is reflected in the growth arrow across the competencies categories. The core mastery is represented by the black full arrow showing where the students are expected to operate in the full mastery of the skills proficiency outcome level say SPO1: Undertake a comprehensive examination and assessment of the patient/client or the needs of a client/population group. At the specialty expertise competency level, the students are required to focus on core intermediary skills since there are other specialists such as obstetrics and gynecology, Surgeons, and Critical care specialists to collaborate within the healthcare system. This justifies the interdisciplinary coherence in the curriculum map (Costa, 2009). The skills proficiency outcomes train the students to integrate higher-order thinking skills with requirements such as formulating a diagnosis, prognosis, and treatment plan, providing consultation within their expertise, determining when patients need to be referred to another health professional, implementing therapy intervention/treatment program, and assess the outcomes of any interventions/treatments. All these make the physiotherapists in training to develop the habits of the mind and the proficiency of the hands intentionally to produce the level of care required of a physiotherapist to integrate rehabilitation in the healthcare system from primary through to secondary healthcare (Hall, 2022; Jacobs, 2004). In targeting higher-order thinking skills, curriculum skill proficiency is central in designing this curriculum map and the teaching model. This is because students must develop autonomy to work effectively and continue to grow in their careers through continuous professional development or further education despite operating in limited equipment and human resources settings. The interdisciplinary coherence gives them a good balance between manual therapy and electrotherapy but with a concentration on manual therapy. This is not just because of the lack of electrotherapeutic agents and modalities but a question of effectiveness, consistent and holistic patient care over passive care from over-dependence on electrotherapeutic agents and modalities. It is with this thinking that the habits of the mind across the curriculum become central. These habits are crafted and designed as the skills proficiency outcomes of the curriculum matrix in Table A1.

The curriculum map was employed as a tool to evaluate the alignment, vertical, and horizontal coherence, and interdisciplinary coherence. This curriculum evaluation has answered the research question and serves as a tool for continuous improvement of the curriculum (Sherer et al., 2014). The curriculum map has proven that it is a dynamic tool for the continuous tool for development of the curriculum. This is the value of the curriculum map in converting Tyler’s Model of curriculum development from and linear process to a circular process of continuous improvement.

7. Discussion

Based on the curriculum map evaluation, the research question of what structure a Bachelor of Science curriculum for the training of physiotherapists should have to enable them to function effectively within the comprehensive healthcare system can be answered as Tyler’s model designed. This is because Tyler’s model Bachelor of Science in Physiotherapy developed by the Baptist Institute of Health Sciences has proven to be an effective guide for an apt curriculum Development. This is because a properly designed curriculum based on Tyler’s model will reduce the level of vertical redundancy in the curriculum and foster interdisciplinary and subject area-specific coherence. It will also tap into the advantages of horizontal redundancy to provide the possibility of life-long learning behavior reinforcement in the learners. All of these will be possible if attention is paid to the cruciality of the educational purpose stage and the evaluation stages of the curriculum development process. The curriculum map is a much more appropriate tool for the evaluation stage of Tyler’s model in that it converts the process from a linear process to a circular process providing a framework for continuous improvement/reinforcement of the curriculum. The Bachelor of Science in Physiotherapy curriculum after evaluation is found to have zero vertical redundancy as well as a strong interdisciplinary coherence. This compactness of the curriculum is reinforced by a spiral curriculum approach that has resulted in a strong degree of horizontal redundancy. This horizontal redundancy is important in building efficiency in clinical judgment in the students as they learn to operate at the advanced level of PO1, PO2, PO3, PO4, PO5, and PO6 from the curriculum map. From the fundamental competencies, through the core competencies level to the specialty expertise level, the students are expected to grow proficient and efficient in POs 1, 2, 3, 4, 5, and 6 to attain autonomy.

8. Recommendations and conclusion

Tyler’s model of curriculum development is an effective framework for curriculum development. A curriculum map is a crucial tool in evaluating and transforming the linearity of Tyler’s model into a circular model. The curriculum map can be used to evaluate a curriculum both at the macro and micro level of syllabi or course outline evaluation. This is in confirmation of the recommendation of Dr. Jacob on a cyclic review of the curriculum for continuous improvement and effectiveness (Jacobs, 2010). The Bachelor of Science in Physiotherapy program of the Baptist Institute of Health Sciences provides the guide for a robust curriculum structure that trains physiotherapists to operate effectively within a comprehensive healthcare system in Cameroon. The curriculum has zero vertical redundancy and covers all the eight domains of physiotherapist Practice competence prescribed by the Physiotherapist Education Framework (World Physio, 2018).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Mbohjim Othniel Mobit

Mbohjim Othniel Mobit is an economist and educationist by training and has 10 years of experience working in the Higher Education milieu in Cameroon. He has 6 years of higher education administrative experience ranging from Head of Department, Dean, and Director of a PHEI in Cameroon. In 2016 he started developing skills and expertise in online education for implementation with the Blended Learning Model. He has experience in Google Classroom and the Constructivism Modular Object-Oriented Dynamic Learning Environment (MOODLE). In March 2022 he was appointed as the Vice Dean for Academic Affairs at the Baptist Institute of Health Sciences. His responsibility is around Academic Standardization, Academic policy development, and guidance. He was the curriculum developer for the Bachelor of Sciences in Physiotherapy curriculum for the Baptist Institute of Health Sciences. He was the trainer of trainer for the implementation strategy for the blended learning model of the Baptist Institute of Health Sciences.

Lorraine Elit

Lorraine Elit is a Gynecologic oncologist. She is a professor emeritus in the Department of Obstetrics and Gynecology at McMaster University. She retired from her Canadian role to spend greater time in the global context. To this end, she is a faculty in the Pan African Academy of Christian Service (PAACS) working at Mbingo Hospital as part of the Cameroon Baptist Convention Health Services. In this capacity, she is an Associate Professor in the Global Health division of the Dept of Ob-Gyn at Loma Linda University, USA. She is Vice Dean for Research at the Baptist Institute of Health Sciences (BIHS) at Mbingo. She directs the master’s in public health in connection with Next Genu at the BIHS. With a wealth of experience in research, she has been the editor-in-chief of most of the articles and grant applications from the Baptist Institute of Health Sciences.

Dennis Duane Palmer

Dennis Duane Palmer DO, FACP, FWACP is the Emeritus Dean of the Baptist Institute of Health Sciences and Pioneer Program Director of the Christian Internal Medicine Specialization (CIMS) Program at the Baptist Institute of Health Sciences.

Dr. Dennis Palmer served as a medical missionary in Cameroon from 1979–1984 and 1988–1991, primarily at Banso Baptist Hospital. In 2004, he returned to Cameroon to serve as Field Director and Field Administrator, stationed in Bamenda. Dennis also served as the Director of the new HIV/AIDS treatment program. After four years in those positions, he moved to Mbingo Baptist Hospital where he began the Internal Medicine residency training program (CIMS). Dennis served as Clinical Supervisor of Mbingo Baptist Hospital and as the Program Director of the Christian Internal Medicine Specialization Residency, at Mbingo Baptist Hospital. During this period, he co-authored the book entitled The Handbook of Medicine: A Manual for Practitioners in Low Resource Settings that have been revised into over five editions. He later became the Pioneer Dean of the Baptist Institute of Health Sciences (BIHS). On his retirement from this role in March 2022, he remains a major consultant to the BIHS Board member as Pioneer Dean of BIHS. He was the adviser and customizer of the Global Active Learning curriculum. He recommended the voice-over PowerPoint flipped classroom instructional design strategies.

Nancy Lea Palmer

Nancy Palmer, BFA, MA, Ph.D (cultural/medical anthropology) has lived and worked in Cameroon for over twenty-seven years. She has taught at universities in Canada, the USA, and Cameroon. She served as the Registrar at the Baptist Institute of Health Sciences from 2017 until 2022. She served as the Curriculum Committee chairperson for the development of the Bachelor of Sciences in Physiotherapy curriculum implemented at the Baptist Institute of Health Sciences. She wrote the first drafts of the BIHS philosophy of education and the students’ handbook for the bachelor’s and master’s programs of the B Baptist Institute of Health Sciences.

Timothy Njobula Fanfon

Timothy Njobula Fanfon is the Supervisor of Physiotherapy at the Cameroon Baptist Convention Health Sciences. He has been a physiotherapist with the Cameroon Baptist Convention for over 22 years. He has been passionate about the process of upgrading the skills, level of training, and quality of physiotherapy services in the Cameroon Convention Health Services and the nation of Cameroon. He has served as a trainer for the Non-operative Management of Fractures and Dislocations course in Cameroon which has been held yearly since 2013, he is a trainer for Cameroon Clubfoot Care using the Ponseti Method of treatment, and a member of the Cameroon National Clubfoot coordination committee. He is a trainer and mentor of the Support Tools Enabling Parents (STEP) which is a community-based treatment approach for children with severe neurologic disabilities and he currently serves at the Baptist Institute of Health Sciences as the Deputy Program Director in charge of Clinicals. He was part of the team that carried out the feasibility study of the rehabilitation landscape in Cameroon as part of the Analyze phase of the ADDIE model. He provided the first draft of the curriculum for the Bachelor of Sciences in Physiotherapy.

Appendix

Table A1. Program outcome matrix.

SN	Expected Outcomes	Dimension of the Outcome
1	Provide quality care and safely enhance the well-being of clients.	Use evaluation and treatment processes in a way that ensures the safety and comfort of patients. Identify precautions, contraindications, and risks specific to individual patients. Recognize and respond appropriately to adverse events. Provide services that balance client needs and available resources.
2	Provide client-centered care.	Build and maintain a relationship of trust with patients by respecting their rights, autonomy, uniqueness, diversity, and best interests. Provide necessary information to the client to empower them to take responsibility for their care.
3	Perform proper assessment of patients.	Get the necessary in-formation about the client’s health situation, and personal and environmental factors through client interviews and from other sources. Identify urgent health conditions needing im- mediate attention and take appropriate action. Identify health-related conditions that may benefit from referral to other services and advise the client accordingly. Select and perform appropriate tests and ex-examinations. Determine the client’s expectations and their relevance to physiotherapy. Identify the client’s body structure and, function impairments, activity limitations, and participation restrictions (ICF).
4	Establish the right diagnosis and prognosis.	Interpret assessment findings and develop a physiotherapy diagnosis (and prognosis). Determine if physiotherapy is indicated and the type of intervention needed. Communicate these clearly to patients. The document is clearly in the patient’s health booklet/chart. Determine if referral to another physiotherapist or another healthcare provider is indicated.
5	Develop and execute an intervention plan.	Develop a treatment plan and prescribe measurable goals and intervention activities. Implement the treatment plan. Assist patients in making necessary adjustments to treatments/interventions. Develop a discharge or transition of the care plan and ensure it is well documented and communicated within the team.
6	Monitor and evaluate an intervention plan.	Monitor the client’s response to interventions and modify the intervention plan/program as necessary.
7	Understand community and family context.	Identify further needs and opportunities for the client. Understand community, environmental, and family factors impacting the client’s health and recovery. Identify opportunities for health promotion activities and networks amongst different groups within the population, especially for children and people with disabilities.
8	Communicate effectively.	Use verbal and non-verbal communication effectively respectfully, and promptly. Speak audibly, confidently, clearly, and concisely, using appropriate terminology to fit the context. Use and respond to body language appropriately. Listen actively to build confidence and enhance the give and take of information. Give and receive feedback respectfully and constructively. Write in a clear, concise, and legible fashion. Use electronic technologies appropriately and responsibly, ensuring all electronic medical records are completed. Use images, videos, and other media to enhance communication with the client.
9	Work effectively with others to provide inter-professional and intra-professional care.	Identify needs that may benefit from collaborative care. Recognize that client care is multidisciplinary and respect the roles of each other’s roles by maintaining mutually supportive working relationships with other healthcare colleagues. Recognize conflict or potential conflict and respond constructively. Apply conflict resolution principles in a structured fashion.
10	Manage self, time, resources, and priorities to ensure safe, effective, and sustainable services.	Manage own time effectively. Support the mission, vision, policies, procedures, and directives of the organization to ensure professional standards. Maintain a clean, organized, and accessible work environment, including maintenance of equipment. Apply best-practice infection control measures. Adhere to the individual, team, and system-level safety practices, and identify and solve workplace risks and hazards. Apply quality improvement strategies in direct service provision and participate in organizational quality enhancement initiatives.
11	Champion the health needs of patients and promote physiotherapy innovation.	Advocate for accessible and sustainable physiotherapy and other services across the continuum of care. Engage in activities to support the advancement of the physiotherapy profession. Contribute to leadership activities in the workplace. Be aware of and address the spiritual needs of patients.
12	Demonstrate a commitment to excellence in practice through continuous learning, the education of others, the valuation of evidence, and contributions to the PT profession.	Incorporate the best available evidence, clinical knowledge, experience, and client context into clinical decision-making. Contribute to research activities by identifying issues requiring study, formulating researchable questions, accessing reliable sources of information, critically appraising information, and contributing to knowledge management. Identify learning needs based on self-reflection and external feedback, and develop, and implement a plan to address such needs. Identify the physiotherapy-related learning needs of others and contribute to this education and the clinical education of students.
13	Commit to working in the best interest of patients and society, and to maintaining high standards of behavior.	Comply with applicable legislation. Maintain privacy and confidentiality at all times. Behave with honesty and respect for others. Maintain professional and ethical standards. Address physical, emotional, and psychological factors Negatively impacting workplace performance. Accept accountability for own decisions and actions. Maintain professional boundaries [33].