Supportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa’s national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL).A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011–2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers , purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined.While all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained.This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.The online version of this article (10.1186/s12960-019-0360-x) contains supplementary material, which is available to authorized users. Evidence from countries around the world has shown that community health workers (CHWs) can contribute significantly to the efforts of improving the health status of populations, especially in countries with human resource for health crises , 2. The However, there are still many challenges associated with CHW programmes, related particularly to their integration (or not) into health systems. Problems with CHW remuneration, training, role clarification, referral systems, information management and provision of supplies abound –3. TheseSupervision is a key component of human resource management and amongst a number of important strategies to improve health worker performance and health outcomes , 24. VarHolistic definitions outline three basic functions served by supervision: management/administrative, educational/developmental and support , 28. TheCommunity health workers are not a new phenomenon in South Africa. Over the years, CHWs have played a significant role in the health sector in a wide variety of areas such as maternal and child health, HIV, TB and other chronic conditions –32. In 2A ward-based PHC outreach team (WBOT) is comprised of a nurse as the outreach team leader (OTL) and an average of six CHWs. The team is attached to a facility, operates within a municipal ward and provides promotive and preventive services to individuals at household level. Training for CHWs is standardised with official tools outlining the functions of the team leaders, CHWs, facility managers and other managers at the district, province and national levels. National guidelines, policy and training documents were developed for the WBOT strategy, specifying roles and functions for both CHWs and OTLs , 38, whiThis article describes the extent to which the national policy and training documents related to WBOTs in South Africa provide guidance on supervision processes; how these documents conceptualise supervision; and how they balance the production and people components of supervision. The article then explores how those involved in implementing the WBOT strategy perceive the current supervision practice versus prescribed policy and training documents. This study aims to contribute towards understanding of the design of supervision strategies, and their alignment with the implementation of support and supervision processes in CHW programmes. The study was based in two districts of the North West Province, an early adopter of the programme. The province started implementation immediately after the NDoH announced the programme in 2011, with pilot teams in all 19 sub-districts across the province by 2012. By December 2015, 72.6% of the 382 wards in the province reported functional teams, compared to an average of 36.4% for the country as a whole .A descriptive qualitative study of policy and practices related to supervision of WBOTs in two districts of the North West Province was conducted.To describe the policy on WBOT supervision, all NDoH guidelines, policy and training documents related to the WBOTs and available in the public domain since the inception of the WBOT programme were sourced. To explore practices, focus group discussions were held with facility managers, team leaders and community health workers involved in the immediate supervision system of WBOTs in two districts of the North West Province.Focus group discussions were conducted in one sub-district in each district. From each sub-district, one older and one recently established outreach team and their associated PHC facility managers were purposefully sampled. The four ward-based outreach teams were purposefully sampled, in consultation with sub-district managers, as being typical examples of functioning WBOTs established in the earlier and later phases of the programme, and for their knowledge and experience, and therefore, potential as information rich cases.The document review was conducted on all NDOH policy and training documents, which contained any text relating to supervision or support of the WBOT programme. The policy framework and strategy for WBOT document was sourced from NDoH soon after its distribution. The remaining documents were obtained from the provincial office responsible for overseeing the programme. The district confirmed that they used most of them as reference documents. The documents include a set of guidelines issued in the inception stages of the programme 2011), three guides for CHWs (2014), team leaders (2012), and middle to top managers (2012), respectively, and a recent policy framework (2017). The documents are listed in Table 1, three All the text related to supervision and support for CHWs and the WBOTs was extracted from the documents and entered into an excel spreadsheet. The text was organised along the three domains of supportive supervision  that emerged from the literature. Within each of the three domains, themes and sub-themes and the specific elements were inductively coded based on the material in the documents.Both authors agreed on the framework for the analysis and read the documents. The first author (TA) did the coding, which was then discussed and validated with the second author (HS).A semi-structured interview guide with open-ended questions on the supervision of WBOTs was used to conduct focus group discussions (FGDs) with a total of 40 respondents Table .Table 2FRespondents were provided with information sheets to familiarise themselves with the research topic and given an opportunity to ask questions. They gave written consent to participate in the study and were made aware of their right to withdraw from the study at any time. FGDs were conducted with the three categories—facility managers, team leaders and CHWs—as separate groups to avoid power relations arising from professional status and hierarchies inhibiting participation. A semi-structured FGD guide loosely structured the discussion, allowing for probing for more information and seeking clarification where necessary. The FGDs were conducted by the first author (TA) and took place at respondents’ place of work as chosen by the sub-districts. All the interviews were conducted in English, including the CHWs, all of whom have at least secondary level schooling and attend training programmes in English. The interviews were audio recorded, transcribed and coded using the ATLAS.ti 8 .Analysis of FGDs was done using the thematic content analysis approach . The resThe FGDs were conducted as part of a longer association of the authors with the WBOTs in the North West Province, in both support/technical (TA) and research (TA and HS) capacities. The trustworthiness of the study was thus enhanced by these well-established local relationships, shaping the depth and quality of FGDs, and the ability to draw on wider contextual and tacit knowledge in the analysis.The Toolkit is the first document that was distributed at the beginning of the programme and is widely used as a reference guide for implementation. However, this document remains in draft format and is yet to be revised or issued as a final document. The Policy document is the most recent and most significant of the documents, but lists supervision functions in very summary terms.Table . There is consensus across documents that team leaders are to supervise CHWs and oversee activities of the team and that CHWs report to the facility manager through their team leaders.The line authority sub-theme includes the following functions as captured from the documents: the recruitment of team leaders, ideal candidates for team leader positions, CHWs supervisor and team leader supervisor. Only two of the guides—the CHW Manual and Team Leader Guide—cover all these functions comprehensively. According to the documents, districts and sub-districts appoint team leaders and facility managers supervise and participate in the recruitment of team leaders. The team leader’s scope of work requires a professional nurse , but with a shortage of this cadre, the new Policy document encourages provinces to “Identify mechanisms for each facility to assess current staff vis-a-vis new PHC structure – particularly with respect to who will supervise the outreach team” . There iThe performance evaluation sub-theme functions include how to monitor, record and report on performance, and the designation of responsibility for these functions to facility managers and team leaders. As with the line responsibilities, these functions are addressed in all the documents, bar the CHW Manual, which only mentions that the team leaders manage the performance of team members with no further details. The Team Leader Guide goes further to include performance evaluations forms for CHWs, developed by supporting partners as part of the monitoring and evaluation (M&E) system tools at the inception of the WBOT programme. However, when NDoH adopted the M&E system for WBOTs, the performance evaluation forms were not officially endorsed for use by teams, and none of the other documents reviewed refer to these forms.The resources sub-theme includes the provision and management of basic resources and availability of physical space for storage of records and team meetings. Basic resources for service delivery include transport, stipends, basic clinical supplies and stationery for recording keeping and reporting. The Policy document states that the provincial Department of Health will fund the programme and make available resources for the teams and that it is the responsibility of the facility and sub-district managers to supply and manage these resources. It further mentions that the department will ensure availability of space for WBOTs through the Ideal Clinic programme, a national clinic accreditation programme. The remaining documents refer to resources in either passing or not at all. In none of the documents is there a specific list of items to be supplied.The development theme relates to the level of guidance provided in the documents on capacity building for WBOTs members and their supervisors. There is formal training for CHWs and orientation for team leaders, facility managers and middle managers to support the programme. The CHW manual is the South African Qualifications Authority (SAQA’s) accredited curriculum for the first phase of the formal training. The documents mention that, beyond the formal CHW training, supervision of WBOTs includes training, mentoring and coaching of CHWs. This capacity building is to be achieved through induction, skills development, clinical guidance and technical support in the form of in-service trainings and workshops. According to the CHW Manual, Team Leader Guide and the Management Guide, the team leader is responsible for CHWs’ capacity development. However, this is not categorised by format, frequency and content. The CHW Manual identifies the health promoter as a source of technical support on health promotion but also provides no further details. The Policy document simply mentions that the department will confirm the training content and method to build the required capacity for CHWs and the development and maintenance of a capacity building system at district level. In general, basic training is well established, but further development post in-service is only superficially acknowledged.Except for the Team Leader Guide, the documents provide some guidance on how supervisors need to support WBOT members, but do so in very limited terms. The Team Leader Guide provides more details around mentoring and coaching of the WBOT members.In sum, the documents reviewed provide considerable detail on the management functions of supervision, but much less on development and support, the two other crucial pillars of supportive supervision. All the documents acknowledge the need for supervision and outline basic reporting lines. One of the objectives in the Policy document seeks to “ensure adequate supervision and support for CHWs as well as for team leaders” but provides no elaboration. Neither the Toolkit nor the Policy spells out a comprehensive approach to supervision, support and line authority functions. Rather, decision-making is delegated to sub-national levels. For example, the Toolkit refers to “Setting up supervision, reporting and monitoring systems for outreach teams through consultations with heads of facilities (through sub-district/ district-level meetings)”. The Policy document refers to, as one of the key responsibilities for the province, “approving the implementation plan in the districts…”, and for the district to “develop an implementation plan…”.The training documents, on the other hand, provide considerably more detail on the procedures and style of supervisory relationships. Both the Team Leader Guide and the Management Guide were piloted in the North West Province and distributed through workshops at the beginning of the programme, and the team leaders who were in pilot WBOTs at the time were oriented on the contents. However, the induction workshops were subsequently discontinued and the Team Leader Guide document was then distributed as part of the team leader package, where its status remains semi-official. The CHW manual remains in use as part of the first part of the formal training for CHWs.While the documents reviewed refer to supervision in various places, currently, there is no standalone, overarching and coherent framework or document for the supervision of CHWs and WBOTs. Moreover, most of the documentation, which exists, although widely available and referenced, has uncertain status.… I depend on walk-ins (manager).… so we volunteered .So I was just requested [to be a team leader] .I heard over the radio that there was an advertisement… So I went to the district office to find out about that … it was confirmed and then we had to do some applications and … we were called for an interview. .In establishing the line authority function of WBOTs, the North West, as other provinces, struggled to attract professional nurses as team leaders to rural areas where most of the WBOTs are based. As a result, the province sought to recruit professional nurses from facilities and retired nurses to work as team leaders. Team leaders were recruited in a variety of ways, most commonly volunteering to take on the role.In most areas, facility managers were tasked with supervising the outreach teams. It would appear that the department did not explain the WBOTs’ scope of work to facility managers “we didn’t know what was expected of us” . The facility managers were also not involved in the recruitment of team leaders. As one facility manager responded, “I was just told… [I was] not part of the selection” . Facility managers mentioned things such as “supervise, discipline, in-service training, provide resources” , to highlight what they thought their role was towards outreach teams. However, as one facility manager expressed, there was uncertainty on what this role really entailed in practice “… we are not told how far you should go with the management of the team leader” . In some areas, districts delegated professional nurses as “focal persons” at sub-district and district levels to coordinate and oversee the WBOTs programme, who sometimes also directly supervised the team leaders.As indicated, performance evaluation forms to enable team leader to monitor and review the performance of CHWs were developed and distributed during the inception phases of the programme in the North-West. Although the FGDs suggested that there was some form of unofficial evaluation occurring between team leaders and CHWs, as one CHW explained, “…[the team leader] checks that I present myself well and that I fill the forms correctly” , the performance evaluation forms were never made official and most team leaders were not oriented on them. There was no formal performance review system for team leaders and WBOTs as a whole. This was compounded by the fact that CHWs and retired nurses (as team leaders) were contracted on a short-term basis with no performance agreement. As a result, facilities felt they had no control over the functions of team leaders and WBOTs, even if informal monitoring took place. As one operation manager indicated “[there is] no measuring system where we measure their progress and performance.” . Some facilities also reported holding meetings with the WBOTs to update each other on achievements and challenges within the communities.At the beginning of the programme, the department provided the majority of the CHWs with kit bags as part of their phase 1 training. These bags had basic supplies such as bandages, gloves, and condoms. The districts instructed facilities to replenish the supplies of WBOTs reporting to them on an ongoing basis. However, CHWs indicated that the supplies were limited and not provided regularly. Some facility managers made mention that they provided resources such as gloves and nappies to outreach teams. However, not all CHWs concurred, as one CHW stated, “the facility will say it’s not their job to give us [supplies]” . All teams indicated that they did not have space to work and had to improvise with solutions to do their work and keep records safe. As explained by one team leader “I don’t have any space for my records. I keep them in my car…” .There is shortage of transport in the province, and in instances where wards are vast, households are hard to reach on foot. As a result, the province decided to allow team leaders who had vehicles to use them for WBOTs support and claim for up to 500 km travelled per month. However, team leaders indicated that there were problems with this arrangement as they would sometimes also be expected to transport supplies for the facilities such as medicines and administration materials, “… we are a shuttle service” .The basic training of CHWs is provided through accredited Regional Training Centres located at district level. Trainers include maternal and child programme coordinators, team leaders and professional nurses, who are not necessarily team leaders. Team leaders are encouraged to attend CHWs trainings to familiarise themselves with the curriculum and observe how CHWs perform in the training. In some instances, team leaders are also trainers. As indicated earlier, in the inception phases of the programme, the department provided a non-compulsory 5-day orientation workshop for team leaders in the province. However, team leaders recruited beyond the pilot phase were not offered these workshops.Team leaders regarded it as their responsibility to provide CHWs with in-service training to improve clinical and technical skills and appeared motivated to improve the capacity of CHWs. As one team leader explained, “it is our responsibility to give CHWs in-service training, guide them how to deal with communities and whenever they encounter challenges they are encouraged to consult us” .Team leaders were also reported to have good relations with CHWs. As explained by one CHW, “Our relationship with our team leader is excellent … [when] we want the team leader to go with us to make a follow up… she comes. The presence of team leaders at household level allows the clients to be more receptive to the service and makes the work easier” .Outreach teams interacted with facility staff, but WBOT members generally felt that facility managers did not understand the role of the teams. Facility managers were described as putting pressure on teams to assist in the facilities. As one team leader narrated, “the facility manager usually says, we have a shortage … go to another [consulting room] and assist” . As a result, team leaders felt constrained in supporting CHWs in the communities. However, not all facility managers were described in negative terms. Some understood their role as supportive, as expressed by one facility manager, “the role of the facility manager is to empower them… check their challenges and then address them” .Relationships between WBOTs and other facility staff varied. There were teams where relations had evolved positively, as one CHW recalled, “Firstly, the nurses from the facility were treating us badly. Now they are much better, they know our role” .If you tell them that I have to go out and assess the CHWs, they will say we are just gallivanting in the location, you are not doing anything. .Our relationship is very, very poor in the clinic, very poor .Others felt they were poorly treated:Most sub-districts in the province have programme coordinators that are responsible for different programmes such as maternal and child health and chronic disease care. However, there was no indication that there was any interaction between programme coordinators and outreach teams.In sum, in the absence of a clear supervision framework, teams and facilities functioned in an ad hoc manner that best suited them in the delivery of services. In practice, there was a variety of reporting lines, development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams. However, facility managers struggled to supervise the teams amidst high workloads in facilities, and relationships between WBOTs and facilities often remained strained.The WBOT programme plays a critical role in extending PHC services to community and household level and making health accessible in terms of distance and information . CommuniWhile all the official policy documents and guidelines reviewed acknowledge the need for supervision and support, they are inadequately developed both in terms of scope and in providing firm guidance on supervision of WBOTs. Moreover, texts on supervision are not standardised, neither do they cross-reference each other, with some aspects present in some documents, but absent in others. In relation to the basic functions of supervision, the documents generally had more details around management and less so on development, and to some degree, also on support. The absence of a coherent framework for supervision of CHWs/WBOTs, and the misalignment and lack of details on supervision observed in these documents are likely to impact on the effectiveness of WBOTs .In the absence of aligned and mutually reinforcing policy documents and a holistic supervision framework, supervision and support of WBOTs is poorly done. Policy and training documents outline a line of authority between CHWs, team leaders and facility managers. However, the dearth of professional nurses affects the recruitment of team leaders, and as a result, the WBOT programme is seen as an added responsibility and burden , 48.Team leaders in their role as supervisors of CHWs are generally regarded as good supporters . FacilitPerformance management has been defined as a process that is used to measure and improve the performance of workers in order to improve the performance of the organisation –58. DespThe list or package of basic resources WBOT members need to perform their functions is not explicit in the policy documents and WBOTs had limited basic resources and physical space . A SouthThere is formal basic training for CHWs in the WBOT programme, but the induction and in-service training for CHWs is not formalised and organised . SuperviThe national frameworks reviewed substantively shaped how the North West Province approached the supervision of WBOTs and the findings in this province are likely to be mirrored in other provinces. Although provinces are required to develop implementations plans where adaptations may be introduced within the broad framework, in practice, at the time of this research, the national policy documents were being implemented without much provincial and local adaptations. Nonetheless, the day-to-day experiences of supervision largely depend on the nature of local leadership and context from districts to facilities, and in turn, this is likely to result in variations across provinces and districts.This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit and coherent guidance in policy, and the failure to address constraints to supervision at local level, undermines the performance and sustainability of the WBOT strategy in South Africa. The study highlights the need for holistic conceptualisations of the supportive supervision function in policies on CHW programmes, and the importance of recognising the key facilitators and barriers to local implementation. In particular, CHW programme designs based on teams (peer support) and dedicated professionals to support them (such as outreach team leaders) enable supportive supervision. Conversely, PHC facility managers cannot be assumed to be willing and capable supervisors of CHWs and need to be adequately prepared and supported to fulfil this role.Additional file 1:A full text extracted from the documents that talks to supervision. (XLSX 14 kb)


Various evaluative studies have been carried out to obtain the views of multiple stakeholders involved in community-based biomedical research projects. However, rarely have the viewpoints of postgraduate students and junior faculty involved in such initiatives been explored. Thus, the aim of this study was to examine the views of postgraduate students and junior faculty at a rural-based university on the effect of a longitudinal biomedical research project on their acquisition of relevant skills. In-depth interviews and a focus group discussion were conducted. The thematic content analysis technique was used to analyse the qualitative data. Both postgraduate student and junior faculty groups indicated that they had acquired considerable research skills and knowledge; gained experience; were exposed to practical reality; and strengthened their interpersonal skills and general personal development. However, some respondents highlighted that they still believed that training in data analysis and exposure to new laboratory techniques would have strengthened their individual capabilities to conduct cutting-edge research. The results of this study highlight the need for community-based biomedical researchers to equip members of their teams with the skills and knowledge that will help them achieve their academic and career goals. Engagement can be partially achieved through creating communication platforms in which project participants share their experiences and thoughts regarding research projects conducted in their communities. Through such interactive processes, researchers and development practitioners would gather information that might help in planning and implementing future initiatives. Although numerous studies on community-based biomedical research projects have been conducted, the viewpoints of postgraduate students and junior faculty involved in such initiatives have rarely been explored. Exploring the perspectives of postgraduate students and junior faculty might assist research project leaders to better plan similar initiatives and to take some corrective action when the need arises. Moreover, studies of this nature are likely to reveal the effects of community-based biomedical research projects beyond merely generating scientific knowledge. In addition, exploring the ‘hidden’ issues of biomedical research projects has the potential to bring about a holistic understanding of community-based projects and the benefits accruing to members of study teams. The preceding arguments necessitated carrying out the current study. In this study, the perspectives of postgraduate students and junior faculty on the effects of a biomedical community research project on their human capital development were explored.Various evaluative studies have been conducted in different parts of the world, which aim to elicit multiple stakeholder viewpoints and experiences. Among these have been studies focused on community-based biomedical projects or programmes.5 define human capital as ‘processes that relate to training, education and other professional initiatives in order to increase the levels of knowledge, skills, abilities, values and social assets of an employee which will lead to the employee’s satisfaction and performance and eventually on a firm’s performance’. The Organisation for Economic Co-operation and Development6 concurs with these views and defines human capital as knowledge, skills, competencies and attributes embodied in individuals that assists in the creation of personal, social and economic well-being. Included in this definition are non-economic attributes such as motivation, communication, inter-personal skills, perseverance, self-discipline, behaviour, and physical, emotional and mental health of individuals.6 Thus, investing in human capital is a strategy that helps increase economic returns.5 Human capital can be acquired either through formal early childhood learning, primary and high schooling, tertiary and post-tertiary training, adult education or through informal education such as family, peers or on the job learning.6 It is evident from these perspectives that education is a primer for development. In the current study, human capital refers to the acquisition of skills and knowledge, experience and exposure, interpersonal skills and personal development through informal post-tertiary training. Human capital attributes such as motivation, confidence building and working independently are also included in the definition.Marimuthu et al.7, anchored the current study. Becker8 argues that human capital is linked to economic growth and that education, training and health are the crucial elements of human capital. Becker8 also points out that education, training and health are important investments that precipitate human capital, because they assist in raising income, improving well-being and enhancing the good habits of an individual over their lifetime. Education and training increase the chances of being employed.9 When individuals acquire relevant skills and knowledge, they often make better informed decisions about their lives, such as those relating to career path, financial investments, how to live amicably with others, eradicating poverty, nutrition, healthy lifestyles and various other ways of improving their well-being.8 Nhamo and Nhamo10 postulate that education enhances the potential earning capacity of individuals, given that enlightened individuals tend to be more productive and are able to perform more complex tasks. Mincer11 lends weight to this view and states that employers set better rewards for employees with higher qualifications because they are more skilled and, in general, are more productive. It is also worth noting that globalisation is now heightening competition for skilled human resources.12 Personnel with higher educational qualifications, relevant expertise and experience can be recruited from any part of the world. Thus, investments in human capital are crucial.Human capital theory, which is rooted in the works of Schultz and Becker13 and the MAL-ED Network Investigators implemented the MAL-ED project. Postgraduate students and junior faculty from a rural-based university were recruited and trained to collect data on feeding habits, childhood diseases, vaccinations and biospecimens, among others. As highlighted earlier, the aim of the current study was to interrogate the perspectives of postgraduate students and junior academic staff who participated in the MAL-ED project with respect to the impact of the project on their human capital development.The current study was embedded in the ‘Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development’ (MAL-ED) South Africa project, which was initiated in 2009 and undertaken in the Dzimauli community of the Vhembe District in the Limpopo Province of South Africa. Bessong et al.The study was conducted between 1 January and 28 February 2016 at a rural-based university in Thohoyandou in the Limpopo Province of South Africa. The study site lies approximately 180 km north of Polokwane, the capital city of the Limpopo Province.14, qualitative research entails obtaining subjective assessments of attitudes, opinions and behaviour. Santha et al.15 also explain that this type of research is concerned with the opinions, experiences and feelings of individuals, implying that subjective data are collected. It was deemed appropriate to adopt the qualitative research approach in the current study because it allowed the investigators to interrogate the perceptions of participants with a view of getting deeper insights on their acquisition of relevant skills.A case study research design was adopted. This study was exploratory and qualitative. According to KothariOut of a target population of 34 people, 15 postgraduate students , 7 junior faculty and 3 heads of departments (HoDs) voluntarily participated in the study. Of the 25 people who volunteered to participate in the study, 23 of them had been involved in the initial phase (24 months of follow-up) of the MAL-ED project. The remaining two participants were HoDs who had not been directly involved in the project but supported junior faculty from their departments to actively participate. It was deemed necessary to obtain their views on the academic performance of the members of staff from their departments who had been involved in the MAL-ED project. Out of the 15 postgraduate students who participated in the study, 11 took part in the individual face-to-face interviews. The remainder were interviewed telephonically because work-related commitments made it impossible for them to present themselves for scheduled interview sessions.Open invitation letters were sent to the postgraduate students and junior faculty requesting them to participate in the current study. The purpose and benefits of participating in the study were clarified in the invitation letters. Furthermore, the letters revealed that participation in the study was not compulsory, meaning that they were free to withdraw at any point. The participants were 25–51 years old. The highest academic qualification was a doctorate, with the lowest being a diploma.The University Research and Ethics Committee approved the study protocol (protocol no: SMNS/16/MBY/01/0701). This paved the way for the study to be conducted. Before commencement of the interviews, postgraduate students, junior faculty and their HoDs were made aware of the ethics to which the study would adhere. The right to anonymity, confidentiality and the freedom to withhold sensitive information if they so wished were specifically highlighted. Furthermore, permission to use an audio recorder during both the face-to-face in-depth interviews and the focus group discussion was sought from the participants. Signed informed consent was obtained from all the participants prior to their participation in the study.16 The interview guides were given to other colleagues not involved in the study but with relevant knowledge and expertise for their comments. After the pilot testing exercise, the research instruments were re-worked to ensure that the questions were clearer, more precise and could be administered within the stipulated time frame.Interview guides were pilot tested with four respondents who were part of the target population. However, the latter were not included in the final study sample. Pilot testing was done in order to check the reliability of the data collection tools. This testing involved checking how long it took to conduct each interview, clarity of the questions and ease of understanding the interview questions.Data were collected through individual interviews and a focus group discussion. In-depth interview schedules guided the data collection. The interview schedule for postgraduate students and junior faculty sought to determine the relevant skills and knowledge that the participants had acquired as a result of their participation in the MAL-ED project. The principal researcher ensured that the individual interviews were held in a quiet environment and that they did not interfere with the academic commitments of the participants. On average, each interview was concluded within 50 minutes. The participants’ responses regarding the benefits of the project were categorised into four identified categories derived from the themes of the study. However, the responses were so varied that data saturation was not reached.After the individual interviews were complete, a focus group discussion was held. The group discussion involved 10 of the 22 postgraduate students and junior faculty who had participated in the individual interviews. The remaining 12 persons failed to participate in the focus group discussion because of other commitments. The focus group was designed to establish if group dynamics would elicit different perspectives from those obtained in the individual interviews. The participants chose their own chairperson and scribe from within the group. This approach enabled the group to select an impartial person who would allow them to express their views freely. The chairperson facilitated the group discussion and the scribe recorded the responses once there was consensus on an issue. The principal researcher ensured that there was order in the engagements. The focus group discussion took about 1 hour to complete.As already reported above, HoDs were interviewed individually. The interviews took 50 minutes to complete. The focus of the interview questions for the HoDs was to find out whether there were any noticeable changes in the academic performance of staff members in their departments which could be attributed to their participation in the MAL-ED project.17 The principal researcher transcribed the audio-recorded data. Codes were generated and the emerging themes were recorded. The data were then fed into the Atlas.ti software version 7.5.10. The results of analysis were linked to the themes that had been identified earlier. The researchers deliberated on the outputs and reached consensus on the final themes and categories to be adopted.Qualitative data obtained from the postgraduate students, junior faculty and HoD interviews were analysed using the thematic content analysis approach.The participants’ perceptions on the various aspects of their human capital development as a result of active involvement in the MAL-ED project are described below and are presented one theme at a time. Research skills and knowledge, experience and exposure, interpersonal skills and personal development were the themes distilled from the results of the interviews and focus group discussion. Also addressed below are the expectations of postgraduate students and junior faculty regarding their participation in the biomedical community research project.Of the 22 postgraduate students and junior faculty, 18 agreed that participating in the project resulted in them being empowered with research skills and knowledge. Cognitive testing, conducting anthropometric tests, and collection of bio-specimens such as stools and urine were specifically cited as the knowledge and skills they acquired. Some junior faculty were happy that they had been entrusted with leadership and supervision roles, which included overseeing data collection, checking completed forms, reviewing assessments and training field workers. The satisfaction is evident in the following views:It was a privilege for me to be recruited for the project. The project brought a lot of things to my research. I learnt how to do cognitive testing, to get data from children, to adapt to new equipment and to collect quality data. (Participant #14)I am now overseeing data collection. I do quality checking of forms, reviewing assessments and training of fieldworkers. I collaborate with the Data Coordinating Centre. I was promoted to a lecturer position because of what I learnt from the MAL-ED project. I have been called to many interviews because of the skills I now possess. (Participant #13)A total of 14 of the 22 postgraduate students and junior faculty alluded to the fact that they had gained experience and valuable exposure. Some of the participants learnt how to relate with different people such as the mothers, children and community members involved in the studies. It was highlighted that the participants managed to put the theory they learnt at university into practice. Some participants attested to having gained experience in using laboratory equipment in addition to being exposed to the general ‘world’ of research. Some of these views are presented below:The project has taught me to put theory into practice. At school, things were theoretical but the project gave me the practical side of things. I learnt to conduct anthropometric measurements. I gained a lot of experience in the field. I learnt about how people react to issues. I learnt how to relate to people. (Participant #1)The project is full of laboratory work, blood processing, fieldwork and ordering of laboratory supplies. I got a lot of experience in DNA extraction from stools and saliva. I also attended field meetings. I have gained a lot of experience and exposure to blood processing from the project. MAL-ED has widened my scope on many issues. (Participant #12)Another benefit that accrued to participants in the MAL-ED project was the enhancement of interactive skills. It was explained that the acquisition of interpersonal skills resulted in continuous communication with community members and colleagues. In the process, the participants in the project worked well as a team, and respected and appreciated their diversity in terms of people, ideas and cultures – which is crucial for fieldworkers because it helps create conditions that enable collection of data of high quality. Some participants articulated their experiences as follows:I have learnt how to relate to people and I have made friends in the process. I have learnt to communicate with different community members. (Participant #2)I have learnt how to communicate well with community members and to understand community issues. I have learnt to interact with everybody, poor or not. I have a good relationship with the participating mothers. I know how to maintain good relationships with children. (Participant #5)It was revealed that the MAL-ED project helped expand the capabilities of those involved in implementing it, developed and strengthened their character and also motivated others to pursue further studies or advance seemingly stalled careers. These experiences highlight the fact that even though the participants were recruited to implement the project, they were empowered and learnt to enhance the capacities of others as well. Some respondents commented:The project has improved my confidence. I have learnt to work with different people of different cultures. I now understand how people respond to pressure and commitment. I have learnt to understand my work colleagues. (Participant #3)The project helped me in my personal development. I also felt a sense of belonging. The project gave me enough ground to explore my capabilities. I was able to empower someone to take over from me. From MAL-ED, I learnt to write manuscripts, attend conferences and present papers and to interact with more experienced researchers. MAL-ED was like a family to me. (Participant #22)Despite the varied human capital benefits that accrued to the postgraduate students and junior faculty through their involvement in the MAL-ED project, 9 out of the 22 postgraduate students and junior faculty indicated that they needed further training on data analysis and interpretation, exposure to a wider range of laboratory techniques as well as time and project management training. Active listening, how to handle children and research techniques were other areas that were identified for further training. Some participants wanted to be involved in other laboratory procedures and in data analysis that was conducted downstream. The following sentiments shed more light on these results:An opportunity in analysing quantitative data and interpreting it would have helped me. (Participant #8)I wish I could be exposed to other new laboratory techniques and attend more training workshops. (Participant #12)In general, the HoDs interviewed in the current study corroborated the views expressed by junior faculty. They were of the view that research skills such as data collection, data analysis, writing of quality manuscripts and mentoring were enhanced. In addition, they believed that the project assisted the participants in their personal development. Some of the members of staff seemed to collaborate with other scientists much better than they had before. They demonstrated more mature behaviour in the way they executed their work, with some gaining promotion mainly because of the quality of their research outputs as a result of their participation in the MAL-ED project. Below are some of the views of the HoDs:The multi-disciplinary approach of the project  exposes one to different people and a different way of looking at a problem. The project exposed people to practical ways of understanding issues. Staff members have shown maturity in the way they manage focus group discussions, transcribing, collecting data and writing articles. (Participant #25)Research related skills have improved. There has been improvements in the skill of data collection, experience in research protocols like community entry and ethical issues. The skill of data collection has been enhanced. Staff members have been exposed to manuscript writing. (Participant #23)The quality of publications are much improved in the sense that works were accepted in high profile journals which in a way attests to the quality of the work. Some members of staff have become professors based on the output from the project. This has enhanced their careers. (Participant #25)The most prominent responses drawn from individual in-depth interviews are presented in 18 contention that improvements in skills and knowledge increases individuals’ employment prospects and related size of remuneration packages. The improved employability of the research participants is worth highlighting, especially considering the high levels of unemployment in the country. These results suggest that the quality of postgraduate programmes can be improved if students are integrated into ongoing research projects that senior academics run. Thus, it is prudent to take this into account in the course of designing innovative curricula for research-based postgraduate degrees.Participation of postgraduate students and junior faculty in the MAL-ED biomedical community research project was found to have particularly enhanced their skills and knowledge. The projects that postgraduate students and junior academic staff mount, the lectures prepared for delivery and manuscripts written for publication in scientific media depend on and demand that quality research be undertaken. A considerable number of the postgraduate students and junior faculty who participated in the MAL-ED project secured jobs in the public sector, highlighting the immense value and capacity enhancing power of participating in the project. Other participants explained that, as a result of their involvement in the project, they were promoted to senior positions. This is in agreement with Ibok and Ibanga’s16 study conducted in the community in which the MAL-ED project was implemented. Acquisition of knowledge and research skills enhanced personal development and enabled the grassroots community members in the forefront of project implementation to secure jobs. A study by Dongre et al.19 in India which focused on the benefits of exposing medical undergraduate students to community-based surveys yielded similar results to those of the current study. The benefits that accrued to the medical students included the ability to conduct interviews, better communicate with local villagers, collect and enter or store data using computers, and apply learning to research work as well as enhanced awareness of the public health process.The participants’ views in the current study resonate with those expressed by the grassroots community members in Moyo et al.’s20 in a study in Atlanta .Postgraduate students and junior faculty also reported that the project enabled them to gain experience and exposure to new research techniques and practical realities. For instance, they pointed out that the project had enabled them to apply the theory they had learnt at university to real-life situations. This enhanced their understanding and appreciation of key concepts that might have otherwise remained abstract. Many participants were exposed to the realities of community-based research for the first time through this initiative. They had the opportunity to work with and interact with children and their mothers together with other grassroots community members for the first time. This helped to build and strengthen their social relationships and networking and enhanced their communication skills. In the process, the research participants acquired valuable experience and exposure, resulting in them gaining confidence in what they do. These views corroborate the observations of Tingen et al.20 study had limited exposure to research processes prior to their involvement in the study.In the latter study, undergraduate nursing students gained professional experience and personal development through their participation in a research project conducted by their faculty. As was the case with the MAL-ED South Africa project, the nursing students in Tingen et al.’s21 highlighted the benefits of exposing health science students to off-campus education. Students were able to interact with local residents. Afterwards, they expressed positive views about their community-based experience. Thus, exposing students to real-life environments enhances their understanding of issues and is likely to result in better graduate attributes.The students revealed that their involvement in the project improved their research skills, in particular data review, analysis and writing manuscripts for scholarly publishing. This reinforced the widely held notion that ‘experience is the best teacher’. Another study in Japan22 concurs with this viewpoint and emphasises that effective interpersonal communication skills are a prerequisite of social interaction and building sustainable relationships.Research participants cited enhancement of interpersonal skills as another attribute of human capital development gained through the current study. They mentioned improved ability to communicate well with grassroots community members and peers and researching together with mothers and their children as they collected time series data. As they participated in the project and remained in constant contact with the participants and grassroots community members, they became less judgmental of others and learnt how best to interact with a diverse range of people. Having an accommodating personality helps improve social relationships and cohesion – all of which are important prerequisites for individual and collective development. RamanLastly, personal development was achieved through creating opportunities for the participants to apply the theory they had learnt in class to real-life situations, thereby boosting their confidence. When an individual’s confidence is boosted, they often feel motivated to perform better in the tasks assigned to them. Ultimately, they improve the performance of the organisation for which they work. The fact that some participants became so motivated that they eventually pursued further studies was crucial because it helped build their professional careers. Their desire to improve their educational qualifications resonates with the ideals of the late Nelson Mandela who alluded to the fact that education is the most powerful weapon which one can use to transform oneself and the world around them. Others reported that they were better organised, more disciplined and were able to work more independently as a result of their involvement in the MAL-ED project. All these are positive attributes that demonstrate maturity, which their HoDs confirmed to be the case. Thus, it can be concluded that participation in the MAL-ED project enabled both postgraduate students and junior faculty to unlock and sharpen their capabilities.Although only 25 and 10 people participated in the interviews and focus group discussions, respectively, their insights into the benefits accruing to them as a result of their involvement in the MAL-ED project were quite revealing. Ideally, having more than one focus group could have enabled deeper, independent interrogation of issues. However, the fact that the results of the individual interviews and focus group discussion were virtually the same, highlighted the fact that what is reported here was a true reflection of participants’ experiences.Skills and knowledge in research, experience and exposure, interpersonal skills and personal development were the major benefits that accrued to postgraduate students and junior faculty as a result of their participation in the biomedical community research project. Some participants highlighted the need for training workshops that focused on data analysis and interpretation, exposure to other laboratory techniques as well as time and project management training. These findings are useful as inputs into the planning and implementation of future similar projects.


Social network analysis (SNA) might have an unexplored value in the study of interactions in technology-enhanced learning at large and in online (Problem Based Learning) PBL in particular. Using SNA to study students’ positions in information exchange networks, communicational activities, and interactions, we can broaden our understanding of the process of PBL, evaluate the significance of each participant role and learn how interactions can affect academic performance.The aim of this study was to study how SNA visual and mathematical analysis can be sued to investigate online PBL, furthermore, to see if students’ position and interaction parameters are associated with better performance.This study involved 135 students and 15 teachers in 15 PBL groups in the course of “growth and development” at Qassim University. The course uses blended PBL as the teaching method. All interaction data were extracted from the learning management system, analyzed with SNA visual and mathematical techniques on the individual student and group level, centrality measures were calculated, and participants’ roles were mapped. Correlation among variables was performed using the non-parametric Spearman rank correlation test.s(133) = 0.27, p = 0.01), interaction with tutors (rs (133) = 0.22, p = 0.02) are positively correlated with academic performance.The course had 2620 online interactions, mostly from students to students (89%), students to teacher interactions were 4.9%, and teacher to student interactions were 6.15%. Results have shown that SNA visual analysis can precisely map each PBL group and the level of activity within the group as well as outline the interactions among group participants, identify the isolated and the active students (leaders and facilitators) and evaluate the role of the tutor. Statistical analysis has shown that students’ level of activity (outdegree rSocial network analysis is a practical method that can reliably monitor the interactions in an online PBL environment. Using SNA could reveal important information about the course, the group, and individual students. The insights generated by SNA may be useful in the context of learning analytics to help monitor students’ activity. Social constructivists view learning as an active construction of knowledge that occurs through social interaction and dialogue among learners. Interaction becomes particularly meaningful when learners are coached in a positive atmosphere and when the students have the chance to argue, debate, and offer alternate perspectives or contribute to ideas , 2. AimiOnline problem-based learning requires students to engage in active discussions in two types of dialogical spaces; the content and the relational spaces. Learners interact in the content space towards the goal of acquiring a deeper understanding of the domain of knowledge; activities include collecting information, discussing concepts and proposing solutions to the problem –7. CommuThere is overwhelming evidence of the value of learners’ interaction with peers, teachers, and the content, which is widely recognized as a pivotal ingredient of modern education , 10. HowSocial network analysis (SNA) is a collection of methods and tools that could be used to study the relationships, interactions and communications. As such, SNA is suitable for the study and possibly monitoring of online interactions as it can automatically analyze interaction data, bringing a bird-eye view of the group social structure, the interaction patterns, as well as the mapping of all communications in the relational space –17. SNA SNA visualization renders relationships between actors in social networks by graphs known as sociograms; the sociogram portrays actors (nodes in SNA terms) as points, and relationships (edges in SNA terms) as arrows originating from the source of the interaction and pointing to the target of interaction . SNA mayThe SNA mathematical analysis quantifies network parameters on individual actor levels, as well as group level. The mathematical analysis of SNA uses graph theory concepts to calculate metrics representing the nodes, the links or the network. Such as the distance to other actors in the network, the number of interactions with other actors, or how many times it bridged interactions between communities. These metrics are important in quantifying interactions, ranking nodes, or relationships. Parameters calculated at the actor level are called centrality scores, these scores are measures of the node position or importance in the social network. Since there are different contexts and probably different ways to consider the role important, there are different centrality scores. The measures chosen for this study are centrality measures of role and position in information exchange . For exaPrevious research has indicated the utility of SNA in the study of collaborative learning; J Zhang and J Zhang  used SNAThere is an apparent gap of the studies about the interactions in online PBL, particularly the relational and communicative activities. Most studies about the interactions in PBL targeted the content dimension through effortful resource intensive methods such as interviewing the learners, recording, and coding of PBL sessions or text mining techniques. Other researchers have used indirect examination and exploration using surveys and open-ended questionnaires , 22. SucWhat can SNA visual and mathematical analysis tell about PBL?What interaction parameters as measured by SNA associated with better performance?The research question of this study can be formulated as follows:The study was designed as an exploratory case study; a case study design allows an in-depth investigation of a case (Online PBL course in our study) from different perspectives.The study included data from 135 first year students  and 15 tutors , three students did not sign the ethical approval and 11 students dropped out of the course and so their data were not included. The course chosen was the Growth and Development of the year 2017, attended by first year students, the course is the third course in the year. The course covers issues of growth and development from different aspects, including anatomy, physiology and embryology. By the third course, students should have acquired a fair experience of the educational system and practiced online PBL for three months. The course duration is around 45 days, within them four weeks of PBL sessions were completed by all students.Qassim College of Medicine, Saudi Arabia has introduced PBL since 2001. The college adopted the seven jumps approach, student is expected to attend two sessions physically, one at the beginning of the week and another at the end, in between these sessions, students are offered an online forum where they continue to interact. The interactions start on the first day of the week by posting the learning issues of the weekly problem. Students are encouraged to discuss the learning issues, share information, collaboratively construct the required knowledge and work towards achieving the goals and the objectives of the PBL problem. By the last day of the week, each group is expected to wrap up what they have learnt together. The online discussions are assigned to the same students in the physical group and facilitated by the same tutors .The PBL represents the backbone of the educational system at the medical college and the objectives of the PBL sessions are written to cover the course objectives. The lectures, seminars and other educational activities are designed to support students understand the problem used in the PBL. The students are evaluated by multiple choice questions (MCQ), modified essay questions (MEQs) and Short-answer Essay Questions (SEQ) as well as practical exams. The grades considered for this study are only the sum of MCQ, MEQ and SEQ as they are designed to test students’ knowledge acquisition of PBL objectives and the exam blueprint is designed according to these objectives. The mean difficulty index of MCQs was 0.67, the mean discrimination index was 0.32 and the reliability index was 89.2%.Interaction data were extracted from the learning management system. Custom Structured Query Language (SQL) queries were used to extract interaction data along with attributes of students and properties of posts, the data extracted for each post were the id of the sender, the id of the receiver, time the post was written, time it was modified, the content of the post, and forum and thread IDs. For each user we extracted user Id, role, PBL group and the posts he contributed. All participant IDs were removed to protect their confidentiality and re-coded, so the students labeled as S1 to S135 and the tutors were recoded as T1 to T15.The analysis of SNA was done using Gephi version 9.2. Gephi is an open source application that has the capability to visually and mathematically analyze social networks through a graphical user interface. It can import a range of formats as well as export analysis data in an easy to use format for analysis .The course network, as well as group networks, were analyzed and studied visually. Visualization was implemented to describe the general properties of the course network, such as the interactivity level, participants’ contributions, who is participating and identify the types of communications. The same was performed for each PBL group with special emphasis on the student-student and student tutor communications.Mathematical analysis of participants’ interactivity may shed lights on important aspects such as interactivity and information exchange. As such, mathematical analysis was done at two levels, Individual students’ level (student and tutor), and group level, since they are the important factors in the PBL process.Indegree centrality: the number of posts that are directed to a user, such as replies. A user receives more replies to contribution if the contribution is noteworthy, useful or arguable. As such in-degree centrality in this context reflect the importance of a user contribution as voted by other users. Out-degree centrality: the frequency of posts made by the user and reflects the activity of the user in the discussions.Degree centrality: is the sum of indegree and outdegree centralities and reflects the overall activity of the userBetweenness centrality: is the frequency a user connected two other unconnected users, or lied in-between their interactions. As such, it may be viewed as a measure of bridging others and helping communications among interacting participants.Closeness centrality: reflects the distance between a user and all other users in the group, a user with high closeness centrality can be easily reachable by all others.For each student, we collected the following parameters: Type of interactions . We also calculated centrality measures that are relevant to interactions and role in information exchange:As this article is beyond the discussion of the theory, mathematics and concepts of centrality measures, interested readers can have further details in this article .For each group, we collected the following parameters: The total number of interactions and type , average in-degree centrality , average degree centrality (average degree of group members).Statistics were performed using Paleontological Statistics Software Package for Education and Data Analysis version 3.2. Correlation among variables was performed using the non-parametric Spearman rank correlation test .The course included 15 PBL groups; each group had a range of 6 to 12 students with one tutor. There were six discussion forums: five PBL discussion forums and a news forum , students to teacher interactions were 4.9% and teacher to student interactions were 6.15%. The range of interactions in each group was 48 to 332 . The picture was also similar on the course level; students dominated the interactions. Some groups were highly interactive such as groups 150, 144 and 149 and some were not such as groups 146, 140 and 141. A breakdown of each interaction type is presented in the course is presented in Table SNA can be used to map the relationships among actors, groups  and calculate the mathematical metrics of interactions and actors. The visual analysis was used to explore its role in shedding lights on the individual actors and their groups and how could this help learners or teachers. Furthermore, the mathematical analysis was used to quantify the interactions on the same levels, to demonstrate the utility of quantifications of interactions and how it compares to visual analysis.SNA visual analysis can be used on different levels, in our case three levels are relevant: the whole course level, the PBL group level and individuals’ level. Following is a demonstration of what each level can reveal visually.finding communities. This property is useful in finding the group of members who frequently interact with each other. The Figure shows each PBL group and the interactions among participants. Active groups can be recognized; an example is group A, B, and C; the three groups have dense interactions among participants. Groups D, E, and F, have a moderate level of activity; while G and H groups are less active with very few interactions among participants. Using such method may help pick the groups that need attention, a focused review or support.One of SNA biggest advantages is the ability to sum up and map all interactions, as such it offers a bird-eye view of the relational dynamics in a course or a group. In the next Fig. While the insights from the whole course network can be helpful to have a course overview, a focus on each group separately can demonstrate deeper information. In each group, the visual analysis using SNA can reveal the patterns of the interactions occurring in the group and how the students and the tutor perform; which are relevant factors for the evaluation of the PBL process. To demonstrate the potential of SNA and how much insight it can give, we present three Figures, in Fig. In contrast to the previous group, the next group (I) shows far lower level of activity. However, as shown in Fig. On the individual level, SNA can highlight the network of individual users. For instance, we can have a student of interest that we would like to see his performance. For that situation, we can isolate his network in what is known as an ego network. To demonstrate this, we demonstrate the ego network of the tutor in another group, namely the ego network of the tutor of group I in Fig. Mathematical analysis offers a quantification of interactions and roles which may enable accurate comparison of students and groups. It is also potentially useful as a measurement that can be used to forecast performance. The descriptive properties of participants in our study were as follows: the average outdegree centrality was 17.47, which means each participant has contributed with an average of 3.5 posts/week during the five weeks duration of the course, which is an indication of a relatively interactive course. The centrality measures of information exchange were also acceptable, the closeness centrality normalized score was 0.66, meaning that most students had moderate to high reachability. Same parameters can be obtained for the group and they are presentenced in the next section.Further details are in Table As a demonstration, the mathematical parameters of a student are summarized in Fig. To sum up a student or a user activity, we propose using SNA as a monitoring tool that displays the activity of a use  compared to own group for the teachers to use. The social network profile concept we propose can be applied in a learning management system dashboard to show social profile, connections and parameters. To demonstrate this, we chose a student from group A, showing ego network, the activity level and parameters for clarity, we also compare the activity to the group side by side. Comparison to his group will show if his activity level is proportional to colleagues or not and will highlight the other participants’ role. In case there is an unsatisfactory level of activity, one can understand the reason.To see which of the SNA factors might correlate with better achievement, we categorized the parameters into three main groups: personal, group and tutor factors. The results indicated that outdegree centrality of a student, being in a group with higher average grade, communicating with the tutors, are the factors most correlated with better learning. The full details of correlation coefficient are displayed in Tables This study was done to evaluate the role SNA can be used to evaluate online PBL and offer insights to administrators, tutors, and students. We have looked at the visual analysis and the quantitative interaction statistics. The type of interaction based on the involved participant whether he is a tutor or a student was considered. We also used role classification to try to understand the dynamics of intragroup interactions.On the quantitative level, SNA interaction analysis offered simple, easy to interpret indicators for the level of activity of students and tutors; these indicators helped identify the active groups, tutors, and students alike. The indicators also helped flag a potentially dysfunctional or inactive group and the inactive student or a disengaged tutor. The SNA measures of role and position in information transfer highlighted qualities that can’t be easily recognized by the interaction parameters (number of posts). For instance, betweenness centrality reflected the role of students in moderating information, connecting the unconnected students and brings them into the discussion. Closeness centrality pointed to students who were not easily engaged in the discussions.When coupled with visual analysis, it gave further insights into the dynamics of the interactions in the groups, such as who was active, who were the students interacting together and highlighted the isolated students. The role analysis we have performed in our study added another dimension to the utility of SNA. Identifying each role and who plays it enables tutors to understand dynamics in the group, helps motivate discussions and mitigate conflict or prevent dysfunction in interacting groups as well as appreciate different points of view , 29.Studies of interaction analysis in online PBL are scarce, our review of the literature identified one study about the analysis of problem-solving online discussions, which is apparently not precisely online PBL , 31. Ano“Many of the EDM researchers are in reality users of Data mining frameworks and tools. Because student modeling commands the focus of more than half the approaches.”While content analysis might have added insights about the exchanged information in online PBL, it is resource intensive and requires long, exhaustive work. Since content analysis is usually done manually, it is not a practical choice for automatic monitoring of thousands of interactions. Content analysis has also been criticized for being subjective and difficult to standardize –35. EducWhile our research was feasible due to the availability of data recorded by the learning management system and the relative ease of obtaining it, a similar approach can be extended to include the face-to-face PBL. The modern voice recognition techniques can accomplish it, since transcribing tools that are becoming more accurate, cheaper and easier to implement. The implementation would require more discussion about what to transcribe, what to store and how to handle this data.We think that our study offered a demonstration of the potentials of SNA as a tool for interaction analysis of online PBL. We hope that this study can kindle the discussions about the need for automatic monitoring of PBL. We hope that future research can examine, improve or critique our approach. An obvious future approach to online PBL could couple learning analytics methods with SNA methods.While this study has shed lights on the communicative and relational aspects of the online PBL, it is not without limitations. We recognize the limitation and the need for a reliable content analysis method. An automatic EDM method that is designed to capture the PBL elements and give a credible insight into the content of the discussions. We also recognize that our results might need further confirmation in other contexts to advance our understanding of the process, especially different implementations of online PBL.Social network analysis is a practical method that can reliably monitor the interactions in an online PBL environment. Using SNA can reveal important information about the course, such as the general activity and the active groups. On the group level, it renders a more detailed picture about the group and the participants. Thus, helping to identify the active, inactive or isolated students and tutors alike. Using mathematical parameters can also help add insights about the level of activity in a precise way. Furthermore, the insights generated by SNA can be useful in the context of learning analytics to help monitor students’ activity.


Pulmonary complications are common in primary immunodeficiency diseases (PID) and contribute to morbidity and mortality in these patients. However, their varied presentation and a general lack of awareness of PID in this setting make early diagnosis and treatment difficult. The aim of this study was to define the warning signs of PID in patients with respiratory manifestations, the necessary diagnostic tests, and the therapeutic management of both children and adults.A review of the literature was performed, and 43 PID interdisciplinary specialists were consulted.This document identifies the pulmonary and extrapulmonary manifestations that should prompt a suspicion of PID, the immunological and respiratory tests that should be included in the diagnostic process according to the level of care, recommendations regarding the use of immunoglobulin replacement therapy according to the specific immunodeficiency, and the minimum recommended immunological and pulmonary monitoring in these patients.This document is the first to combine scientific evidence with the opinion of a broad panel of experts specializing in the treatment of patients with immunodeficiencies. It aims to provide a useful tool for all practitioners who are regularly involved in the management of these patients. Immunodeficiency diseases (ID) are disorders involving a quantitative and/or functional disorder in the immune response  that mayPIDs comprise a heterogeneous group of more than 300 diseases. The Primary Immunodeficiencies Classification Committee of the International Union of Immunological Societies (IUIS) divides PIDs into 8 groups , depending on their clinical and immunological phenotype . The varThe prevalence of PID in Europe and the United States ranges from 41 to 83 per 100,000 inhabitants, depending on the study , 6. The et at highlighted the low sensitivity and specificity of these warning signs, recommending that PID awareness initiatives should be mainly targeted at hospital pediatricians and families with a history of PID although these initiatives should also include the general public [New warning signs alerting to a suspicion of PID are being increasingly described, based on clinical presentations - mainly infectious diseases - and, in some cases, family history. Fifteen years ago, the Jeffrey Modell Foundation (JMF) defined the warning signs of suspected PID in children and adults , 11. Thil public .Pulmonary complications in PID are common and significantly contribute to the morbidity and mortality of patients. Recurrent respiratory tract infections often constitute the first warning sign in some PIDs and are often the main cause of death in adults with PID , 15.The aim of this study was to define which warning signs should alert to the suspicion of PID in patients with respiratory manifestations, and to develop proposals for intervention in these cases. This document is aimed at primary care (PC) professionals and specialists who see both adult and pediatric patients with respiratory diseases. This study is part of the ID-Signal Project, which aims to generate a series of documents based on the clinical manifestations of IDs dedicated to non-immunologists who may take care of patients with PID or SID in their clinical practice.Initially, an interdisciplinary expert group formed of 2 pulmonologists, 2 immunologists and 2 pediatricians specializing in immunodeficiencies identified items to be addressed in the areas of clinical and laboratory testing, diagnostic imaging, functional tests, and therapeutic approach, and prepared a series of recommendations. A review of the literature was then performed, which acted as a basis for a discussion of the contents of the document in an in-person meeting. The main conclusions and recommendations were forwarded to an external panel of experts for their individual evaluation, depending on their specialty. Although we could have done a Delphi process involving at least two rounds, we preferred a single consultation to have a general view of the opinion of a larger group of experts and to make the process easier. The external panel consisted of 43 experts from all over Spain, with experience in the diagnosis and treatment of PID, working in Spanish National Health System centers. In total, 19 immunologists specializing in adults , 15 pediatric specialists in immunodeficiencies , 5 pulmonologists taking care of adults , and 4 pediatric specialists in pulmonology  participated.This panel indicated their level of agreement on a scale of 1 to 4, with 1 reflecting “strongly disagree” and 4 “strongly agree”, and they could also add comments when necessary. The results were pooled and the percentages of votes in the categories 1 and 2 (disagree) and in the categories 3 and 4 (agreement) were calculated. Unanimity was determined when 100% of the experts agreed with recommendation/conclusion; consensus, when at least 80% of the experts agreed without unanimity; majority, when more than 65% and less than 80% of the experts agreed with the recommendation/conclusion; and disagreement, when the percentage of agreement was 65% or less.Streptococcus pneumoniae and Haemophilus influenzae, followed by Mycoplasma spp., Staphylococcus spp., Moraxella spp., Pseudomonas aeruginosa, and other viral pathogens, and more rarely Pneumocystis jirovecii and various fungi [In general, lung complications caused by PID include respiratory tract infections, interstitial lung disease (ILD), and cancers . Recurreus fungi .However, since mortality due to infectious complications has declined, non-infectious complications have begun to account for a large number of the poor clinical outcomes observed in some of these patients . Thus, sThe patient profile (adult or pediatric) and pulmonary manifestations (infectious or non-infectious) that lead to a consultation in PC or with a respiratory medicine specialist may be different. Manifestations that should prompt a suspicion of PID are included in Table PIDs have been divided into several categories, according to their clinical characteristics and immune system involvement. In any case, we must remember that inclusion in one category or another involves an important academic component, and in routine practice, the clinical context of the patient will help guide their classification. There are some lung manifestations that should lead to the suspicion of a specific PID. This is the case of pneumatocele and AD-hyperIgE syndrome, bronchiectasis and antibody deficiencies, severe bronchiolitis and severe combined immunodeficiencies or pulmonary fungal infections and phagocyte disorders, among others. However, most lung diseases can occur in a wide range of PID, in which a wide but phased diagnostic protocol is recommended.Table Table It is very important that the specialist who evaluates a patient with suspected PID due to lung problems also takes in account the presence of extrapulmonary manifestations that might support the clinical suspicion of PID, since one of the main characteristics of PID is its ability to affect multiple organs or systems simultaneously or sequentially. PID may present with skin –22, gastOn the other hand, there are some histopatological findings which would prompt the clinician to consider a diagnosis of PID before having the suspicious of it. This is the case of granulomas or the absence of plasma cells in a gastrointestinal biopsy.A large number of PIDs can be diagnosed from a detailed clinical history that includes a family history of PID, consanguinity, or family members who died at a young age, a comprehensive physical examination, blood tests, and a determination of serum immunoglobulin (Ig) levels. These tests are available in the vast majority of laboratories, even in PC. The physical examination should be detailed and ordered by body system, and it is important to assess the patient’s nutritional status, with particular attention to height and weight and sequelae from previous infections. The presence of lymphadenopathies or the absence of nodal chains, tonsils, hepatosplenomegaly, etc. must be determined, since in some cases these parameters may orient the professional towards a specific PID. A complete blood count (CBC) with a differential count provides important information on suspected cytopenias  and qualitative cellular changes . The detThere are obvious differences between diagnosis in children and adults since, usually, most severe PID are diagnosed in childhood while recurrent respiratory infections, which can be caused by many other non-immunological entities and are the clue for the diagnosis during adulthood. Adolescents are a special population with mixed manifestations. Therefore, first line diagnostic tests in adults are almost specifically based on ruling primary antibody deficiency out (immunoglobulin levels and antibody production assessment), while clinical manifestations will orient the initial tests in childhood .It is important to assess the results according to the reference values for each age, since there are significant differences which, if not taken into account, can cause PID to be overlooked . In addiWith regard to tests that are specifically “pulmonary” in a patient with suspected PID, tests adapted to the disease and based on the clinical history are recommended: this is the case for lung function tests and high-resolution computed tomography (HRCT) to evaluate the lung structure, sputum cultures to detect respiratory infections, and sputum cell counts (neutrophils and eosinophils), among others . Chest XTables Immunoglobulin replacement therapy (IGRT) is essential in patients with PIDs that directly affect B cell function and antibody production, primarily in severe cases, but also in patients in whom involvement is not obvious from routine testing . IGRT haThere are currently 6 PID phenotypes for which IGRT is indicated or may be indicated : agammagSince IGRT was introduced in the 1980s, the administered dose of Ig has been gradually increased to achieve higher IgG plasma concentrations . For exaIGRT can be administered by 2 routes: subcutaneous (SCIG) and intravenous (IVIG); the muscular route has fallen into disuse. There is also a facilitated SCIG which improves its bioavailability and allows infusions every 3–4 weeks . AdequatDifferent factors must be considered when selecting the route of administration, as not all patients benefit equally from both . FirstlySurvival and quality of life of patients with certain PIDs has improved significantly in recent years, particularly as a result of better diagnosis and treatment of infections and other comorbidities, the development of highly potent antimicrobial agents, and the development of specific therapeutic alternatives, such as IgG and others . HoweverThe decision on the frequency of evaluations of PID patients depends on several factors, including the type of PID, clinical conditions, and age. There is currently no internationally agreed consensus on the follow-up of patients with PID and lung involvement, but it has been suggested that patients should be evaluated at least once every 6–12 months with a full clinical history and physical examination . WheneveThe literature reviewed proposes that the follow-up of patients with pulmonary complications should include serial lung function tests and imaging studies, along with regular sputum cultures , 56. CheTable This study is the first to focus on PID from a pulmonary point of view, addressing the diagnosis, treatment and follow-up of both adult and pediatric patients, while simultaneously including the opinion and clinical experience of more than 40 experts from different fields and specialties who regularly treat these deficiencies. This document is intended to be a useful tool for both primary care professionals and specialists who are treating patients with lung disease, helping them to identify the warning signs of PID in order to make an early diagnosis or else to refer the patient to a specialized unit, thus avoiding unnecessary complications. Other approaches that may help an early identification of PIDs should include education and awareness for specialists. Finally, future possible shortcomings of the study will involve other medical specialties and other clinical manifestations of IDs.