Abstract
Background: Service-learning is a powerful, but underutilized, educational tool in Asian medical schools.
Aim: We compared the ability of two programs providing medical care to low-income populations (clinic-based versus home-based approach) to teach community medicine skills in an Asian medical school.
Methods: We conducted a cross-sectional study using a self-administered anonymized questionnaire on medical students who participated in the programs using the Fund for the-Improvement of Postsecondary Education Survey Instrument. Participants also gave an overall score for their learning experience in the programs.
Results: Participation rates were 97.4% (760/780) and 95.8% (230/240) across the two programs. A majority of participants in either program felt that the experience helped them to improve in all domains surveyed. Regardless of whether one compared those who participated in either program or both programs, the home-based approach was superior at teaching communication skills, teamwork, identifying social issues, gaining knowledge, and applying knowledge. Improved knowledge on long-term management of chronic diseases (β = 1.25, 95% CI, 0.55–1.96) was strongly associated with the overall score for those participating in the home-based program.
Conclusions: Service-learning programs, in the Asian context, have potential educational value for medical students in a wide range of domains. The home-based approach is superior at teaching certain aspects of community care.
Introduction
Service learning, defined as “a structured learning experience combining community service with preparation and reflection,” is a useful and powerful tool in medical education (Cashman & Seifer Citation2008). Such community–campus partnerships can benefit the community while training doctors-to-be (Seifer Citation1998); and are popular components of Western medical curricula. In particular, there exist student-run health clinics in many US medical schools, which provide medical care to underserved populations. These service-learning programs are targeted at the poor thus, fill a gap in the largely insurance-funded healthcare system, and are important contributors to both patient care and medical education (Simpson & Long Citation2007; Meah et al. Citation2009). In particular, exposing medical students to the healthcare challenges faced by the lower income can promote positive attitudes in physicians-in-training toward serving such populations in the future (Seifer Citation1998; Cox et al. Citation2006; Wear & Kuczewski Citation2008), and such community-based approaches might enjoy an advantage over the traditional curriculum in teaching key skills like communication, teamwork, and the management of chronic diseases (Whitehouse et al. Citation1997).
In Asia, however, service learning is not as well established, with few studies on its value (Xing & Hok Citation2010); there are also no reports of student-run-clinics among Asian medical schools in the literature. However, it is likely that such programs, if established more widely in Asia, would have similar potential to significantly benefit medical education (Leung et al. Citation2007). Little work has been done on attitudes towards the underserved amongst students at Asian medical schools; however, with rising health disparities in Asia (Tang et al. Citation2008), it is clear that service-learning initiatives targeted at helping the underserved can also fulfill the two-fold aims of providing care for the needy and equip doctors-to-be with the skills to operate in such settings (Wee et al. Citation2010). More needs to be done to quantify the pedagogical benefits, as well as the appropriate program design and target population, of such programs, especially in an Asian setting where such data is lacking.
In Singapore, service-learning is a recently introduced component to undergraduate medical education experience. The Yong Loo Lin School of Medicine (YLLSoM) is Singapore's sole undergraduate medical school, with a 5-year course consisting of 2 years of foundational lectures (pre-clinical) and 3 years of clinical rotations. Introduction of service-learning into our medical school has taken place only in the past decade, and was driven largely through student-led initiatives to create two service-learning programs, the Public Health Screening (PHS) in 2000 and the Neighborhood Health Screening (NHS) in 2009. The PHS runs in the first half of the academic year, and the NHS in the second. Although participation in these programs is voluntary and there is no academic credit given for participation, participation rates are high—about 66% of the student body across all 5 years participate in these programs yearly, and most students will have participated at least once by the time they graduate from medical school. Although the Singaporean healthcare system is funded through a mix of government subsidy and forced-saving accounts (Lim Citation2005), the lower income segment of the population still has substantial inequality in access to health services (Joshi & Lim Citation2010; Wee & Koh Citation2010). Hence, both programs have as their focus providing medical care and health screening to the lower income segment of society, especially in the area of chronic disease management (such as diabetes, hypertension, and dyslipidemia). In these programs, volunteer physicians on-site provide supervision and students can request for physicians to join them if they needed assistance during the patient encounter. A crucial difference between the two, however, is that while the PHS operates from a fixed location, seeing mainly walk-in patients, the NHS, unlike the majority of student-run-clinics in the USA (Simpson & Long Citation2007), is mobile and operates door-to-door in needy neighborhoods. A comparison of the two programs is found in . NHS allows medical students to witness first-hand the patient's living environment and interact more closely with the patient's family. Such a home-based setting may be more pedagogically effective and psychologically engaging (McWilliams et al. Citation2008; Ngai Citation2009; Anderson et al. Citation2010); however, there is a paucity of studies on the effect of home-based service learning programs outside of the West. It is thus of interest to examine whether these unique approaches translate into a different service-learning experience for students and equip them with community medicine management skills, as such information may inform both future and existing service-learning programs for medical students in Asia and the West.
Table 1. Comparison of the PHS and NHS service-learning programs at the Yong Loo Lin School of Medicine, Singapore
Methods
We conducted a study to gauge the differences in educational experiences, using an anonymized questionnaire, on all medical students who participated in the NHS and/or PHS. The questionnaire was modified from the Fund for the Improvement of Postsecondary Education (FIPSE) Survey Instrument (Eyler & Giles Citation1999), in particular the Ability Scale, which was previously used to assess the ability of a service learning program in Taiwan to teach community medicine management skills (Xing & Hok Citation2010). Questions rated students’ self-reported gains across nine domains: leadership skills, communication skills, teamwork, critical thinking skills, ability to identify social issues, action skills, ability to see consequences, and gaining and application of knowledge. All questions used a four-point Likert scale (agree, uncertain but probably agree, uncertain but probably disagree, and disagree) to capture a wide range of responses but we collapsed responses into two categories (agree vs. disagree) during analysis for easier data interpretation. The overall educational experience was also evaluated on a scale of 1–10 (10 being the best and 1 the worst) for both NHS and PHS. We compared the overall rating of the learning experience for NHS and PHS between students who had only participated in either program (after controlling for demographic characteristics) as well as between those who participated in both programs.
Descriptive statistics were computed for the student participants. Chi-squared analysis was used to compare the gains across the nine domains between students who had participated only in the PHS, and those who participated only in the NHS. We then used logistic regression to adjust for potentially confounding demographic factors, such as gender, year of study (preclinical = first and second years; clinical = third to fifth year) and role in the program, when comparing between those who participated in either PHS or NHS only. McNemar's chi-squared test was used to compare the educational gains for those who participated in both the NHS and PHS. The mean overall rating of the learning experience between NHS and PHS was compared between students who participated in NHS or PHS only using two samples unpaired t-test and among students who participated in both NHS and PHS using paired t-test. Backward linear regression was used to determine the main learning domains, which were independently associated with the final overall rating of the learning experience. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, Version 17.0, USA) and statistical significance was set at the conventional p < 0.05.
Results
The majority of the students who participated in the service-learning programs completed the survey instrument. 97.4% (760/780) and 95.8% (230/240) of the participants in the PHS and NHS, respectively, completed the questionnaire. Of those who completed the questionnaire, 594 students participated in PHS only, 64 students participated in NHS only, and 166 students participated in both. The demographics for NHS and PHS, respectively, were as follows: 47.8% (110/222) and 54.9% (417/760) were male; 70.9% (163/230), and 62.9% (478/760) were pre-clinical students; 3.5% (8/230) and 2.4% (18/760) served on the student committee that organized the program.
There were significant differences in the self-reported pedagogical value of the two programs across the nine domains surveyed, both for those who had only participated in one of the programs () and for those who had participated in both (). Comparing between those who had only participated in either program and controlling for gender, degree of clinical exposure, and role in the program, the home-based approach of the NHS was superior at teaching communication skills, teamwork, identifying social issues, gaining knowledge, and applying knowledge. The same findings were found when the NHS and the PHS learning experience was compared among those who had participated in both programs. For those who had only participated in one program, the overall rating of the NHS was 7.68 (SD = 1.20) and the overall rating of the PHS was 7.53 (SD = 1.71); the difference was insignificant (p = 0.510). For those who had participated in both PHS and NHS, the rating of the NHS was significantly higher (8.53 [SD = 1.12] for NHS; 6.05 [S.D = 1.16] for PHS; p = 0.032) With regards to which responses to individual questions were independently associated with the final overall rating of the educational experience, improved ability to interact with patients (β = 0.95, 95% CI, 0.47–1.43), appreciation of challenges to healthcare faced by the lower income groups (β = 0.79, 95% CI, 0.49–1.37), and appreciate my own health, living condition (β = 0.67, 95% CI, 0.38–0.96) were strongly associated with the final overall rating for those who took part in PHS only. Improved knowledge on long-term management of chronic diseases (β = 0.125, 95% CI, 0.55–1.96), was strongly associated with the final overall rating for those who participated in NHS alone. For those who volunteered at PHS and NHS, only improved ability to interact with patients (β = 2.07, 95% CI, 1.04–3.11) at the NHS was strongly associated with the overall rating of their learning experience.
Table 2. The pedagogical value of the PHS (clinic-based) and the NHS (home-based) for medical students who participated in either the PHS or the NHS program in 2010
Table 3. The pedagogical value of the PHS (clinic-based) and the NHS (home-based) for medical students who participated in both the PHS and NHS programs in 2010 (N = 166)
Discussion
The majority of medical students reported gains across all domains, regardless of which program they were in. This suggests that service-learning programs are equally effective when transplanted into Asian communities. Indeed, learning more about chronic disease management and appreciating the health needs of the disadvantaged were key components of students’ overall rating of the learning experience; suggesting that these service-learning programs were effective pedagogical tools in this regard, and that the medical students highly valued their learning in these areas. Service learning programs that teach chronic disease management are highly relevant (Dent et al. Citation2010), given that the prevalence of chronic disease is rising in Asia as well as around the world.
Students had different aims when signing up for either the home-based NHS, the centre-based PHS, or both programs. For those who participated exclusively in the home-based NHS, improved management on the long-term management of chronic diseases was strongly associated with the final overall rating of their educational experience, suggesting that this was an objective of their signing up for the NHS and evaluated their educational experience based on how well the program fulfilled these goals. Given the various motivations that students may have for participation in such service-learning programs, it is ideal to give students access to a variety of programs so that they can gravitate to whichever program fits their learning objectives best.
Despite the emphases on different learning objectives in the three groups of students, the home-based service-learning program (NHS), in the Asian context, notably provided greater benefits to students. We were initially concerned that in the Asian culture with its greater emphasis on privacy and “face,” needy residents might not open up to the students and thus compromise on interaction between patients and students. However, our fears proved unfounded. Instead, the home-based service learning program was better in helping students to develop communication skills, various elements of teamwork, identify social issues, improve knowledge on chronic disease management and healthcare challenges faced by lower-income Singaporeans, and apply knowledge learnt to better interact with patient's relatives, recommend screening tests, refer for psychosocial help, and improve patient compliance. Students reported that they were more confident at tackling the various steps of the care pathway: first screening, then clinical procedures, and finally encouraging compliance and providing non-medical assistance, eventually leading to better management of chronic disease. Clearly, bringing the student into the resident's home made for a better learning outcome; this beneficial approach could be replicated in similar service learning programs (Batra et al. Citation2009). The reasons for this could possibly be due to differences in how the patients were seen, as well as the structure of the programs. All the patients served by the NHS were seen at home; as such, a larger proportion of them were seen with their families, compared to the walk-in nature of the PHS. Hence, this provided an opportunity for the student to involve the patient's family in his/her care, contributing to them gaining a more complete understanding of a patient's needs. Rather than seeing individual needy patients one-by-one in the clinic as the PHS program did, seeing needy people within the context of their community and home environment might have enabled these students to better empathize with the plight of the poor via the ‘pedagogy of discomfort’ (Boler Citation1999). Finally, another possibility is that the home-based nature of the NHS program allowed medical students to form personalized relationships with the poor. While not an official part of the program, students could and did return to the needy community even after the program ended to follow-up with the residents that they had come to know. Such one-to-one relationships could offer future doctors greater insight into the lived plight of people in poverty, rather than a one-off meeting in the clinic (Hilfiker Citation1990, Citation2001). A possible tradeoff, though, was that consultations between the students and their patients were longer, which led to students seeing less patients at the NHS compared to the PHS.
There are, however, concerns with regards to the wider adaptation of the service-learning model and student-run clinics. Common criticisms include: that quality of care may suffer, given limited resources and high turnover of students and physicians relative to traditional, professional clinics; and sustainability issues, given limited resources and limited leadership continuity among student-run initiatives (Buchanan & Witlen Citation2006; Simpson & Long Citation2007). For the two programs presented here, the following safeguards were in place: supervision by either faculty or volunteer physicians was present at all sites of patient encounters; official communications (e.g., referral letters and letters informing patients of screening test results) were reviewed and counter-signed by supervisors; students identified themselves as such in patient–student encounters; and contact details of faculty/supervisors were made available for patients to register any concerns. Both programs are currently expanding to serve more patients and to more sites, in line with the experiences of those who argue that such programs can actually improve patient care via increased productivity, when shifting to an education-and-service model (Fournier et al. Citation1993). Finally, we were also much encouraged that students in both programs reported gains in leadership skills, ability to identify social issues, and ability to take action. We hope that this might translate into more students initiating such projects, or participating in leadership roles, in order to increase the sustainability of these programs. Indeed, the student initiators of the NHS program were inspired to create this program, in part, via their participation in the PHS program. We also note that the aim of these student-run clinics was to supplement, not supplant, the existing medical system; and that such clinics provide reasonable standards of care and meet national targets for clinical care (Lough et al. Citation2011; Wee et al. Citation2011; Zucker et al. Citation2011).
Our study has some limitations. When comparing students who had participated in either program, we were only able to control for demographic factors like degree of clinical exposure, gender, and role in program; we could not control for, say, students’ baseline measure of community medicine management skills. This limitation was partially addressed by comparing the experiences of students who had participated in both programs, who thus served as their own comparison group. However, as a much smaller number of students participated in both programs, the experiences of this smaller group might not be reflective of the whole collective population. We thus decided to report results for both comparisons, so that we could be more confident that differences seen in both students who had participated in either program, and students who had participated in both programs, were genuine differences. Furthermore, as these programs were established only recently (PHS in 2000 and NHS in 2009), we could not collect longitudinal data on the long-term educational outcomes of these programs. While participants might report greater inclination towards care for the indigent, this might not be sustained post-graduation from medical school. Learning outcomes were self-reported and not objectively tested, and thus subjective. Nevertheless, this does not reduce the value of student-perceived learning outcomes. In addition, as participation was voluntary, those who participated were probably a self-selected group who were more likely to report a positive learning experience. However, a majority of the student population did participate in the two programs—at least 66% (824/1250) of the cohort participated in either program in 2010.
In summary, service-learning offers great potential to make a difference to patient care and medical teaching in Asia, where it is relatively unknown and under-utilized. In particular, although practice at sites located within the community can still deliver good educational outcomes (Anderson et al. Citation2003), we showed that bringing students into the homes of patients themselves can produce a better educational experience. We hope that our success in adapting this concept to an underserved Asian community can serve as the catalyst for greater adoption of this idea and concurrently address health disparities in Asian societies. Similar to the experiences of other programs, we also hope that these students will continue to play a proactive role in serving the community after graduation (O’Toole et al. Citation2005), and that we have ignited the spirit of altruism and empathy in these doctors-to-be (Haq et al. Citation2002).
Ethical Approval
Ethical approval for this study was granted by the Institutional Review Board, National University of Singapore.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Acknowledgments
The authors thank the NHS and PHS 2010 Organizing Committees for supporting this study. Thanks also to the National Cancer Institute, Singapore; the Department of Epidemiology and Public Health, NUS; the Singapore Cancer Society; the Singapore Anti-Tuberculosis Association; the Health Promotion Board; Southwest Community Development Council, and Taman Jurong Community Centre for providing the resources for this program.
References
- Anderson ES, Lennox AI, Petersen SA. Learning from lives: A model for health and social care education in the wider community context. Med Educ 2003; 37: 59–68
- Anderson ES, Smith R, Thorpe LN. Learning from lives together: Medical and social work students’ experiences of learning from people with disabilities in the community. Health Soc Care Comm 2010; 18: 229–240
- Batra P, Chertok JS, Fisher CE, Manseau MW, Manuelli VN, Spears J. The Columbia-Harlem Homeless Medical Partnership: A new model for learning in the service of those in medical need. J Urban Health 2009; 86: 781–790
- Boler M. Feeling power: Emotions and education. Routledge, New York, NY 1999
- Buchanan D, Witlen R. Balancing service and education: Ethical management of student-run clinics. J. Health Care Poor Underserved 2006; 17: 477–485
- Cashman SB, Seifer SD. Service-learning: An integral part of undergraduate public health. Am J Prev Med 2008; 35: 273–278
- Cox ED, Koscik RL, Olson CA, Behrmann AT, Hambrecht MA, McIntosh GC, Kokotailo PK. Caring for the underserved: Blending service learning and a web-based curriculum. Am J Prev Med 2006; 31: 342–349
- Dent MM, Mathis MW, Outland M, Thomas M, Industrious D. Chronic disease management: Teaching medical students to incorporate community. Fam Med 2010; 42: 736–740
- Eyler J, Giles DE. Where's the learning in service-learning?. Jossey-Bass, San Francisco 1999
- Fournier AM, Perez-Stable A, Greer PJ, Jr. Lessons from a clinic for the homeless. The Camillus Health Concern. JAMA 1993; 270: 2721–2724
- Haq C, Grosch M, Carufel-Wert D. Leadership opportunities with communities, the medically underserved, and special populations (LOCUS). Acad Med 2002; 77: 740
- Hilfiker D. Facing brokenness. Second Opin 1990; 11: 93–107
- Hilfiker D. From the victim's point of view. J Med Humanit 2001; 22: 17–31
- Joshi VD, Lim JF. Health insurance in Singapore – who's not included and why?. Singapore Med J 2010; 51: 399–405
- Leung KK, Liu WJ, Wang WD, Chen CY. Factors affecting students’ evaluation in a community service-learning program. Adv Health Sci Educ 2007; 12: 475–490
- Lim MK. Transforming Singapore healthcare: Public-private partnership. Ann Acad Med Singapore 2005; 34: 461–467
- Lough LE, Ebbert JO, McLeod TG. Evaluation of a student-run smoking cessation clinic for a medically underserved population. BMC Res Notes 2011; 4: 55
- McWilliams A, Rosemond C, Roberts E, Calleson D, Busby-Whitehead J. An innovative home-based interdisciplinary service-learning experience. Gerontol Geriatr Educ 2008; 28: 89–104
- Meah YS, Smith EL, Thomas DC. Student-run health clinic: Novel arena to educate medical students on systems-based practice. Mt Sinai J Med 2009; 76: 344–356
- Ngai SS. The effects of program characteristics and psychological engagement on service-learning outcomes: A study of university students in Hong Kong. Adolescence 2009; 44: 375–389
- O’Toole TP, Navneet K, Mishra M, Schukart D. Teaching professionalism within a community context: Perspective from a national demonstration project. Acad Med 2005; 80: 339–343
- Seifer SD. Service-learning: Community-campus partnerships for health professions education. Acad Med 1998; 73: 273–277
- Simpson SA, Long SA. Medical student run health clinics: Important contributors to patient care and medical education. J Gen Intern Med 2007; 22: 352–356
- Tang S, Meng Q, Chen L, Bekedam H, Evans T, Whitehead M. Tackling the challenges to health equity in China. Lancet 2008; 372: 1493–1501
- Wear D, Kuczewski MG. Perspective: Medical students' perceptions of the poor: What impact can medical education have?. Acad Med 2008; 83: 639–645
- Wee LE, Yeo WX, Tay CM, Lee JJ, Koh GC. The pedagogical value of a student-run community-based experiential learning project: The Yong Loo Lin School of Medicine Public Health Screening. Ann Acad Med Singapore 2010; 39: 686–686
- Wee LE, Koh GC. Hypertension awareness, treatment and control in an urban low-income setting: A community-based study in Singapore. Prev Med 2010; 51: 447–448
- Wee LE, Koh GC, Lim VKG. Caring for underserved patients through Neighborhood Health Screening: Outcomes of a Longitudinal, Inter-Professional, Student-Run Home Visit Program in Singapore. Acad Med 2011; 86: 829–839
- Whitehouse C, Roland M, Campion P. Introduction. Teaching medicine in the community: A guide for undergraduate education, C Whitehouse, M Roland, P Campion. Oxford University Press, Oxford 1997; 3–18
- Xing J, Hok KM, Carol, editors. 2010. Introduction. In: Service learning in Asia: Curricular models and practices. Hong Kong: Hong Kong University Press. pp 3–5
- Zucker J, Gilen J, Ackrivo J, Schroeder R, Keller S. Hypertension management in a student-run free clinic: Meeting national standards?. Acad Med 2011; 86: 239–245