Liang En, Wee; Koh, Gerald Choon-Huat MMed FM, GDGM, FCFP, MGer; Lim, Vivien Kim Geok PhD
Service learning is a structured learning experience combining community service with preparation and reflection1 that has been shown to be an appropriate and effective vehicle for teaching undergraduate public health.2 Student-run health centers (SRCs), one form of service learning, combine the provision of medical care to underserved communities with an educational platform for students. Such community–campus partnerships aim to benefit the community while instilling the ethic of service in future health care providers.3 The first SRCs in the United States were established in the 1960s, and today they are widespread amongst U.S. medical schools; over 49 schools have such programs.4,5 In these programs, medical students take primary responsibility for logistics and operational management5; for example, they handle clinic flow, build the clinic's presence within the community, direct learning outcomes, and ensure program sustainability.6 SRCs in the United States tend to serve patients who are underserved, who have low incomes, and who are at high risk of inadequate management of serious medical problems, including chronic disease.7–9 Many educators view these programs as important contributors to both patient care and medical education5,6; however, the results of a 2009 review of the literature showed that little research has been published on the educational value, in terms of outcomes, of such endeavors.6 Medical educators must do more to document and quantify both the pedagogical and clinical benefits of these programs.5,6
In Asia, service learning is not as well established, and few data are available on the effects of the programs that do exist. Through our review of the literature (a PubMed search of the key words “service learning,” “medical education,” and “Asia”), we found only a limited number of reports on service learning in medical education across Asian countries. One of these publications reported that in Taiwan, community service programs exist in many schools, and that one such program, established in 1999, has been pivotal in equipping students with the ability to identify social issues.10 Other publications report community-based programs in Malaysia,11 India,12 and some of the Gulf states.13,14 The reports seem to indicate that Asian SRC programs differ from their U.S. counterparts in four areas. First, Asian programs have a strong home visit component. Whereas only 5% of the U.S. SRCs operated out of mobile units,5 all of the Asian programs our review uncovered revolved around home visits. One program even involved students living in their adopted community for a month.10 The second major difference is that whereas U.S. programs tend to focus on underserved communities, Asian programs have no such explicit focus. The third difference is that in Asia, faculty design and lead, with minimal or no student involvement, all of the programs, whereas in the United States students take on leadership and management roles. Finally, U.S. service learning programs and SRCs are able to provide a range of services for patients who have multiple diseases, whereas the Asian programs focus on specific areas (e.g., providing maternal and child health12 or effecting lifestyle changes13,14). Further, the majority of the reports on Asian programs we reviewed did not present data on students reflecting on their community experiences; hence, these community experiences might not fully qualify as service learning programs.
The lack of good literature on the feasibility of service learning in medical education outside of the United States may preclude more widespread adoption of service learning in an Asian context.15 As health disparities in Asia rise,16 service learning programs, such as SRCs, that focus on populations with low incomes would be of great value. Such programs would not only provide patients who are often underserved with needed care but would also equip doctors-to-be with the skills they need to care for such populations. However, more research is needed to examine the design and effectiveness of such programs, especially those that occur in a home-based setting.
We present the outcomes of a student-managed, home-based, service learning program focused on an underserved community that is run by an Asian medical school. We evaluated the learner-reported educational value of this service learning program for medical and nursing students, as well as the perceived value of this program as reported by patients. In so doing, we hope that our experiences will be useful in informing both existing and future service learning programs, both in Asia and the United States.
The Yong Loo Lin School of Medicine is an Asian undergraduate medical school in Singapore. As part of the National University of Singapore (NUS), it admits high school graduates into a five-year program. During the first two years, students take basic preclinical medical courses, while clinical exposure starts in the third year and continues through graduation to residency. In 2009, the NUS Medical Students' Society began to organize a voluntary service learning program. The program, known as the Neighborhood Health Screening (NHS), bridged an academic health center (the National University Health System) and a low-income community in Taman Jurong, a neighborhood in the western part of Singapore. The inspiration for this program came from the student organizing committee members' grassroots work with this low-income community, during which they perceived firsthand the health care challenges the residents face. The guiding principle of this program was to achieve a balance between service to patients and increased knowledge and skills for the students. The NHS program has taken place from January to June yearly since 2009. Similar to SRCs in the United States, NHS targets a population of patients with low incomes who are living in public housing. Unlike the majority of SRCs in the United States,5 NHS does not operate from a fixed location. Instead, NHS is home based, so students make door-to-door visits. The primary thrusts of NHS are multidisease health screening, chronic disease management, and follow-up care.
During three months, from January to March, students go door-to-door in teams on fortnightly visits to encourage patients to attain free health screening (provided either in the patient's home or at the community center, which is a two-minute walk away) for five major chronic diseases: (1) hypertension, (2) diabetes mellitus, (3) dyslipidemia, (4) colorectal cancer (fecal occult blood test), and (5) cervical cancer. During these door-to-door visits, which typically last 30 to 45 minutes each, students also—as necessary—conduct standard patient education (e.g., advising patients with diabetes on diet and exercise, medication compliance, and managing complications), refer patients to further health programs, provide social services consultations and/or referrals, assist patients with completing their health forms, test for visual acuity, provide smoking cessation advice, and conduct physical examinations. Volunteer physicians on-site (at the community center) provide supervision. Although physicians do not generally accompany the teams, students may request that a physician join them should they need assistance. Students reflect on their learning experience at debriefing sessions organized at the end of door-to-door visits.
Over the subsequent three months (from April to June), students make monthly home visits to selected patients who have medical issues such as poorly controlled chronic diseases (e.g., hypertension, diabetes mellitus, dyslipidemia) or whose health screening test results were abnormal. During these months, students help educate patients about their illnesses and facilitate their regular attendance at government public primary care clinics called polyclinics. The students manage these patients in partnership with the polyclinics by advising the patients on lifestyle changes and by monitoring patients' compliance with care plans.
Both medical and nursing students from the Yong Loo Lin School of Medicine take part in this program. Students are organized into teams for the door-to-door visits. Each team, of four to five, includes students with differing levels of clinical exposure—some preclinical students with no prior patient exposure and at least one clinical-year student. Each team also includes, when possible, a nursing student.
As with programs in the United States, NHS is many preclinical students' first encounter with patients. Hence, it not only offers a valuable opportunity to learn clinical skills but also provides a potentially formative experience that may shape their future career. Participation is voluntary, and 41% of first-year students (94 of 250) participate in NHS, a rate that is similar to the U.S. average of 39%.5 Having participated once, students may participate again in subsequent years.
Students—both medical and nursing students—also take primary responsibility for the administration of the program and stewardship of the funding sources, which amount to about U.S. $4,000 annually. An organizing committee of 15 student volunteers handles the logistical requirements of the program (e.g., purchasing consumables, organizing publicity, coordinating volunteers). These volunteers also manage the program funding (which includes contributions from the school, institutional donors, and individuals), and they work with faculty and community representatives from Taman Jurong to meet the educational and service objectives of the program.
Patients seen by students through the NHS program come from the lower socioeconomic strata of society. Most of them live in rented, one-room flats and survive on a household income of no more than U.S. $2,000/month. (To compare, the national median household income in Singapore was U.S. $3,900/month in 2008,17 and the national home ownership rate in Singapore is 90.1%.18)
To analyze the pedagogical value of NHS for students, we administered an anonymous questionnaire to all medical and nursing students who participated in NHS in 2010. We modified the questionnaire from the Fund for the Improvement of Postsecondary Education (FIPSE) Survey Instrument.19 In particular, we borrowed from the Ability Scale, which researchers previously used to assess the pedagogical value of a service learning program in Taiwan.10 Questions asked students to assess their self-perceived gains across nine domains: (1) leadership skills, (2) communication skills, (3) teamwork, (4) critical thinking skills, (5) the ability to identify social issues, (6) action skills (i.e., the abilities to take action and take on new responsibilities), (7) the ability to see consequences, (8) the acquisition of knowledge, and (9) the application of knowledge. Students answered all questions using a four-point, Likert-like scale (agree, unsure but tend to agree, unsure but tend to disagree, and disagree), but we collapsed responses into two categories (agree versus disagree) for analyses. We also included one question asking for an overall rating (of 0–10 where 0 = poor, 5 = neutral, and 10 = excellent) of the learning experience and one open-ended question asking students to describe their learning experience. We intended for this last question to provide context for or to illuminate the students' ratings of the nine domains of the FIPSE.
To assess patients' views of NHS, we interviewed the patients who participated in NHS 2010. We used a standardized list of questions to obtain both information on their sociodemographic backgrounds and their opinions on the quality of care that they received through the NHS program. For the latter, patients responded either “yes” or “no” to three questions: (1) “Has the NHS program improved your health?” (2) “Was the length of time students spent with you during the NHS program sufficient to address your health issues?” and (3) “Are you satisfied with the services provided by the NHS program?” Finally, to gain a more quantitative measure of the potential effect of the NHS program on patients' health, we tracked, over time, the awareness, treatment, and control of hypertension in patients who participated in the NHS program in 2009 and received follow-up care in 2010.
We obtained ethical approval from the NUS institutional review board to conduct the study to evaluate both the pedagogical and service value of NHS. Study participation for both the students and patients was entirely voluntary and anonymous. We took informed consent from both students and patients at the beginning of the NHS program in January 2010. Participation or refusal to participate in the study did not impact students' evaluations. Although we report the results only of NHS patients who consented to participate in the study, we also provided care through NHS to those who declined to participate in the study but were keen to participate in NHS. We did not provide incentives for completing the questionnaires. Both students and patients completed their respective questionnaires at the end of the NHS program in June 2010.
For all statistical analyses, we used Statistical Package for Social Sciences (SPSS, Version 17.0, Chicago, Illinois) and set significance at the conventional P < .05.
To analyze the pedagogical value of NHS for students, we computed descriptive statistics for the student participants. We used chi-square analysis to compare the self-reported learning in the nine domains between genders, between preclinical (first- and second-year) and clinical (third- and fourth-year) students, and between first- and second-year medical and nursing students. We used logistic regression to adjust for clinical exposure when comparing learning between genders and between nursing and medical students. We used the Mann–Whitney U test to compare the median overall rating of the NHS learning experience among groups. We performed thematic analysis of the students' qualitative descriptions of their learning experiences to extract quotations that contextualized students' ratings on the nine domains of the FIPSE.
To analyze the service value of NHS for patients, we computed descriptive statistics for the patients who participated in NHS in 2010. To compare the awareness, treatment, and control of hypertension within each cohort of patients seen in 2009 and 2010, we used the McNemar test to determine whether there were significant differences in the proportion of known patients with hypertension who sought treatment and/or controlled their blood pressure after one year of follow-up.
The majority of the students who participated in NHS in 2010 completed the survey instrument and consented to the study: 222 (93%) of the 240 medical students and all 34 of the nursing students completed the questionnaire. Table 1 details the profile of the student participants. The majority of the patients seen by NHS in 2010 completed the questionnaires and consented to the study. In 2009, 213 patients with low incomes were seen by students through the NHS program; in 2010, 209 of these patients received follow-up care, and only 4 (2%) were lost to follow-up. In addition, another 150 new patients were seen in 2010, resulting in a total of 359 patients in 2010. Of the 359 patients, 355 (99%) agreed to take part in the study. Table 2 reports the sociodemographic characteristics of the 355 NHS patients in 2010 and of the 209 patients seen previously in 2009.
The majority of medical students felt that NHS was beneficial across all nine FIPSE domains (Table 3). We noted significant differences across the nine domains by clinical exposure and gender. After adjusting for degree of clinical exposure, male students were significantly less likely than female students to report gains of knowledge in two domains: appreciating and identifying gaps and deficiencies in the health care system and improving knowledge of long-term management of chronic disease. After adjusting for gender, preclinical students were significantly more likely than clinical students to feel that NHS had helped them to gain knowledge in the following domains: comprehending the moral and ethical issues in health care, thinking about the future, thinking critically, taking on new responsibilities, gaining knowledge, and applying knowledge. Similarly, the majority of nursing students who participated felt that NHS helped them to improve and learn in all areas; 94% to 100% reported gains across all nine domains, except the ability to make a clinical diagnosis, for which 79% (27/34) reported gains (data not shown). The learning experiences of first- and second-year nursing students were very similar to those of medical students of equivalent experience; the only difference was that nursing students were more likely to report that their leadership skills improved (adjusted OR = 9.11, CI = 1.16–71.8, P = .036; data not shown).
Students reported a strong positive overall rating for NHS (median = 7 out of maximum of 10, interquartile range = 7–8), and we detected no differences in overall rating scores between genders, between preclinical and clinical students, or between medical and nursing students of equivalent experience. Table 4 provides representative quotations organized through thematic analysis to contextualize the students' ratings on the nine domains of the FIPSE. Medical students who participated gave examples of their gains in leadership, communication skills, teamwork, and in their abilities to see consequences, think critically, and identify social issues. They discussed their opportunities to take action and to gain and apply knowledge regarding community medicine in medically underserved settings. We did not do an analysis for nursing students because of the relatively small numbers.
The patients who participated in the program rated the service value of NHS highly. The 355 patients residing in the low-income neighborhood of Taman Jurong, Singapore, who were seen during the NHS program in 2010, were extremely satisfied with the services rendered. Most patients (266; 75%) agreed that their health improved as a result of the program, most (301; 85%) agreed that the length of time the students spent with them was sufficient to address their issues, and most (291; 82%) were satisfied with the services provided by NHS.
As NHS targets chronic disease management, we examined the longitudinal effectiveness of the program in managing a chronic disease, namely hypertension, among the patients with low income whom NHS served (Figure 1). In the cohort of 209 patients from 2009 who received follow-up care in 2010, 82 (57%) had previously (2008 or earlier) been told by a doctor that they had hypertension (“known hypertension”), whereas 61 (29%) of them were newly diagnosed with hypertension by a student in the NHS program in 2009. By 2010, treatment rates among the 82 patients with known hypertension increased significantly from 63% (52/82) to 93% (76/82) (P < .001), and blood pressure control among these same 82 patients improved significantly from 42% (22/52) to 79% (60/76) (P < .001; data not shown). However, of the 61 patients who were newly diagnosed with hypertension in the program, only 49% (30/61) of patients had achieved blood pressure control a year later. Over the course of the program, uptake of chronic disease screening also increased; participation rates for hypertension screening rose from 36% (77/215) to 99% (212/215); for diabetes mellitus screening, from 35% (98/280) to 40% (112/280); for dyslipidemia screening, from 26% (70/267) to 30% (81/267); and for colorectal cancer screening, from 6% (15/251) to 16% (41/251) (data not shown).
Discussion and Conclusions
NHS, a student-initiated service learning program that provides medical care to the underserved in a home-based setting, provided perceived educational benefits to the student participants and also achieved improvement, as measured by rates of treated blood pressure, in the health of the patients it served. These benefits and improvements were achieved at a reasonable cost (U.S. $4,000/year) and within a relatively short time frame (one year), suggesting that similar programs, if implemented in other Asian settings, may enjoy similar results.
With regard to the pedagogical value of NHS, student participants reported that NHS was effective in equipping them with the clinical competencies needed for practice in the community. The high degree of student involvement at all levels of this student-initiated project, from design to organization and implementation, enabled students to acquire not only skills that were useful in the patient encounter (e.g., communication skills)20 but also skills such as leadership and teamwork. We observed some differences in the learning experiences of medical students by gender and by degree of clinical exposure. The perceived educational value was higher for students without clinical exposure, a finding that is similar to those reported by many SRCs in the United States.21,22 However, these differences were expected, as it is well known that gender23–25 and degree of clinical exposure26,27 affect medical students' attributes and attitudes toward learning. In hindsight, although we did structure the teams to include a mixture of preclinical and clinical-year students, we could have structured the teams to ensure a balanced mix of genders as well. Nursing students found NHS particularly useful in providing opportunities for leadership. The nature of NHS as a student-run, joint partnership between nursing and medical students may have enhanced the opportunity for leadership and suggests that such interprofessional training is indeed useful.
The community also benefited, as demonstrated by the high degree of patient satisfaction with service that is comparable to some U.S. SRC programs.28 This satisfaction suggests that the U.S. concept of student-run clinics can be applied, with appropriate modifications to suit local context and needs, in Asian communities. One adaptation we made was the provision of medical services in the patient's home. Instead of working from a fixed location, undergraduate medical and nursing students provided door-to-door services for patients. Local considerations largely drove this adaptation. The densely built-up nature of highly urbanized Singapore made door-to-door service relatively feasible, and the high proportion of persons aged 60 years or older in the target community (compared with the general population [50%–60% versus 10%18]) meant that there was a large pool of patients with mobility issues—patients who would otherwise be underserved if the clinic did not come “to their doorstep.” Congested urban environments and poor elderly populations are not unique to Singapore. Many cities in many countries contend with concentrated populations of elderly poor with limited mobility. Thus, this concept of a student-run, home visit program is applicable to both other Asian and many non-Asian settings. Although service considerations drove us to bring medical students into patients' homes, this adaptation had an extremely positive impact on students' learning experience. By witnessing firsthand the patients' living environments and by interacting closely with the patients' families, students may have been better able to empathize with the plight of the poor via the “pedagogy of discomfort.”29 Some students continued to provide follow-up care to the patients whom they had seen during the course of NHS even after the program ended. Longitudinal relationships, such as those fostered by NHS, could offer doctors-to-be more insight into the ongoing plight of people living continuously in poverty than could a one-time meeting in the clinic.30,31 Further, this continuity of care has the potential to both provide a more comprehensive educational experience for the students and better clinical care for the patients.8
Our program chose to focus on chronic disease in order to fill a need. Singaporeans could not use their compulsory medical savings account for outpatient treatment of chronic disease until the recent (2006–2007) introduction of the Chronic Disease Management Program (CDMP), which covers treatment of diabetes, hypertension, and dyslipidemia at outpatient clinics.32 Even now, patients with low incomes in Singapore may face barriers in accessing the new CDMP, and the students organizing NHS sought to fill this potential gap. This experience is similar to the origins of SRCs in the United States, which lacks universal health insurance coverage: Many U.S. SRCs arose initially to assist people who were uninsured.4–6
NHS' focus on chronic disease was useful pedagogically because medical students provided follow-up care, allowing them to care for patients and their families over a period of time. Beyond the educational benefits of such an approach, however, NHS also achieved some degree of medical benefit in one area of chronic care. As illustrated by the improved rates of treatment for and control of blood pressure (the latter increasing from 27% to 73% in just one year [Figure 1]), NHS—although student-run and serving an underserved community—achieved good results in hypertension management when compared against government-run schemes such as the nationwide CDMP, whose estimates for controlled blood pressure control rose from 64% to 72% after a year's follow-up.33 Moreover, these results are similar to those of other studies demonstrating that reasonable estimates of goal blood pressure control are achievable in SRC settings.34 However, improving hypertension treatment and control in patients with newly diagnosed hypertension was much more difficult in NHS; perhaps more time is needed to witness results. As the burden of chronic disease is rising in other Asian countries,16 service learning programs focused on chronic disease can be useful in both teaching principles of managing chronic disease and providing medical care to those in need.
Our study has limitations. Because this program was established in 2009, we could not collect longitudinal data on longer-term pedagogical outcomes of this service learning program. Although participants might be more favorably inclined to care for the indigent, they might not maintain this inclination after graduation from medical school. Learning outcomes were self-reported and not objectively tested. However, the fact that evidence of educational gain was supported both by qualitative and quantitative data is encouraging. Participation was voluntary, so participating students were probably a self-selected group who were more likely to report a positive learning experience; however, a significant proportion of the first-year students (41%; 94/250; Table 1) participated in NHS, and we expect this proportion to continue in the years to come, given the strong support for the program from both faculty and students. Finally, although we measured and report some clinical outcomes, to accurately compare the quality of care provided at NHS against national programs is difficult because of a lack of data on the effectiveness of national interventions targeted at underserved groups in Singapore.
In summary, the student-run NHS is a powerful example of service learning that offers the potential to make an important contribution to patient care and medical teaching in Asia, where service learning is relatively underused. We hope that our positive experiences in adapting this concept to an underserved Asian community can serve as the catalyst for greater adoption of this idea, which, in turn, will hopefully help to reduce health disparities35 in the context of Asian societies. Future research could include the assessment of the impact of such student-run home visit programs in an Asian setting using more objective tools, such as clinical performance examinations, as well as the investigation of the impact of similar service learning projects on patients' long-term clinical outcomes. We hope that the lessons our NHS students learned will encourage them to continue to play a proactive role in serving the community after graduation, and that we have ignited in these future doctors the spirit of altruism and community service.36
The authors would like to thank the Neighborhood Health Screening Organizing Committee 2010 for supporting this study. They would like to acknowledge the following medical students for their contributions to organizing the Neighborhood Health Screening Program: Mr. Tan Chong Keat, Ms. Chiong Yee-Keow, and Mr. Yeo Wei Xin. The authors also extend their thanks to the National University Cancer Institute, Singapore; the Department of Epidemiology and Public Health, National University of Singapore; 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 to organize this program.
The National University Cancer Institute, Singapore; Southwest Community Development Council; and Taman Jurong Community Centre provided funding support for the purchasing of medical consumables and transport for volunteers.
The institutional review board of National University of Singapore granted ethical approval for this study.
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