Responding to change in a medical student rural community service: Insights from activity theory

Abstract

Introduction Medical students have voluntarily initiated service‐learning programmes with the aim of providing assistance to medically underserved communities, especially within remote indigenous villages. However, their values and goals have been challenged because rural health care demands have changed considerably since the introduction of integrated delivery system (IDS) programmes, that is, programmes that integrate local health care providers with outreach services provided by contracted hospitals. Our study aimed to explore how a health care service‐learning group negotiates its position and how it responds to the tension of IDS implementation and changes in rural health care demand. Methods Medical students who have been engaged in building or operating the health care service‐learning group of one university in Taiwan were invited to participate in the study. We used cultural–historical activity theory (CHAT) to help us interpret the interactions between students, indigenous communities and the public health sectors and to understand the evolution of the service‐learning relationship and its effectiveness. Results Eighteen participants were recruited for in‐depth interviews. The implementation of IDS programmes brought change to the rural community and challenges to students' service learning. Utilising cultural–historical activity theory, we highlighted points of fragmentation within the system. This tension lead to medical students' personal conflict and also served as an impetus for change and learning. Flexible goal setting and coping ability were considered critical to the sustainability and maintenance of students' value systems. Conclusions IDS implementation can upset the balance of rural health care supply and demand, resulting in accumulating tensions within and between activity systems. Those contradictions exposed medical students to an expansive learning cycle, resulting in transformational change and learning. Under the context of IDS programmes, health care service‐learning can create a ‘win‐win’ situation. Not merely medical students but also community residents gain benefits. This result may be extrapolated to health care service‐learning programmes with similar context.

Comparison of attitudes toward the medical student-led community health education service to support chronic disease self-management among students, faculty and patients

“…The educational value of CSL for medical undergraduates, the interest and availability of medical students in provision of individualized healthcare service were appreciated by most responding students, faculty members and patients; both teachers and medical students showed their agreement with the roles of CSL initiatives based on medical student-led community service to support chronic disease self-management in engaging students in active professional learning, social skill development, and professionalization process. These findings were in line with the known pedagogic advantages of CSL programmes [18,[23][24][25][26][27][28][29]. More importantly, some disparities were found to exist among the attitudes of three stakeholder groups, showing that students were more unaware of the current situation of community primary care; patients Table 4 Comparison of the students' and faculty members' attitudes on the possible educational benefits of the medical student-led community health education service to support chronic disease self-management (Mean ± SD) felt more uncertain of the support of higher medical education system for primary care practice and the students' competency, and were less interested in participating in the medical student-led community health service; and faculty were more appreciative of CSL and their own roles in CSL programs.…”

“…The participants were informed about the aims of this survey and the idea of CSL as an explanatory letter at the beginning of the questionnaire. The initial questionnaire items were developed by the research team based on existing literature about CSL [18,[23][24][25][26][27][28][29]. The clarity, content validity, relevance, and conciseness of the questionnaire items were appraised by 2 specialists in medical education external to the research team.…”

“…As an interactive learning tool in experiential education engaging students in human-centered service-learning activities to address community needs as well as develop students' professional value and knowledge, the community service learning (CSL) has achieved broad acceptance among medical schools and educators [18,[23][24][25][26][27][28]. So far, the positive educational effects of CSL have been demonstrated at all levels of learning for the cognitive, affective, and psychomotor domains [27].…”

Cultural historical activity and the complexity of health professions education

“…How then can we seek to form an understanding of the educational or other outcomes of such an initiative, and in a way that anticipates and accommodates the likely complexity? In their study in this issue of Medical Education, Hu et al have used Cultural Historical Activity Theory (CHAT) as the theoretical basis of their qualitative study to do just that 1 …”

“…In their study in this issue of Medical Education, Hu et al have used Cultural Historical Activity Theory (CHAT) as the theoretical basis of their qualitative study to do just that. 1 Life is messy. While we can set out with one intent, who knows where we will end up.…”