Family Adoption Programme for Medical Undergraduates in India – The Way Ahead: A Qualitative Exploration of Stakeholders’ Perceptions

Abstract

Introduction:

Community engagement in medical education gives the students an insight into the living conditions of the public and how they influence their health. Community Medicine departments accomplish this through field practice and family health studies. The Family Adoption Programme, newly mandated for all medical undergraduate students, brings its own set of challenges and opportunities. The study aims to understand the perceptions of various stakeholders regarding this program.

Material and Methods:

A qualitative exploratory study was conducted. The faculty, undergraduate and postgraduate students, and field workers were purposively invited to participate. Thematic analysis was done on qualitative inputs obtained by Key Informant Interviews and Focussed Group Discussions.

Results:

The participants felt that FAP will provide a good insight into the patient’s living conditions and also motivate the students for the kind of career they have to prepare for. The major challenges were the lack of transport and logistics in government colleges and the faculty shortage in private colleges. There was a difference of opinion regarding the right time to initiate the student into FAP. Gaining the trust and cooperation of the family and reducing the expectations were also felt important. While more field involvement by faculty was advocated, increased workload and reduced faculty requirement specifications were a matter of concern.

Conclusion:

While there was mixed response regarding the utility and long-term sustainability of FAP, it was hoped that with proper motivation and supervision, this program can create a significant difference in medical education and also the lives of adopted families.

INTRODUCTION

Community engagement gives medical students a first-hand experience of the living conditions of the people they encounter as patients in the hospital. The students also understand how various determinants of health influence patients in real life.[1] The specialty of Community Medicine serves the dual purpose of benefitting the medical students, as well as the community which the institution has adopted.

The Re-orientation of Medical Education (ROME) program, though largely discontinued, is still followed by a few institutions. Such successful models make the public active stakeholders, rather than limiting it to a charity activity.[2,3]

The National Medical Commission (NMC) has mandated Family Adoption Programme (FAP) for MBBS students from 2022. Every student is to be allotted at least five families. The student is expected to establish rapport, understand their health and related factors, and help improve the healthcare of the family, and by extension, the community. Thus it is expected to help in achieving Universal Health Coverage.[4,5]

FAP brings its challenges and opportunities. It is a very challenging task to implement this program by allotting families to each student and sustaining the follow-up throughout the undergraduate period. It is imperative to get feedback in the initial stages of implementation. The community outreach practices in select institutions were evaluated and published. But there is a paucity of data on the challenges in the implementation of FAP specifically. Hence this study aimed to understand the perceptions of various stakeholders regarding FAP and identify various challenges and opportunities.

PARTICIPANTS AND METHODS

This qualitative study, undertaken in May–June 2022, involves Faculty members, undergraduates, postgraduates, and medico-social workers (MSWs) in various colleges across Andhra Pradesh. Willing participants were purposively included. Potential participants, who were identified by the authors as vocal and outspoken and likely to contribute to the study objectives were approached. The participants who agreed to be part of the study were included. The initial number of participants was not fixed. The authors kept on approaching and including participants till data saturation was reached. The inputs were obtained through Key Informant Interviews (KIIs) for faculty and MSWs and Focused Group Discussions (FGDs) for students. KII/FGD: The KIIs were conducted in person or through telephone as per feasibility. The FGDs were conducted in person. The KII/FGDs were recorded throughout. After the recording was started, the need for the study was once again explained. The participants were assured that this study is to understand their perception of what the stakeholders feel. This has no relevance to them individually or their institution. Their consent for recording was verbally specifically obtained during the recording itself. They were also informed on record of their right to drop out of the KII/FGD at any point. The KII/FGDs were conducted based on a loosely developed guide, and newer inputs were probed. Data was collected till saturation was reached.[6] The KII/FGDs were conducted by Author 1, supported by Authors 4, 5, and 6. The recordings of KIIs and FGDs were transcribed in total. All the lines or parts of lines contributing to the research question were marked as codes. The codes were then categorized under various themes. In addition to the three basic themes in the FGD/KII guide, new themes were also generated based on the codes. The coding and thematic analysis were done manually. Coding and thematic analysis were done separately by two different authors trained in qualitative research. The agreement was reached on 90% of the codes. For the representational purpose, a Forced Field Analysis was made with inputs for and against FAP, as shown in Table 1. The study was undertaken after obtaining clearance from the Institutional Ethics Committee (ASRAMS BHR-EC/Approval No. 30/2022). The recordings of the KII/FGDs were kept as soft copies in the custody of the Principal Investigator. They were labeled using reversible coding. The same code was used for the transcriptions of the recordings. Care was also taken not to bring any individual/institutional identification during the KII/FGDs.

Table 1.

Force Field Analysis with 22 Faculty Members Regarding FAP

Inputs favoring FAP	n (%)	Inputs against FAP	n (%)
Provides a long-term, holistic insight into the health of the family	10 (45.4)	Lack of transport and supportive staff	14 (63.6)
Understand the public perception of health	8 (36.3)	Shortage of faculty in private colleges	10 (45.4)
Creates relevance and interest for academics	5 (22.7)	No clarity over timing and scheduling	7 (31.8)
Opportunity to focus on “health” rather than “disease”	5 (22.7)	Overburden of faculty with other programs	5 (22.7)
Early Community Exposure	4 (18.1)	Too early for first-year students; risk of losing confidence and relevance	4 (18.1)
Long-term, full-fledged extension of Family Health Study	4 (18.1)	Getting overly attached and vulnerable to manipulation	3 (13.6)
More scope for interaction compared towards	4 (18.1)	Over expectations from family	3 (13.6)
Opportunity to form long-lasting bonds with the families	3 (13.6)	The reluctance of faculty to go into the field	3 (13.6)
The right time to create the impression in students’ minds	3 (13.6)	Too many new initiatives at once by NMC	2 (9.1)
New catchment area for hospitals	2 (9.1)	The student strength is very high compared to reputed institutes running this program earlier	2 (9.1)

RESULTS

A total of 22 faculty members, three MSWs, 19 undergraduates, and five postgraduates participated in this study. These participants were drawn from 12 medical colleges (six government and six private colleges) in Andhra Pradesh. Twelve faculty participants were from government colleges and ten were from private. The faculty comprised seven Professors (including four Heads of Departments), six Associate Professors, and nine Assistant Professors. Five faculty members declined to participate due to various reasons. The participants in FGDs ranged from 6-8. None of the participants dropped out during KII/FGD. A total of 25 KIIs and four FGDs were conducted. The duration of KIIs ranged from 14:35 minutes to 32:20 minutes. The FGDs duration ranged from 26:30 minutes to 44 minutes.

Themes

Initially, the FGD/KII guide was prepared loosely based on the following themes:

• Advantages of FAP

• Challenges of FAP

• Measures to Improve FAP

In addition to the above, during data analysis, the following themes were generated:

• Acceptance of the students by the family

• Role and readiness of faculty

• The ideal time to initiate FAP

• Policy decisions regarding FAP

In reporting thematic analysis, the legends used for F (Faculty), UG (undergraduate), PG (postgraduate), and MSW (MSW).

Theme 1: Advantages of Family Adoption Programme:

The participants felt that FAP will have a positive impact on medical education in several ways.

1. Useful to students of affluent classes, as they have no idea about patients’ backgrounds.– F2

2. The student thinks about how best he can help them, in their context within their constraints – F14

3. Spirit of doing something for the people and the country… will motivate – F6

4. Rather than just learning what are important topics for the exam, we will know what are important health problems– UG3

5. A lot of misconceptions about health among the general public. How much they are relevant…how they affect health…we see now – UG 9

6. Hospital communication is controlled by a doctor… very tense. Only the most important things are spoken. Here, the family can talk about anything with us, even gossip about neighbors’ health. – UG 16

   Other participants were doubtful whether FAP will be useful, especially for families.

7. Benefits the student, but little to the family, since the students have very limited knowledge. I don’t think it helps the community or in attaining UHC – F12

8. If the family already has a trusted doctor, they won’t bother about the medical student. – F2

9. Healthcare coverage has exponentially increased now. Everyone knows some doctor. –F1

   This was also seen as an opportunity to set a new trend in our healthcare system.

10. Will bring back the family doctor system. instead of running to specialists – F14

Theme 2: Limitations of FAP:

The biggest limitation expressed by participants was the shortage of logistics.

1. No bus to take them to nearby Anganwadi only, how to take to another village – F7

2. We have one – two buses, but can’t take 250 students – F2

   Shortage of human resources is highlighted by the participants.

3. NMC reduced faculty requirements but increased duties and responsibilities. Already burdened by SDLs, SGDs – F11

4. Enough faculty, but no MSWs and Health Educators. They are important in engaging – F13

   Other logistic issues were also explored regarding the implementation of the program

5. Can students come back, have lunch and attend a 2 PM class? In such a hurry, not enough quality time in the field – F3

6. If extended to a full day, the issue is lunch, toilets, and place to gather - F2

7. Can villages handle 250 MBBS students roaming around? – F13

8. If done in batches, our academics are definitely affected – UG 6

   Another concern flagged by the participants is any form of harm to or bad influence on the students by the families.

9. Very challenging. The consequences… can’t say. At this age, they don’t know. Get involved passionately – F12

10. Misuse of personal information, numbers, and pics of students – F14

11. Outside students can’t speak Telugu, forget talking with village people. – F18

Theme 3: Right time for initiation into FAP

This theme, which inadvertently cropped up in the course of interviews, was the most polarizing topic.

1. In the first year, the student has no knowledge, fresh from Inter (10 + 2). If we send him into the field, he will not be able to manage. – F12

2. He should feel like a doctor, then only he can command the public. If he goes to learn, then no use – F16

3. In the first year, don’t leave him on his own. He will be cornered and misguided. It is like sending an NSS cadet to war. – F14

4. We can start from the third semester, with Family Health Study and continue it till internship – F8

   However, an equal number of participants felt the first year is the right time to initiate the students into FAP.

5. The right time to create the first impression – that this is what you have to deal with your entire life – F7

6. We all wondered why we are studying this artery or doing that experiment. FAP will make it relevant – F7

7. In CBME, Early Clinical Exposure is from the first year itself. So why can’t we have Early Community Exposure – F22

8. Not much difference. Today, many interns can’t tell Metformin dose. But now 1^st years will. – F15

Theme 4: Acceptance of students by the families:

The participants were hopeful that the students will be accepted by the families.

1. Not in a single visit. Gradually acclimatized. Every time he goes talks and helps, the more confidence he wins – F7

2. After 1–2 months, they will easily open up. Age difference will help. – F6

3. Depends on his crowd-pulling nature. Anyway, people skills will decide how successful he will be. It begins here – F7

   Some participants felt that unless the families feel the students are adding some benefit, they will be vexed soon.

4. Simply going every time and taking their details, they will get frustrated, and stop cooperating. –F12

5. These people should go and engage them and talk to them, not just take details like census people every time. – MSW2.

   Another aspect of acceptance is what the families expect from the students

6. Mere health education is not enough. People don’t expect doctors to talk about drains and waterlogging. Sanitation people should. -PG2

7. ASHAs and ANMs can’t give a holistic approach. Mostly centered on MCH… or now COVID. Our students are better. –F7

8. If anyone shows us attention and concern, we like it. Human nature. So they will be okay. –PG2

9. Too many expectations. Treat the disease then and there for free… accompany in hospital, collect reports, jump queues, no limit – F8

   Some participants who have experimented with such ideas in the past were optimistic about acceptance.

10. Many years ago, I asked our students to follow up with their Family Health Study families till the internship. They connected very well. – F22

11. In UG, we followed up with the family till the internship. Became so close, even invited us for functions… – F12

    The experiences of the students enrolled in FAP reflected the hopes and concerns of the faculty

12. The family allotted to me was warm and cordial, comfortable– UG2

13. Only one old lady in my family. Getting emotional frequently. But nice to me. – UG7

14. In my family, there is a nurse and ASHA. They get irritated and speak all medical terms. I felt inadequate and embarrassed. – UG8

Theme 5: Role and Readiness of the Faculty in FAP

The participants discussed issues like time and manpower shortage as impeding the participation of faculty in FAP

1. Many duties like CBME, MET, CISP, NAAC, NABH, NSS, and NMC. Continuous inspections. All are dumped on para-clinics people only. Now another added work. – F4

2. Each faculty should monitor 25 students. Where are the ten faculty? Even then, one should monitor 125 families. That too for one batch. – F21

   Some participants found wanting the enthusiasm and commitment on part of the faculty.

3. The rapport should be built by the faculty. It’s missing in medical colleges. We confine to classroom teaching. Don’t want to go into the sun. If we are not interested, PGs also won’t be interested. – F11

4. At the department level, there is little resistance. But it can be taken care of. – F10

5. Today’s youngsters in Community Medicine had very little field exposure. So they resist having to go to the field. – F22

Theme 6: Measures to make FAP more effective

The participants suggested several measures that can be taken to make FAP more effective

1. Bring management on board for logistics. Convince that we get new patient-feeder areas. – F2

2. Thorough planning at the beginning. for this and the next five years – F4

3. Orientation is needed for 1–2 days. On how to engage with them – UG 2

4. Should clarify they’re first-year students, not doctors. Lower the expectations – F7

5. Proper evaluation and grading. Otherwise many will go and do timepass – F9

6. Follow-up presentations on experiences and problem-solving; and periodic inter-college discussions – F4

7. Plan active health interventions like alcohol de-addiction – F13

8. Tertiary care follow-up in the hospital is a must. Otherwise, they will lose trust in no time. – F7

Theme 7: Policy-making regarding Family Adoption Programme

The participants also offered insight into the decision-making regarding FAP

1. CBME started three years ago. Two were gone in COVID. Let one batch complete it properly, before starting new programs. – F18

2. The reforms should be gradual and sustained. Not initiated in a hurry – F22

3. Why only villages. Some cities are so urbanized, no village for 40km. – F22

4. There should be some flexibility to maintain the quality. The number of families, days, hours, and location.should be left to colleges. – F20

DISCUSSION

The experiences of several medical colleges in community engagement can show the right direction.

The deep-rooted community engagement programs in some institutions were evaluated.[2,3] Similar to the present study, they also voiced concerns about cooperation from the public and adjustment to the academic schedule.[7] The biggest motivating factor was spending time in the field and interacting with the general public.

The expectations of faculty and support staff addressed in this study were similar to those identified earlier.[8] They included concerns regarding logistics and career growth.

Other medical colleges have recently started their own community-orientated medical education programs and have reported positive outcomes.[9-11]

Patient satisfaction in rural health training centers was limited.[12] This program may improve satisfaction. Institutions with deep-rooted community outreach could sustain their service delivery even during the lockdown and ensure uninterrupted care and compliance.[13]

CONCLUSIONS

As with any new initiative, FAP throws multiple challenges to medical colleges. Transport in government colleges and faculty shortage in private colleges were among the biggest impediments. Various issues arising at different levels should be properly addressed. This will motivate the stakeholders to sustain this program more effectively.

Recommendations

Proper planning in community engagement and allotment of families

Address the gaps in logistical issues and scheduling of academics

More commitment on part of faculty and support staff

Operational autonomy for medical colleges

Gradual and sustained reforms in medical education

General Out-Patient Division managed by Community Medicine coordinates these families visiting the hospital, which is already running successfully in some premier institutes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.