Implementing and Evaluating Risk Assessment as a New Learning Tool in Family Adoption Program: A Qualitative Study

Abstract

Background:

Training and engaging undergraduates in Family Adoption Program (FAP) is challenging due to increased visits, a large batch of students, limited resources, and less community cooperation. Routinely students are involved in history taking and community diagnosis. Risk assessment has the potential to be a part of the learning tool in FAP as it has not been utilized. To explore the perceptions of students, faculty, and villagers on risk assessment tool application in FAP and understand its challenges and suggest solutions.

Methodology:

Various risk-scoring scales and screening tests were introduced to the second-year students. It was a program development and evaluation design using qualitative techniques. By purposive sampling, focus group discussions were conducted with students, in-depth interviews obtained from villagers, and written feedback from the faculty. Data were collected till information saturation and manual thematic analysis was performed.

Results:

This method showed improved student knowledge and clinical skills, enhanced communication, health education, early case identification, and management. The impact on villagers was increased awareness, improved trust in community response, and positive behavior change. Faculty perceived it as an effective utilization of visit timings with educational benefits and engaged students as it is a task- and outcome-based learning. Challenges included limited resources, community mobilization, language barriers, and insufficient training. Adequate student training and preparedness, provision of learning resources, improved patient referrals, and follow-up care were the major solutions suggested.

Conclusion:

Adopting risk assessment tool learning in the FAP curriculum facilitates better student learning and engagement, along with improved community response and patient outcomes.

INTRODUCTION

As a part of the undergraduate medical education program, the National Medical Commission (NMC) introduced the Family Adoption Program (FAP) in 2022 to attain the competencies of an Indian medical graduate.[1] This has been implemented earlier by many medical colleges under different names of Family Health Advisory Services, Community-Based Medical Education (CBME), Reorientation of Medical Education (ROME) posting, and village adoption program.[2,3,4,5]

The FAP is an initiative for community-based teaching that involves the adoption of families by medical students, who work closely with them to identify and address their health needs. It provides students with valuable hands-on experience in community medicine, while also providing families in rural areas with access to quality healthcare services. In FAP, each student has to adopt five families and it will be followed up from the first professional year till the period of third year through regular designated family visits. Routinely students are involved in collecting health profiles and community diagnosis. The new curriculum has currently proposed 9 visits early in the course of the first year, from 6 to 10 visits in the second year followed by 5 to 7 visits in the third year.[1]

However, with an increased number of visits, a large batch of students, and limited resources for training, monitoring, and engaging undergraduates in FAP is challenging.[6,7,8] Moreover, as the number of family visits increases, students tend to lose interest and the assigned families are less cooperative as they perceive fewer benefits. To overcome the challenges and improve student involvement, various risk-scoring scales and screening tests were introduced to the second professional year, after considering the FAP objectives.

Notably, risk assessment (RA) tool learning is an important aspect of medical education and these tools can be used to evaluate a wide range of health risks, including those related to lifestyle factors, medical conditions, non-communicable diseases, and genetic predispositions.[9] They are highly effective in identifying individuals at risk, thereby facilitating timely diagnosis and intervention, and hence best suited for mass screening programs in the community. By incorporating risk assessment tools into practice, students can provide more effective and targeted interventions, improving the overall health outcomes of the families they serve.[10]

Even though a few studies have been reported on FAP, no study has been performed on the risk assessment approach in FAP. Henceforth, we explored whether risk assessment tools can be effectively utilized as a teaching tool for undergraduates in the community setting of FAP and provide suggestions.

METHODS

The Department of Community Medicine, Sri Manakula Vinayagar Medical College from Puducherry has been running CBME since 2011 for undergraduate medical students. Currently, as per the NMC recommendations, the curriculum has been reshaped into FAP.[3] After the introduction of FAP, the RA model was implemented for 1 year. We conducted the present study with phase II, 150 batch MBBS medical undergraduates, post-graduates, and faculty members of the community medicine department, after obtaining Institutional Ethics Committee approval. It consisted of program development and evaluation design, using in-depth qualitative techniques conducted for a period of 2 months from June to July 2023.[11]

The flowchart [Figure 1] depicting the process of integration of FAP into the curriculum is described below.

Figure 1.

Integration of FAP into the curriculum

Development and Implementation of FAP in the first-year curriculum

The family adoption program was designed to include six full-day visits during the initial phase of the professional year, followed by half-day visits in the subsequent phases. These visits aimed to provide regular exposure to community-based teaching throughout the medical curriculum.

As a novice, initial visits primarily focused on establishing rapport with the family and conducting interviews to gather information about their family profile, environmental factors, personal hygiene, and addictions. Then, the subsequent visits were planned to emphasize nutrition topics such as the usage of salt, sugar, and oil, along with conducting a diet survey (raw food weighing method and 24-h recall method). Students gained insight into community nutrition and dietary habits, which enabled them to develop diet recommendations based on deficits, locally available fruits, and vegetables in alignment with cultural practices. Transect walks and environmental protection initiatives such as plant sapling including cleanliness drives were organized to create awareness and better understand the rural community.

Development and Implementation of Risk Assessment Tool in Second-year Curriculum

In the second professional year, apart from collecting history, students are expected to conduct clinical examinations, organize health camps, maintain communication to follow up with the families and help to improve the status of health of family members of allotted families. Consequently, considering the FAP objectives, we implemented the risk assessment tool to engage the students in FAP. Various risk-scoring scales were introduced such as the healthy lifestyle STEPS questionnaire, Indian Diabetic Risk Score, NCD risk assessment score, CVD risk prediction score, and screening for hearing and vision[12,13,14,15] [Figure 2]. The risk assessment tools were selected based on validity and reliability, and questionnaires were modified to the Indian context. It created a sense of responsibility among students as doctors and led to enthusiastic family follow-ups. Furthermore, the integration of risk assessment scales with screenings, clinical examinations, diagnostic tests, and mobile camps increased willingness among family members to share information. This comprehensive approach benefited the families and also ensured better cooperation, as it moved beyond mere data-gathering activities to tests that directly benefit them. As a result, the assessments became more objective and effective.

Figure 2.

Roadmap to risk assessment tools for the visits

The following TRI-ReFF steps [Figure 3] that were used in the process of implementation of RA in the FAP curriculum are described below

Figure 3.

TRIReFF strategy in the implementation of risk assessment in the FAP curriculum

1. Training:

   On the day of visits, an initial briefing was conducted by a trained faculty, followed by a practical demonstration on how to conduct the survey. The hearing, vision, and NCD screening training program was carried out collaboratively with other departments, such as ENT, Ophthalmology, and Medicine, involving them in training students in respective clinical examination skills. The students were trained in a survey questionnaire, created in the Epi Collect application, and instructed to record the final output in the FAP record. They practiced the assessment and screening of peers for 20 min and filled out the survey form, during which their queries were clarified. By the time the students reached their assigned villages, they were familiar with the risk-scoring scale, even the bus journey served as an opportunity to acquaint themselves with it.

2. Risk Assessment in Community:

   Under the supervision of mentors, the students conducted the risk assessment for the adults in the community using a screening questionnaire and the necessary equipment. The team comprising faculty, postgraduates, interns, and medical social workers ensured the quality and the consistency of data collection. Mentors monitored and checked the data collection in Epi Collect simultaneously, providing appropriate feedback to the students.

3. Identification of at-risk individuals:

   In the first round of second-year community medicine clinical posting, the students were trained to analyze the data entered in Epi Collect and presented their findings, gaining insights into community diagnosis and statistics. A part of the second-round clinical posting was focused on completing the family risk assessments. Students identified the at-risk individuals, risk factors, socio-cultural, and clinical issues through self-directed learning and proposed solutions, formulating management plans with faculty guidance and seeking specialist’s opinions.

4. Referral services and management:

   For the referral patients, follow-up services and medical camps were organized within the community. Individuals with high-risk scores were directed to confirmatory tests and services. Students accompanied the family members to the mobile camps and learned about their health conditions. Patients diagnosed with cataracts were referred to the ophthalmology department for surgery. These patients were regarded as community camp beneficiaries and were provided with free surgery, including transportation. High-risk and newly diagnosed diabetic patients were referred to the NCD clinic. Subsequent follow-up visits were scheduled for specialist consultations at our nearby rural health training center and medical college.

5. Follow-up and Health Education:

   For post-risk factor assessment and solution identification, students shared their findings during family presentations in clinical postings, with faculty providing additional inputs for improved management. Subsequently, they were briefed on creating health education materials using the PATH guidelines.[16] The students prepared chart-based health education materials addressing the families’ key issues, which were evaluated using a checklist, and improved based on the feedback. These materials were used to educate their adopted families on preventive aspects in subsequent visits. A field-level observation checklist was used to assess their communication skills.

6. Feedback (Qualitative study design)

   To measure the effectiveness of Risk Assessment tool learning in medical education, a qualitative inquiry was made. We developed a comprehensive systematic interview guide with open-ended questions about various aspects of learning experiences, impact, benefits, and challenges faced in risk assessment learning, and proposed solutions for better improvement. Five focus group discussions were held with 40 students using purposive sampling to understand their learning uptake. We also conducted in-depth interviews with 12 villagers who were part of the FAP to gain their perspectives.[17,18] Two investigators trained in qualitative research conducted the interviews until information saturation.[19] To further enrich the evaluation process, written feedback was collected from the faculty (5) and postgraduates (4) who were involved in the program as mentors and facilitators. After obtaining informed consent and ensuring confidentiality, the interviews were audio-recorded using a mobile phone. Field notes were taken simultaneously during the interview. All the interviews were conducted at a convenient time and place for the participants, each lasting about 15 to 20 min. To ensure accuracy, participant validation was carried out through debriefing after each interview. The transcripts were translated into verbatim on the same day of the interview. Two of the authors analyzed the data and resolved any discrepancies through discussions and reaching a consensus.

Analysis of qualitative data

A manual descriptive thematic analysis was conducted.[19] The transcripts were read repeatedly and the codes were deducted. Similar codes were merged and grouped into categories under the broad themes. The COREQ guidelines were followed for reporting the study findings.[20]

Thus, by the end of second-year visits, students had an orientation about the evolving health and disease dynamics in their assigned families. They documented the health trends, action plans, and follow-up notes in the record book, gaining insights into lifestyle and environmental modification, levels of prevention, and modes of intervention. Moreover, the reinforcement of teaching students to value empathy and helping them to understand the link between risk factors and disease strengthens their ability to appreciate the intricate web of causation. Thus, the RA was integrated into the continuum of care in FAP training.

RESULTS

The village had a total population of 3,186 and students screened an average of 840 individuals during each visit. The participant’s perspectives on the risk assessment approach in FAP, which were explored on the themes of student learning, perception of villagers, benefits [Table 1], challenges, and solutions [Table 2] are described below. The action plan was prepared based on the solutions suggested by the participants for effective implementation of the RA model in FAP. The statements in italics are directly verbatim from the participants.

Table 1.

Perception of students and faculty on benefits attained to risk approach in FAP

Student’s perspectives	Faculty perspectives
Improved knowledge and clinical skills    •Able to identify risk factors and the web of causation for disease    •Learned about preventive aspects and public health    •Felt more confident in screening procedures and clinical skills	Effectiveness    •Easy, simple, convenient, and mobile based    •Benefit students and the community    •Effective utilization of visit time    •Engage student involvement as it is task and outcome-oriented    •Students interested to know the final score/outcome    •Scoring system, easy and understandable
Enhanced communication    •Gained community trust    •Able to give health education	Integration with curriculum    •Early clinical exposure in the community setting    •Improved practical knowledge    •Valuable teaching tool to screen common conditions & NCDs in the community    •Helps to search and formulate a management plan (SDL)
Early case identification and management    •Identified new cases    •Able to do appropriate referrals and follow-up	Enhanced accuracy    •More accurate results as standard tools were used    •Observer bias eliminated, using standard risk scores    •Students identified high-risk individuals and provided targeted intervention
Behavioral change:    • People willing to change their health behavior    • Led to community discussion on risk factors    • People are opening up and responding more to RA screening	Community benefits    • More people were screened    • Increased awareness of NCDs and their risk factors    • Early diagnosis and timely intervention reduce health cost    • Confirmatory tests needed only on high-risk individuals

Table 2.

Challenges faced and solutions offered by participants in risk assessment of FAP

Challenges

Solutions

Logistics    • Instruments shortage    • Prolonged waiting time for screening tests.    • Confirmatory tests were difficult due to limited resources Community mobilization and acceptance    • Convincing people for screening is difficult    • Reluctant to get screened without drugs and from young medical students    • People had difficulty accepting high-risk scores in RA    • Family members not following health advice provided by students Communication barrier    • Difficulty in understanding local terms    • Language issues    • Family members deviating from the topic    • Difficult to gain family member’s trust Skill and Training    • Field-level difficulties in screening and measurement    • Lack of confidence in performing RA    • Inability to address other health-related queries    • Poor knowledge of students on the importance of RA

Training and preparedness    • RA questionnaire in local language    • Small group demonstration in the field    • Hands-on training by specialist experts    • Training in communication skills and local terms    • Demonstration videos Provision of learning resources    • Diet chart on local food habits, health education material on preventive aspects, and approach to NCD management in primary care Improved logistics    • Increase equipment and manpower    • Mobile camps on all days of FAP visit Improve screening and follow-up care    • Specialist camp along with respective RA.    • Provision of free essential drugs    • Connection link in the hospital between the community and students    • Mop-up visits    • Follow-up of high-risk individuals    • Evaluation for other common health conditions    • Referrals need to be documented and followed up    • Needs to focus on confirmatory tests after screening

Student’s Learning on Risk Assessment Tool in FAP

The RA tools in FAP facilitated experiential learning for students covering all domains of learning including knowledge, practical skills, communication, attitude, ethics, and understanding of cultural factors of people. These tools provided an opportunity for medical students to understand risk factors, and gain hands-on experience, knowledge, and confidence in community healthcare. They bridged the gap between theory and practice, enabling students to apply their theoretical knowledge in real-life situations. It paved for ethical considerations in providing healthcare services to families in a community setting, emphasizing the importance of consent, and non-judgmental behavior. Students enhanced their communication skills, encouraged community participation in screening, and learned local terminology.

“In the first year, I thought like I have not even spoken to all my batchmates, then how will I talk to the villagers? But now in the second year, I wonder how I mingle with them and have the potential to convince them to screening tests.”

“In the first year, we just asked questions and collected the history. Now with the application of risk assessment questionnaires and screening tests, I was able to explain the medical terms in layman’s language to make them understand.”

Perception of villagers on risk assessment in FAP

The villagers felt happy about the student’s visits and reported that the risk assessments were beneficial. They gained better knowledge and became more aware of risk factors, health issues, disease complications, and normal cut-off values for diabetes and hypertension. The program promoted diabetes control, regular check-ups, and screening intervals. The villagers made attempts at positive lifestyle changes, adhered to dietary advice, altered food habits, started exercising regularly, and avoided junk foods. They received effective health education on nutritious food, diabetic diet, salt and oil restriction, physical activity, lifestyle modification, and personal hygiene. They perceived increased healthcare access, including screenings, free medications, investigations, treatment for NCDs, and easy access to elderly home care. This resulted in improved health outcomes such as better drug compliance, diabetes symptom improvement, and controlled sugar levels. Follow-up care was provided at subsequent visits.

“It was helpful, as we don’t do regular health check-ups.”

“We are happy to know that how doctors care for our health, coming to our doorstep.”

DISCUSSION

The present study aimed to explore whether screening communities using risk assessment scales can be an effective teaching-learning strategy in FAP to benefit both students and adopted families, as perceived by various stakeholders.

As evidenced in our study, early exposure to medical practice allows students to strengthen their learning more applicable. Studies have shown task-based teaching model in the community improves students’ knowledge and enhances practical skills.[21] Further FAP provides an opportunity for communication skill training throughout the curriculum as it involves longitudinal follow-up of families in the community settings. Noteworthy, communication skills can be developed not only by history taking but can be acquired by practicing clinical skills and counseling people in the community.[22]

Similar to the findings in our study, the risk assessment tool was more effective in motivating high-risk individuals for lifestyle modification to reduce the disease risk.[23] It was doubtful that families gained benefits from young students with basic health education.[6] However, community-directed health programs increase access to healthcare, promote healthy behavior and favor improved health outcomes to achieve universal health coverage.[24]

Student involvement and families support during visits has been a daunting task in the effective implementation of FAP.[25] In previous studies, some family members were very cooperative and willing to provide information about their health problems, but some members were not willing, which was a challenge to the students.[26] In our study, we found RA tool learning provided the opportunity for efficient use of time during FAP visits and promoted student participation as it is focused on tasks and results. It has an increased community response as family members perceive the benefits of RA screening.

There are several other potential challenges to incorporate RA tool learning into the FAP curriculum. One challenge is ensuring that students have access to the necessary resources and support to effectively learn and apply these tools. Similar challenges were reported in the previous studies where lack of transportation and logistics was the primary issue. Increased workload and lesser number of faculty were also a matter of concern.[6,25,27] It may require investment in training materials, equipment, and other resources, as well as ongoing support from faculty and staff for its long-term sustainability.[28]

Encouragingly, this study has given supporting evidence to use a risk assessment scale as a practical teaching tool for students training in FAP. But the limitation is, that it has been implemented with the current batch of medical students and requires ongoing evaluation of future batches. Henceforth, monitoring and long-term follow-up is crucial to ascertain whether the risk assessment tool is engaging students over routine assessment in a community FAP. As the data were collected from students of a single medical college in Puducherry, the generalizability is limited. Further multicentric studies can be conducted using risk assessment tools to identify the benefits to the community. More health trajectory-based research is needed to assess the extent of the benefits of FAP to rural communities and the effectiveness of FAP intervention.

CONCLUSION

Integrating risk assessment tool learning into the FAP curriculum improves student engagement and learning. Screening the majority of adults in the adopted villages and targeting high-risk groups, enhances community response and improves patient outcomes in community settings. By addressing the challenges such as limited resources, community mobilization, and communication barriers, the RA tool can be a valuable assessment tool in FAP.

Recommendations

Adequate student training and preparedness with the provision of learning resources, along with improved patient referrals, and follow-up care were identified as key components, and are required for the successful implementation. It is also recommended to advocate for the mobilization of funds through government initiatives, NGOs, and public-private partnerships to enhance the availability of resources for screening camps.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.