Overcoming Challenges and Ensuring Effective Implementation of the Family Adoption Program: An Administrator’s Commentary

Abstract

The National Medical Commission, through its Undergraduate Medical Education Board, included “Family Adoption Program” in the undergraduate medical education curriculum. The aim is to provide learning opportunities to medical graduates toward community-based health care and, thereby, enhance equity in health care. The methodology encompasses assigning roles and responsibilities, real-time monitoring by the administrators, and sensitizing various workers involved in the implementation of the program. In the process, the administrators developed a “stakeholder convergence framework.” Through concrete actions under the framework, the external stakeholders have been assured of the mutually beneficial character of the program in producing humane, community (rural), and individual-centric medical practitioners. The implementation of the first batch was in 2021, followed by two more batches, and as of the date, 750 students are under the fold of the program. The students from their presentations, it can be confidently believed that, by the time they complete the program, the students will be groomed to function as holistic health care professionals. Implementation of FAP requires meticulous planning, cooperation, and coordination among various stakeholders. For which an effective stakeholder engagement template must be in place, which should be fine-tuned based on feedback.

INTRODUCTION

The National Education Policy 2020 puts greater emphasis on providing undergraduate medical students with opportunities to get hands-on and on-the-field exposure to community medicine and preventive health care.[1] Accordingly, the National Medical Commission, through its Undergraduate Medical Education Board, included “Family Adoption Program” in the undergraduate medical education curriculum. As per the guidelines of NMC, each student has to be assigned to five rural families, and they should monitor the family’s health status and provide necessary professional help and advice whenever required for a period of 3 years.[2] Preferably, from the first year itself, the chosen villages should not be covered under PHCs adopted by the respective medical colleges. The student is tasked with building rapport, comprehending the health of individuals and the factors influencing it, and contributing to the enhancement of healthcare for the family, consequently benefiting the wider community. This is anticipated to contribute toward the attainment of Universal Health Coverage.[3] Participating in community engagement activities provides medical students with direct exposure to the living conditions of individuals they encounter as patients in hospitals. Through these experiences, students gain insight into how different factors affecting health impact patients in their everyday lives.[4]

STATED OBJECTIVES

During the medical UG training program, the learner should be able to:

• Orient the learner toward primary health care.

• Create health-related awareness within the community.

• Function as the first point of contact for any health issues within the community.

• Act as a conduit between the population and health care facilities.

• Generate and analyze related data for improving health outcomes and evidence-based clinical practices.

The aim of the FAP is to provide experiential learning opportunities to medical graduates toward community-based health care, thereby enhancing equity in health care.

The Department of Community Medicine at SRM Medical College Hospital and Research Centre

As per NMC norms, the Department of Community Medicine of the respective college is bestowed with the task of implementing the “Family Adoption Program.” Our department has been pioneering the process of providing medical undergraduate students with exposure to and knowledge of community-based health care under the erstwhile Family Advisory Program. We have trained around 1500 students over a period of 7 years.

With the introduction of the “Family Adoption Program,” the role and responsibility of this department have attained greater significance. The department has successfully implemented the 1^st and 2^nd cycles of FAP for the 2021 batch and the first cycle for the 2022 and 2023 batches. The department, with all modesty, takes pride in this accomplishment. Coordinating field visits for 250 students and assigning them five families year on year, with an exponential increase in the number of students, is a mammoth exercise. It demands round-the-year planning, real-time monitoring, and, most importantly, taking on board a wide array of stakeholders. The FAP, when implemented effectively, not only benefits the students and community but also the tertiary hospital that is attached to the college. At our department, the administrators have put in place methodologies and processes that will ensure the program is implemented effectively. In the process, a framework emerged. Several other medical colleges have recently initiated their own community-oriented medical education programs and have documented favorable results.[5,6,7]

The following is the commentary of the administrators on how they overcame challenges and effectively implemented the program through a stakeholder convergence framework.

For illustration purposes, the 1^st cycle of 2023, batch is taken as the reference year.

GOALS SET BY THE DEPARTMENT FOR EACH CYCLE OF FAP IMPLEMENTATION

The Family Adoption Program is given the status of a flagship program at SRM MCH and RC. Not only because it falls under NMC norms but also because of the learning potential packed in it for the medical trainees. It is seen as a cradle for community-based medical education. Apart from the stated objectives as per NMC norms, the department has listed five goals to ensure the effective implementation of FAP. Which translates into a mandate for the coordinators.

• To ensure five houses are assigned to each student.

• To ensure that the students have seamless field practice at the adopted village.

• To build the competencies of students so they can be confident during family interviews and conversations.

• To sensitize and take on board the various Panchayat Raj actors.

• To ensure that the village community (families) are sensitized and that they provide their fullest cooperation to the students.

• To ensure the safety of the students during field practice.

STAKEHOLDERS

Stakeholders in the context of FAP have been classified into two categories, namely, internal and external stakeholders. Internal stakeholders include At SRM MCH and RC, the FAP is planned and implemented by the department with the patronage of the Pro-Vice Chancellor, under the guidance of the Dean of Medical, HOD of the Department of Community Medicine, serving as the advisors of the program [Figure 1].

Figure 1.

Organogram of the program

ESTABLISHMENT OF A ROBUST PROCESS WITH ASSIGNED FUNCTIONS AND RESPONSIBILITIES

To begin with, the senior administrators of the program, Professor and HOD of the Department of Community Medicine and Professor and Associate Dean of the college, assumed the role of advisors. Their vast experience in training medical students in community based health care, experience in general and in education administration played a great role toward the effective implementation of the program. To ensure clarity on the various aspects of implementation; a process flow chart was evolved showing the ownership of each process.

ESTABLISHMENT OF A ROBUST AND COMPREHENSIVE ORGANOGRAM

Based on the work process, an organizational chart was developed. To begin with, the senior functionaries of the department made a thorough study of the NMC manual for the Family Adoption Program and designed a workable and robust organizational chart with assigned functions and their ownership.

At SRM MCH and RC, the FAP is planned and implemented by the department with the patronage of the Pro-Vice Chancellor, under the guidance of the Dean of Medical, HOD of the Department of Community Medicine, serving as the advisors of the program. The program is executed by the coordinators appointed on a rotational basis. They will continue to handhold the batch for all the cycles until its conclusion in the third year.

Preparatory Work for the Launch of FAP

The department starts the groundwork six months ahead of the FAP field practice schedule. For example, the preparation for the FAP for January 2024 was initiated during the month of September 2023, with the advisors narrowing down on Karanai Puducherry village as the field practice area. Wide consultation with field staff, considerable research using secondary and primary data, field visits, discussion with Panchayat leaders, and a feasibility study were carried out before making the final decision to fix Karanai Puducherry as the adopted village. The data, which guides the decision, is illustrated below.

The total geographical area of the village is 143.7 hectares. Karanai Puducherry has a total population of 7467, and the pin code of Karanai Puducherry village locality is 603103. Thiruporur is the nearest town to the village for all major economic activities, which is approximately 15 km away. Mannivakkam, Unamancheri, Rattinamangalam, Vengadamangalam, Ponmar, Thazhambur, Navalur, Kannathur Reddy Kuppam, Siruseri, Polacheri, and Sonallur are nearby places of importance.

CHALLENGES IN ENGAGEMENT WITH PANCHAYAT RAJ INSTITUTIONS

At SRM MCH and RC, the Department of Community Medicine designates two faculty members as coordinators for each MBBS batch to facilitate the Family Adoption Program (FAP). Their primary responsibilities include ensuring uninterrupted field practice and safeguarding student welfare. Central to this role is the establishment of a constructive relationship with Panchayat Raj Institutions, particularly the village president, whose cooperation is pivotal to the program’s success.

Prior to each cycle, especially the inaugural one, coordinators and paramedical staff formally meet the Panchayat President to outline the objectives of FAP, its mandatory nature for medical undergraduates, and the reciprocal benefits for both students and villagers. Although local leaders often voice concerns regarding the logistical burden of accommodating large student groups and ensuring their safety, they generally extend full support in recognition of the institution’s longstanding service to rural communities in the Kattankulathur block.

To consolidate stakeholder engagement, social workers and paramedical staff further sensitize ward councilors, members, and ASHA workers. Initial reluctance, influenced by police advisories cautioning against sharing personal details with outsiders, was addressed by assuring confidentiality of collected data and its exclusive use for academic purposes in accordance with government norms. This systematic stakeholder convergence has proven instrumental in mitigating challenges and ensuring the effective implementation of FAP.

INSTITUTIONAL (SRM IST) SUPPORT TOWARD STAKEHOLDER ENGAGEMENT

SRM Institute of Science and Technology (SRM IST) has developed a robust framework for community engagement through multiple outreach units, including the National Service Scheme, Tamil Peravai, Unnat Bharat Abhiyan, and the Rotaract Club. Institutional leadership has reinforced this commitment, with the founder personally meeting nearly 180 key stakeholders in June 2023 to acknowledge community cooperation and assure continued investment in local development.

As part of the Family Adoption Program (FAP), the institution reciprocates community support through multispecialty health camps conducted in adopted villages during field practice days. These camps, inaugurated by senior administrators, cover the entire village and are made more personal by students accompanying members of their adopted families.

Furthermore, patients from adopted villages visiting the tertiary hospital receive additional assistance. Students are encouraged to support their assigned families, with social workers and sensitized hospital staff ensuring smooth navigation of healthcare services.

Regular health education activities, delivered by students with guidance from departmental health educators, have enhanced the community’s perception of the Department of Community Medicine as a reliable resource center. Collectively, these initiatives illustrate how sustained engagement and reciprocal partnerships strengthen the institutional-community interface and contribute to the effective implementation of FAP.

CHALLENGES IN ENGAGEMENT WITH COMMUNITY PEOPLE

Mass Awareness Drive

The medical social workers and paramedical staffs undertake a door-to-door campaign, sensitize the people through conversations, and enlist their participation. Simultaneously, to aid the village head in effectively communicating and soliciting the support of the villagers to participate in the program, the department prepared IEC materials in Tamil about FAP and disseminated them through handbills and WhatsApp groups administered by the ward members. The MSWs and paramedical staffs also conduct a door to door campaign in their designated areas.

CHALLENGES IN ASSESSING THE EXACT QUANTUM OF HOUSES AVAILABLE FOR ADOPTION

Plotting of houses and Mapping of the Adopted Village

Two trained Health Inspectors (HIs) from the department undertook systematic village mapping to support the Family Adoption Program (FAP). Using hand-drawn maps, houses were plotted approximately to scale and assigned continuous numbering, street by street, during the first cycle of implementation. This process provided administrators with precise data on the number and distribution of households, while also serving as a valuable tool for medical social workers (MSWs) and paramedical staff during the canvassing process. Public utilities and landmarks were also recorded, ensuring comprehensive documentation of village topography. In the most recent cycle (January 2024), approximately 1,250 households were identified for adoption. To optimize fieldwork, each village map was divided into 12 segments corresponding to the number of student groups, with three to four streets allocated per group. This facilitated canvassing, streamlined family assignments, and enabled efficient monitoring. For instance, houses numbered 1–5 on the map could be systematically assigned to a designated student [Figure 2].

Figure 2.

Process flow chart

DIVISION OF GROUPS, ALLOCATION OF AREAS OF HOUSEHOLDS, AND ASSIGNMENT OF STAFF IN CHARGES

In the just concluded cycle during January 2024, the 250 students were divided into 12 groups; the first two groups consisted of 20 students, and the remaining 10 groups comprised 21–22 students in each group. A teaching staff, a P.G. student, and a paramedical staffs were assigned to assist each group respectively. The groups were allotted an area comprising four to five streets and consisting of around 130–150 households. It was also ensured that each group had a buffer of 30 extra houses for contingency purposes. To ensure that one member (staff) of the group is well acquainted with the area and to ensure an adequate number of houses for every student, MSWs, along with the paramedical staffs, met the families in the allotted areas, obtained their consent, informed them about the dates the students would visit, and requested that they extend their fullest cooperation to the students.

BRIEFING AND DEBRIEFING SESSIONS

To ensure seamless field practice for the students, feedback and course corrections are essential. Hence, before start of each field practice day, the coordinators conduct a briefing session in which they are provided tips to achieve the day’s field practice objective. After the field practice for the day is complete, the coordinators conduct a debriefing session for the staff. The staff shared how fruitful the field practice was and any difficulties faced in their respective groups. Their suggestions are also recorded and given effect wherever possible. The portion of the discussion that needs to be communicated to the students is done so during the briefing session of the following field practice day.

CHALLENGES IN TRANSPORTATION

During the initial year of the Family Adoption Program (FAP), students were transported in large college buses and dropped at village centers, necessitating long walks to designated households. This arrangement led to fatigue and loss of valuable field time. Recognizing these challenges, the administration engaged with higher authorities and devised a practical solution by involving a private school managed by the same institution. From the subsequent year, 12 school minibuses were deployed on field practice days. The use of minibuses, capable of navigating narrow village roads, significantly improved accessibility by dropping students directly at their assigned locations and ensuring timely pickups. Effective implementation of this arrangement requires sustained collaboration with SRM Public School. A senior social worker coordinates with school authorities and drivers, providing advance schedules and orienting them on FAP objectives. The drivers, through their professionalism and cooperation, have emerged as critical stakeholders in facilitating smooth and safe student field practice.

CHALLENGES DUE TO LANGUAGE BARRIER

As the demography of the students at SRM MCH and RC is diverse, there are always many students who face language barriers while interviewing the family. Hence, students in the first year are given language courses, and to further aid them during field practice, they are paired with a student with knowledge of Tamil. From the feedback of students, it is ascertained that this strategy is very helpful.

CHALLENGES IN OBTAINING PERSONAL DATA DURING INTERVIEWS BY STUDENTS

It is a Himalayan challenge for the students to elicit personal information from some families. Some are educated and show resistance, others are of low education and are extremely reluctant and apprehensive to share personal details. In such situations, the staff approach the family and explain the purpose and confidentiality of the data. In some cases, the help of neighbors is solicited, which works in many cases.

CHALLENGES IN STAFFING

A Throughout the process, different sections of the staff are utilized at various stages and for various purposes. For the mapping and canvassing of households, all paramedical staff posted in various health centers working under the Department of Community Medicine are utilized. In addition, on all field practice days, the entire department, excluding office staff, is on the field assisting the students. 61 staff were in the service of FAP in the latest FAP cycle, i.e., January 2024.

CHALLENGES OF ADDITIONAL WORKLOAD FOR FACULTIES

As coordinators and assisting faculties, managing the additional workload resulting from the Family Adoption Program (FAP) requires effective time management and support mechanisms. Institutions may provide resources, such as extra staff and logistical support, to facilitate faculty engagement. Despite the challenges, faculties are driven by a sense of social responsibility, the opportunity for hands-on learning experiences for students, and the potential positive impact on communities. Their commitment and enthusiasm stem from their belief in the program’s objectives and their desire to contribute meaningfully to societal welfare, fostering a culture of service and community engagement within the institution. Recognition through appreciation is given to the coordinator and staff by the head of the department and the management for effective coordination.

STUDENT DISCIPLINE

Student discipline, per se, is not a challenge as the students are well-oriented and categorically informed to maintain professional ethics while being in the program. However, to be proactive, an ecosystem is created for the students so that, despite, young and initially new to college life, the system enables the students to conform to all rules and regulations; the students have to attend field practice only in uniform along with a white overcoat, ID card, and stethoscope. They have to record their biometric attendance at the beginning and end of each field practice to prevent them from loitering in the streets during field practice. Staff and PGs are on constant rounds in the area allotted to them.

LOGISTICS FOR STUDENT ASSESSMENT

A daylong schedule is involved for the evaluation of students. The students make a presentation reflecting on their field visit experiences and the learning outcomes. The logbook is another source of evaluation. Making logistical arrangements to book 12 classrooms from different departments with functional audiovisual aids requires planning and building rapport with heads of other departments. The evaluation is done by the faculty in charge of the group and assisted by a Community Medicine P.G. student.

CONCLUSION

From 3 years of implementing FAP, it is our firm belief that FAP is an ideal program to impart community based medical education to MBBS students. Moreover, there is huge potential for the students to learn, get familiar with field practice, understand the socioeconomic determinants of illness in rural areas, improve communication, interviewing skills, and relate with empathy. Having said that, the success of the program depends on the motivation and level of preparedness of the students and the convergence of stakeholders toward the common purpose. Therefore, an institution should make sincere efforts to maintain strong relations with the neighborhood communities and various officials.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.