The Family Adoption Program Experience of MBBS Students in North India: A Cross-Sectional Study

Abstract

Background:

Under the Family Adoption Program (FAP) in India, MBBS students adopt families in an underserved rural area, gather sociodemographic and health-related information, impart health education, and facilitate community health services. This study aims to assess students’ learning, attitudes, and perceptions, including challenges and suggestions regarding FAP to improve its implementation.

Materials and Methods:

A cross-sectional study was conducted, including students who had completed Phase I or II MBBS at a medical college in Uttar Pradesh, using self-administered questionnaires. Self-rated scores were obtained for attaining each learning target. Attitudes and perceptions were measured on a Likert scale, with one open-ended question each about challenges and suggestions. Batch-wise and pooled data were analyzed. Responses between phases were compared using Mann–Whitney U-test.

Results:

Of 293 eligible students, 281 (95.9%) responded. The composite scores for achieving learning targets were 64.3% and 67.6% for Phase-I- and Phase-II-completed students, respectively. Most students reported improved communication skills and learning about common health problems but lacked confidence in initial visits due to inadequate clinical skills. Two-third of Phase-II-completed students versus half of Phase-I-completed students (P = 0.004) opined FAP initiation during Phase II MBBS or later. Challenges included high expectations of families, adverse climatic conditions, and difficulty garnering attention of families. More resource allocation and reduction in the number of families were desired.

Conclusion:

FAP as community-based medical education has been embraced by students who have completed Phase I or II MBBS in a private medical college setting. Addressing the challenges can improve the experience of students and the adopted families.

BACKGROUND

The Family Adoption Program (FAP) is a community-based medical education initiative being implemented from MBBS batch 2021 in medical colleges of India following Undergraduate Medical Education Board (UGMEB) National Medical Commission (NMC) guidelines.[1] Three to five families are allotted to each Phase I MBBS student in an underserved rural area that is preferably not covered under the Rural Health Training Centre (RHTC) or Primary Health Centre (PHC) adopted by the medical college. Students are mentored by faculty and resident doctors of the Department of Community Medicine, with field assistance by medical social workers and support staff. Students gather sociodemographic and health-related information, impart health education, and facilitate community health services in collaboration with local health workers till Phase III part 1 MBBS.[1] In the process, they learn communication, behavioral and social skills, and clinical and management skills and become physicians of first contact for the families. The FAP enables the students to serve as a link between the health system and the families and prepares them to be effective and compassionate leaders in the community, as envisioned in an Indian Medical Graduate (IMG).[1,2,3] The longitudinal nature of follow-up supports empathetic bonding between students and families.[2] The FAP envisions students to understand the needs of the most vulnerable sections of society and the rural community better and be able to deliver primary health services as they become doctors while taking into account their cultural practices and limitations.[4] The reflections on FAP experiences allow for a deeper understanding of the community’s needs, increased responsiveness, recognition of social responsibilities, and translation of the knowledge of gaps into action.

Given that FAP is a recent curriculum innovation that can have a transformative impact on medical students and community care, it is vital to identify and address the variety of gaps and challenges that are uncovered over progressive visits across different regions and sociocultural contexts in India. Students are major stakeholders in this medical education initiative. Despite national rollout, few studies have explored student perspectives, particularly beyond Phase I MBBS. Our study addresses this gap in emerging literature. The objectives were (i) to know the attitudes and perceptions of Phase-I- and Phase-II-completed MBBS students of a private medical college in Uttar Pradesh about FAP, (ii) to compare the differences in perspectives of students belonging to different phases of MBBS, (iii) to identify the challenges encountered by students during family adoption visits, and (iv) to seek student opinions and suggestions on improving FAP implementation. Through this study, we proposed to improve FAP implementation for current and future MBBS batches at the institution and add to the growing body of evidence to facilitate its implementation in medical colleges in India.

MATERIALS AND METHODS

We conducted a cross-sectional study from April to June 2024 among students who had completed Phase I or Phase II MBBS in a private medical college in urban Uttar Pradesh. Each student of this institute from MBBS batch 2021 onwards had adopted five families. Students who had completed Phase I or Phase II MBBS with minimum 75% FAP attendance in each phase were eligible for inclusion. There were no exclusion criteria. Google Forms links to separate phase-specific questionnaires were circulated among students of the respective phases for self-administration. The questionnaires were semi-structured and expert-validated. The Google Forms included sections on participant consent, participant details, student perception about achieving the learning targets of FAP, student attitudes, and perceptions about FAP, challenges faced, and suggestions for improvement in conducting FAP. Self-rated scores for achieving each phase-specific learning target ranged from 0 to 10. The mean score with standard deviation (SD) was calculated per target, and the composite score (percentage) for achieving phase-wise learning targets was calculated. Attitudes and perceptions, challenges, and suggestions were assessed on a five-point Likert scale and reported using descriptive and inferential statistics as appropriate. Additionally, one open-ended question each about challenges and suggestions was asked (“Others- please specify”) and analyzed via manual inductive thematic analysis. Two investigators independently read the responses and generated initial codes. Then, through discussion, the codes were clustered into broader themes. Any disagreements were resolved through discussion and consultation with a third, senior researcher. Data from Google Forms were extracted in Google Sheets. Statistical analysis and figure preparation were done using Epi Info 7 (CDC, Atlanta, USA) and Microsoft Excel (Microsoft Corp, Redmond, WA). Batch-wise and pooled data were analyzed. To compare the responses of Phase-I- and Phase-II-completed students, the Mann-Whitney U test was applied. It is a nonparametric statistical test of significance that is preferred when the outcome variable is ordinal (Likert scale response) or non-normally distributed. A P value of less than 0.05 was considered statistically significant.

Ethical approval was obtained from the Institutional Ethics Committee before the study commencement (Reference number: IEC/IIMSR/2024/85). The introductory section of the questionnaire emphasized voluntary participation and data confidentiality, with no negative consequences due to nonparticipation.

RESULTS

A total of 144 students who had completed Phase I MBBS and 149 who had completed Phase II were eligible for inclusion. Of these, 135 and 146 students, respectively, responded. Thus, the overall response rate was 95.9%. The participant age ranged from 19 to 26 years. Among Phase I-completed respondents, 48.1% (n = 65) were male, 51.9% (n = 70) were female, the mean age of respondents was 21.4 (±1.7) years, and the median age was 21 (IQR 20,22) years. Among Phase II-completed respondents, 44.5% (n = 65) were male, 55.5% (n = 81) were female, the mean age of respondents was 22.3 (±1.3) years, and the median age was 22 (IQR 21,23) years. Overall, 46.3% (n = 130) students were male, 53.7% (n = 151) respondents were female, the mean age of respondents was 21.9 (±1.5) years, and the median age was 22 (IQR 21,23) years.

The perceived achievement of learning targets as illustrated in Competency-Based Medical Education (CBME) guidelines is reported in Table 1.[3] The composite scores for achieving phase-appropriate learning targets were 64.3 (±20.8)% and 67.6 (±20.5)% for Phase-I- and Phase-II-completed students, respectively. For each learning target, the mean score was above 6. No significant difference was noted between both batches in perceptions about achieving Phase I learning objectives.

Table 1.

Student-perceived achievement of learning targets of FAP

Learning targets	Number (%) of students reporting score 6 to 10	Mean (±SD)
By the end of Phase I (n=281)
Learned communication skills	189 (67.3%)	6.6 (±2.2)
The allotted families had confidence in me	190 (67.6%)	6.6 (±2.3)
Developed an understanding of community dynamics and healthcare delivery system in rural regions	195 (69.4%)	6.7 (±2.6)
Learned history taking, clinical examination, identification of health problems and malnutrition status	190 (67.6%)	6.6 (±2.4)
Impart health education and remedial measures, follow-up	187 (66.5%)	6.6 (±2.4)
Educate families about ongoing government-sponsored health programs	185 (65.8%)	6.5 (±2.3)
Analyze data obtained from adopted families	187 (66.5%)	6.6 (±2.4)
Participated in activities related to environment protection and sustenance	173 (61.6%)	6.4 (±2.3)
By the end of Phase II (n=146)
Inspired active participation of the community through the families allotted to me	99 (67.8%)	6.7 (±2.5)
Continued active interaction with the families	105 (71.9%)	7.1 (±2.2)
Became the first reference point of my allotted families for access to healthcare or continued facilitation of healthcare provision	95 (65.1%)	6.6 (±2.5)
Started compiling the outcome targets achieved	100 (68.5%)	6.9 (±2.2)

FAP: Family Adoption Program; SD: Standard deviation

The attitudes and perceptions of students about FAP are compiled in Table 2. A comparison was drawn between the responses of students who had completed Phase I and Phase II; the statistically significant responses are mentioned in Table 3.

Table 2.

Attitudes and perceptions of students about FAP

Content of statement	% students reporting 4 or 5 on Likert scale
Pooled results (n=281)
Through FAP, I am understanding the role of communication in facilitating positive health behavior.	71.2
FAP enables me to see for real how people in the community think about their health condition, about the misconceptions they hold, and how it affects their health and health-seeking behavior.	67.3
During FAP, I learned about common health problems in the community.	66.5
FAP gave me a clearer understanding of living conditions in the rural area, which I had not witnessed closely earlier.	64.4
FAP has helped me develop people skills.	64.1
Through FAP, I am able to make a difference in the health of the family members or their attitude toward health and healthcare seeking.	63.0
FAP allowed us to generate and participate in useful educational discussions with peers.	61.2
FAP should be included in the medical curriculum	60.1
It would be better if FAP is started at a later stage of undergraduate curriculum, such as Phase II onward	56.9
Time devoted to FAP in the first year will be better-utilized if it is allotted to learning first-year subjects	56.9
Studying community medicine in Phase I was more relevant due to early community exposure during FAP	53.4
The benefits of FAP are more to the student than to the families	53.0
FAP makes learning first-year subjects more relevant, by allowing me to apply that knowledge to understand the health conditions of families	46.3
Responses by Phase-II-completed students (n=146)
Accounting for socioeconomic status in community setting: aspect often untouched in hospital settings	65.1
Interaction in community vs hospital: people open up in a more relaxed fashion in their home environment and speak about stressors and living conditions	61.0
FAP oriented me to common health problems in the community vs clinical posting, rarer/more complicated health problems	60.3
Early exposure to different health conditions during FAP in Phase I MBBS good for orientation before starting clinical posting in the hospital	59.6
Easier to remember drug names, dosages, and indications in Phase II MBBS because I saw them first-hand or discussed them in the context of FAP	54.8

FAP: Family Adoption Program

Table 3.

Comparison of student perceptions between MBBS phases*

Statement	Phase-I-completed students (n=135)		Phase-II-completed students (n=146)		P
	% students with score 4 or 5	Median (IQR)	% students with score 4 or 5	Median (IQR)
Time devoted to FAP in the first year will be better-utilized if it is allotted to learning first-year subjects.	45.2	3 (1)	67.8	4 (2)	<0.001
It would be better if FAP is started at a later stage of undergraduate curriculum, such as Phase II onward.	48.1	3 (1)	65.1	4 (2)	0.004
FAP allowed us to generate and participate in useful educational discussions with peers.	54.8	4 (1)	67.1	4 (2)	0.012
Logistics and transport should be better arranged.	54.1	4 (2)	69.2	4 (2)	0.004
More doctors and supporting staff should be deputed for the field for FAP.	52.6	4 (2)	69.2	4 (2)	0.017

IQR: Interquartile range. *Only statistically significant results have been reported

The challenges most reported by students were visiting all families in adverse climatic conditions and high expectations of families, such as immediate resolution of health problems, free treatment, and arrangements for their hospital visits such as booking appointments, accompanying them, jumping queues, and collecting reports. The percentage distribution of student responses (n = 281) over a 5-point Likert scale is depicted in Figure 1. A total of 28 responses were considered for thematic analysis of open-ended question on challenges. After removing the responses that overlapped with challenges stated in the Likert scale, themes that emerged were concerns about student safety while exploring interior areas, especially for girls, and the unhygienic conditions of some field areas.

Figure 1.

Challenges faced by students during Family Adoption Program (pooled data, n = 281)

Students strongly suggested the placement of a hospital system that prioritizes consultations of FAP family members and better management of logistics, transport, and human resources. The suggestions reported over a 5-point Likert scale (n = 281) have been represented as percentages in Figure 2. For thematic analysis, total 19 responses were considered. After removing the responses that overlapped with the suggestions reported in Likert scale, a key emergent theme was students recommending briefing and guidance sessions before every visit.

Figure 2.

Suggestions to improve Family Adoption Program implementation (pooled data, n = 281)

DISCUSSION

FAP through village outreach is mandatory from session 2023-24 in medical colleges of India.[2] Its integration in the existing undergraduate medical curriculum underscores India’s commitment to health equity. Our study provides student perspectives on the program, challenges, and suggestions to improve its implementation.

In our study, self-reported scores indicated satisfactory attainment of FAP learning objectives by students of both batches. Also, our study findings align with stakeholder perspectives in literature which indicate that FAP is beneficial to the students as well as the families in several ways.[5,6] FAP provides early clinical and community exposure to students, helps augment their psychomotor skills, improves understanding of community dynamics and rural healthcare delivery system, and enhances understanding of the community medicine subject itself.[5,7,8,9] Studies echoed our findings of improvement in students’ communication skills and interpersonal interaction skills.[6,7,9,10,11] In our study, 63% of the students felt that they were making a difference in the health of the family members or their attitude toward health and healthcare seeking. However, 53% of students thought that the benefits of FAP were more to the students than the families, consistent with a theme identified in another study.[12] The challenges related to poor family cooperation and unmet family expectations (discussed later) could explain this student perception and can be explored further using a qualitative approach.

Available literature generally favored the implementation of FAP but had differences in the when and how aspects.[5,7] Nearly 60% of students in our study favored the inclusion of FAP in the medical curriculum. However, 56.9% of total students opined for the inclusion phase II onward, with delayed inclusion favored by 65.1% of Phase-II-completed students versus 48.1% of Phase-I-completed students (P = 0.004). A study reported 80% of students favoring FAP initiation in the first year itself, but its low overall response rate indicates possible nonresponse bias.[8] Faculty and students in other studies opined that the FAP should be started later in the curriculum.[7,10] Another study reported mixed faculty opinions on the MBBS phase in which FAP should be initiated.[12] Around 57% of students in our study believed that the time devoted to FAP in the first year would be better utilized if allotted to learning first-year subjects, but this was significantly highly voted by Phase-II-completed students compared to Phase-I-completed students. Another study including the first batch of only Phase I MBBS students also reported a similar viewpoint.[10] Notably, Phase-II-completed students in our study belonged to the first batch (2021) in which FAP was initiated nationwide. At that point, all stakeholders including students lacked guidance, dedicated resources, and program experience, which could have introduced disorderliness and the batch opining for FAP inclusion at a later stage of the undergraduate curriculum, after the students had settled into the MBBS course. This explanation corroborates with the response of Phase-I-completed (batch 2022) students in our study, who were comfortable with FAP commencement in the first year itself, possibly due to effective streamlining of the program. Another possible explanation for the significant difference in opinion is that the Phase-I-completed students were less experienced with the MBBS curriculum to appraise the reduction in first-year subject hours. Readministration of the questionnaire a year later could allow them to re-examine their opinion and bring out the changes, if any. Notably, Phase-II-completed students however felt more strongly than Phase-I-completed students that FAP facilitated their engagement in useful educational discussions with peers (P = 0.012), indicating their perception of its utility despite its perceived early initiation.

Since we included Phase-II-completed students also, we could study their views about community interactions compared with hospital interactions. The majority of these students agreed that FAP was a unique opportunity and provided a setting where people opened up in a more relaxed fashion than the hospital. They encountered common health problems and commonly used medicines in the community before exposure to more complicated cases at the tertiary care hospital. Studies have reported the ease of communication in the family setting and how medical undergraduates in FAP can learn about important health problems outside the context of exams alone.[8,12] In our study, students could also learn about life stressors and socioeconomic situations during the family visits and understand their role in health and disease. Another study also reported FAP’s utility in orienting students on how to help families while keeping their constraints and limitations in context, and underscored its eye-opening role for students coming from prosperous families.[12]

The top challenge reported by our students was visiting all five families in adverse climatic conditions. Total 63.7% of our participants suggested the number of families adopted be reduced. Stakeholders in other studies have also reported this suggestion or alternatively, a reduction in the number of visits.[5,6,7]

Unmet expectations of free medication and consultation were identified as challenges in other studies too.[5,8] Combined with a lack of follow-up by health authorities, it can lead to poor cooperation by families.[8] Our participants suggested placing hospital systems to prioritize FAP families; when they have a smooth and comfortable experience, they will perceive participation in FAP as beneficial.

Our students reported the unavailability of all family members during visits, impeding regular clinical examination and anthropometric monitoring. They also reported difficulties in garnering the attention of family members because they were either engaged in household chores or did not realize the benefits of FAP or they knew that the students were not doctors and could not have offered adequate help. Students also lacked confidence while interacting with families due to inadequate clinical skills in Phase I. Similar factors contributed to poor cooperation by families in other studies.[5,7,8] FAP involves collaborative efforts, and gaining the trust and cooperation of families is important for its successful implementation. While competencies have been included in ascending manner in FAP, there is a need to align them further, particularly in the first year when students are yet to build a strong foundation of knowledge and clinical skills to help the adopted families confidently.

Logistics and transport-related challenges were underscored by Phase-II-completed students (P = 0.004) in our study and have been reported by stakeholders across studies.[5,6,7,12] Deputing more doctors and support staff was desired particularly by Phase-II-completed students (P = 0.017), which is important for service provision, coordination, and guidance. Sustained efforts of hospital management are essential to mitigate these challenges.

While communication barrier or language barrier has been reported by nonlocal students in several studies, only a fourth of the students in our research reported a Likert score of 1 or 2 in this domain.[6,7,8,9,12] Prior training of the students in local language and pairing or grouping them with local language-speaking students can help. Furthermore, family members had reservations about disclosing personal details, which resonates with findings from other studies.[8,9] They may be concerned about loss of privacy and fearing judgment for displaying vulnerability, reflecting deeper trust issues. This challenge can be overcome with empathetic communication over subsequent visits which will strengthen rapport.

Responses to open-ended questions included concerns about student safety while visiting families in distant or interior areas. A secure student experience can be ensured by deploying adequate staff to accompany the students, gregarious movement of students of both sexes, and prior sensitization of students and village residents. Regular guidance and mentoring sessions as suggested by students will enrich the student as well as the family experience of FAP.

Strengths and limitations

Our study was contemporary since it included data from the most recent phase completed by students of the first batch of FAP implementation. While most of the available literature included Phase I-completed MBBS students, this study included Phase II-completed students also. This ensured a higher sample size and enabled comparison between two different batches of the same institute. It enabled observing how the student perception has transformed over the academic year, indicating FAP implementation while acknowledging the limitations of a cross-sectional study design. The response rate was high (96%). The study delivers valuable findings to aid the improvement of FAP implementation in medical colleges and guide amendments to the program. While we tried to mitigate bias arising from self-assessment and use of Likert scale, it cannot be entirely ruled out. Since batch 2021 had not completed Phase III Part 1 at the time of the study, that data could not be gathered. Qualitative exploration was limited in this study, and other stakeholders’ perspectives were not included in the objectives. It was conducted in a single private medical college in North India, necessitating cautious generalization and customization in other settings.

CONCLUSION

FAP as community-based medical education has been embraced by students who have completed Phase I or Phase II MBBS from a private medical college in North India. FAP facilitated experiential learning about social and environmental determinants of health in the rural milieu. Further research incorporating Phase III Part 1 student experience and detailed qualitative exploration can offer more insight into the program and ways to enhance community engagement. Research involving other stakeholders such as faculty, resident doctors, social workers, hospital management, other health staff, grassroot-level health workers, and people from the adopted community can provide a 360-degree view of the program. Quantitative validation of questionnaires should be employed in future studies. FAP has the potential to enhance rural healthcare accessibility and cultivate a generation of well-rounded Indian Medical Graduates attuned to rural challenges. FAP calls for unceasing efforts to improve its nationwide implementation and placing student and family experience at the center stage for long-term gains.

Ethical approval

Ethical approval was obtained from the Institutional Ethics Committee before the study commencement (Reference number: IEC/IIMSR/2024/85).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.