Paper Presented at The International Conference on the
Role of the University in Health Research for Development
Madras, India February 5-9, 1995
Special thanks to Stephanie Montgomery (smontgom@muvms6.mu.wvn et.edu) for developing the student database and to Nancy Williams (nwilliam@muvms6.mu.wvn et.edu) for extensive assistance in preparing this paper.
During the last 25 years a powerful movement for educational reform has occurred in the health sciences. Epitomized by Lipkin as "person-centered and population-based" (Lipkin, 1989, p.4), this movement has challenged teachers and students to base their learning, their practice and their research in the reality of their patients' lives and communities. The Alma-Ata Declaration on Primary Health Care in 1978 (World Health Organization), the founding of the Network of Community-oriented Educational Institutions for Health Sciences in 1979 (Lipkin, 1989), and the Institute of Medicine conference on Community-Oriented Primary Care (COPC) in 1982 (Connor and Mullan, 1982) articulated values, goals, and methods of vital importance to this movement. While the movement is one of educational reform, the goal is a social one. This goal was best stated at Alma-Ata: "Primary health care ... universally accessible to individuals and families in the community ... at a cost that the community and country can afford..." (World Health Organization, 1978, p.3).
The teaching community health center, whether urban or rural, has a threefold mission: primary care, teaching, and research. As greater attention is given to primary care as the leading discipline of health care in both the developing South and the industrialized North, more students are receiving a greater part of their education in community-based, teaching practices. This increasing flow of students makes new demands on the primary care practice, but also provides it with a valuable human resource. With creative planning and good organization by the practice, these students can and do make a significant contribution to the COPC work of the practice while they are learning.
Without conducting an exhaustive search, we found a number of reports in the medical literature describing just such an approach. This literature is international and multidisciplinary. The emphasis in these reports is usually on community service and community needs awareness rather than research. However, invariably, elements of community diagnosis, project evaluation, and some report of findings are included within the projects. Boufford (1992) cites reports from the United States, Israel, and Australia in which medical students had required courses in community medicine which included a student project. Boufford and Shonubi (1986) described the training provided through the residency in Social Medicine of Albert Einstein Medical School, which also involved students in community projects.
Several articles stress the development of collaborative relationships among different sectors as another achievement of these student projects. Burback and Baldwin (1992) saw collaboration between university, community and students in an "Action Research Program" for community health nursing students at Vanderbilt University. The program is designed to link "the information needs of grassroots organization and non-profit social and health care services with the research activities of students." (p.37). Rebovich, Wodarski, Hurley, Rasor-Greenhalgh, and Stombaugh (1994) describe a program for registered dietitian students at the University of Akron. In this model, community agencies generate research questions, university faculty contribute research design and grant writing, and students participate in all components of the research process. The COBES (Community-Based Experience and Service) program at the University of Ilorin in Nigeria depends on a partnership of university, government, and community (Bollag, Schmidt, Tryers, and Lawoni, 1989). Medical students spend two months per year during their second through fifth years working in villages with faculty doing community health work, including an epidemiologic investigation of two major health problems.
In this paper, we describe a model in which health professions students are assigned research projects linked to COPC activities in a rural teaching community health center. We also describe the 15 year experience of precepted student research from which this model was developed.
The Center
New River Health Association (NRHA) is located in the Central
Appalachian Mountains of West Virginia. The practice was founded
in 1978 by a group of local mine-worker unions with technical
assistance from the United Mine-workers of America. Initial
support was supplied by the Rural Practice Project of the Robert
Wood Johnson Foundation, which sought to extend the community
responsive practice model to rural communities (Madison and
Shenkin, 1978). This model was based on the principles of strong
clinical and administrative leadership, community empowerment
through non-profit community ownership, and program elements of
accessibility, prevention, health promotion, and community
outreach.
Within a few months of its inception the health center had its first students on rotation. The provision of rural community-based primary care training experiences to health professions students was one of the prime original goals of the lay community board that established NRHA. They saw this as a way of sensitizing young health professionals to the realities of rural life and a way of attracting them to practice in rural West Virginia. The Center developed teaching affiliations with in-state professional schools, a number of out-of-state schools, and a variety of other programs.
From the start a "mini-research project" was a requirement of the standard one-month student clinical rotation. At first, this was an unexpected and sometimes unwelcome requirement for many students. Beginning in 1990, however, most schools began to emphasize the acquisition of research literacy and community diagnosis skills and the NRHA research requirement was strongly supported by school-based faculty.
West Virginia Rural Health Initiative
In 1991 the West Virginia State Legislature approved funding
for the Rural Health Initiative (RHI) -- a state-wide program
focused on expanding educational opportunities in rural health
facilities for health profession students (medicine, nursing,
pharmacy, social work, physical therapy, health administration).
The RHI is dedicated to developing rural academic centers for the
health professions which are tied to community health promotion
activities. Twelve RHI consortia exist throughout West Virginia.
NRHA serves as the lead agency for the Fayette-Raleigh-Nicholas
(FRN) Consortium, which includes six health care facilities.
Student education at the RHI sites emphasizes primary care, problem-oriented learning, and health professionals working in a multi-disciplinary team. In addition to actual clinical experience with health providers and patients, students at the RHI sites are involved in research activities, community activities, and interdisciplinary seminars.
The NRHA Primary Care Research Manual (Doyle, Thach, and Copenhaver, 1994) is intended as a resource for both students and NRHA staff conducting research. The Introduction to the Manual states the threefold importance of research skills for all health workers: "First, as consumers of research, health professionals must be able to critically review literature through using traditional or electronic libraries and applying what they learn to their practice. Second, as interpreters of research, health professionals must be able to explain to their patients and their communities what the latest medical discoveries do and do not mean. Third, as participants in practice performance review, health professionals must acquire the lifetime habit of measuring their practice performance in order to continually improve practice quality." (pp.2-3) The Manual also offers some basic principles which guide the coordination of student involvement in research:
The RHI Coordinator maintains a file of student research project proposals and an updated "Top 10 Priority Projects List". These projects are generated by the practice leaders at NRHA through the use of a "Quality Assurance Research Proposal Form." Upon arrival, the student is oriented to the research requirement, given a loaned copy of the NRHA research manual, provided with a copy of the "Top Ten Priority Research Projects", and encouraged to select a project from this list. If none of these projects are consistent with student interest and educational need, the RHI Coordinator and the student review the project proposal file.
Once a project has been selected, the student meets with the supervisor for that project. This supervisor may or may not be the student's primary clinical preceptor. The student and the supervisor plan, in greater detail, the actual steps involved in the project, time available, and when and where the results will be presented. The student is allotted one-half day per week (10% of total time) to work on the project.
The FRN Consortium maintains a database of all students doing rotations at any of its sites. This database includes information about student projects and has proved useful for educational program coordination. Student projects lie in two main areas: medical services and community outreach activities. Table 1 lists the main types of medical services projects and a detailed example follows.
Table 1: Topical Classification for Student Research Projects
Medical Services Projects at NRHA, 1980-1994
MEDICAL
SERVICES PURPOSE EXAMPLE
Access to care To identify factors Availability of
enabling or preventing appointments for
timely access to care. follow-up visits.
Includes impact of
actions to improve
access.
Quality of To measure the process Proportion of women ages
Care Audit care for a particular 35-70 with breast cancer
condition against the screening in the past 2
accepted standard. years.
Includes impact of
actions to improve care.
Clinical To develop or revise When to do anemia
Guideline clinical practice screening in children.
Development guidelines for diagnosis
or treatment based on
best available evidence.
Includes development of
new actions or tools to
improve care.
Practice To describe patterns of Utilization of opiate
Pattern care by practice staff. analgesics for chronic
Includes case reports. pain.
Prevalence To measure the prevalence Prevalence of smoking and
Study of an important condition non-exercise among
in the practice population diabetics.
or a subgroup.
Qualitative To describe cultural or Spirituality and hope in
Research personal aspects of women with breast cancer.
health using ethnographic
and other qualitative
methods.
Table 2 lists the main types of community outreach projects and a detailed example follows.
Table 2: Topical Classification for Student Research Projects
Community Outreach Projects at NRHA, 1980-1994
COMMUNITY
OUTREACH PURPOSE EXAMPLE
Community To conduct a focused School screenings to
Survey community health identify risky behaviors
diagnosis using the and health problems.
survey method.
Screening To follow through on Follow through on medical
Follow-Up abnormal findings problems found at school
obtained during health screenings.
surveys or screenings.
Program To gather and Establish education and
Development integrate relevant rehabilitation program for
data into working coal workers
elements of new or pneumoconiosis.
revised health programs.
Program To use formative Target group penetration
Evaluation evaluation and of a program for high risk
outcomes data to prenatal patients.
access progress toward
established objectives.
A registered nurse pursuing an MPH degree, a pre-medical student, and two high school students participated in a community survey project conducted during the summer of 1987. The MPH and pre-medical students were on two-month assignments, with stipends, from the Appalachian Student Health Coalition of Vanderbilt University. The high school students were doing a senior honors project for their school. The objectives of the community survey were to measure the prevalence of cardiovascular risk factors, enumerate persons with specific risk factors, measure knowledge and beliefs related to heart health, and inquire about perceived health needs in the community. The method for this survey was a door-to- door interview and examination of all persons sixteen and over in a defined geographic community adjacent to the health center. The MPH and pre-med students worked as members of a six person team directed by a physician principal investigator and a nurse survey coordinator. Results of the survey detailed the prevalence of hypertension, diabetes, smoking, obesity, and inactivity. More detailed analyses were done and a final report was presented to the practice staff, to the Board of Directors, and to the community via the health center news letter. The high school students analyzed responses concerning health needs in the community and presented this to the Board of Directors. Follow-up on this project was a foundation supported "Healthy Heart Project" which focused on self- esteem and healthy lifestyles in youth through a summer recreation program from 1989 through 1992.
From 1978 to 1994 NRHA hosted 492 student rotations. During that time 147 projects were completed, including some physical work projects completed by undergraduate students on one-week voluntary work assignments. Of the 147 projects, 96 were research projects, including, 58.5% completed by MD/DO students, 12.5% by Nursing students, 6% by Pharmacy students, 5% by PA students, and 8% by undergraduate students. Sixty of the projects (62.5%) fell in the general area of Medical Services, and thirty-six of the projects (37.5%) fell in the area of Community Outreach. Table 3 provides a breakdown of research projects by topic area (as defined in Tables 1 and 2) and type of student.
Table 3: Student Projects at NRHA 1980-1994
by Topic and Degree Pursued
TOPIC BS Nursing
or RN or
Less Pharm NP PA MD/DO TOTALS
==================================================================
MEDICAL SERVICES
------------------------------------------------------------------
Access to Care 1 2 0 1 3 7
Quality of 0 0 2 3 10 15
Care Audit
Clinical Guid. 1 2 3 0 11 17
Development
Practice 2 0 4 1 6 13
Pattern
Prevalence 0 0 2 0 5 7
Study
Qualitative 0 0 1 0 0 1
Research
------------------------------------------------------------------
COMMUNITY OUTREACH
------------------------------------------------------------------
Community 10 0 0 0 5 15
Survey
Screening 1 0 0 0 2 3
Follow-Up
Program 2 2 0 0 13 17
Development
Program 0 0 0 0 1 1
Evaluation
==================================================================
TOTALS 17 6 12 5 56 96
The number of research projects grew over the years in parallel with the growing numbers of students. There were 9 projects in the period 1980-84, 34 in 1985-89, and 53 in 1990-94. In the beginning, all student groups (except undergraduate) were more likely to do projects in the medical services category, however, community outreach projects account for an increasing proportion in recent years.
We have found that health professions students can make a significant contribution to the work of primary care through well-defined research projects during their community rotations. The approach described here was developed gradually with feedback from students, clinical faculty, and other practice leaders. An important question with respect to these projects is, "To what extent did they benefit the practice or contribute to the health of the community?" We asked four practice leaders to independently rank the projects as having "no significant contribution", "significant contribution", or "lasting impact" for the work of the practice. Sixty three projects (66%) were ranked as signigicant contribution or better. Eight were judged to have lasting impact.
In addition to these direct benefits, there have been other positive contributions to the practice. A practice research manual has been developed for use by practice staff, as well as students. Practice clinicians and ancillary staff have broadened their own research skills by developing questions, supervising students, and serving as a critical audience for completed projects.
We view the acquisition of research skills as a mutual learning project for both students and practice staff, including clinical staff. Part of this learning process is the recognition and understanding of different types of research design. We used a topical classification in this paper. But when a classification system based on research design is used to examine this set of projects, we find that most fall into the categories of descriptive or action research (Isaac and Michael, 1981). A current program goal is to expand into case-control and cohort studies, to include more qualitative methodologies, and to strengthen our program evaluation methods.
Research activities are on-going for any health care facility concerned with the quality of the care being provided and with the most effective use of limited resources to improve the health status of its community. When community based health teams and students undertake this work together, both groups have much to gain.
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