DOI: https://doi.org/10.21203/rs.3.rs-2215288/v1
Community practice training is an important part of education in medicine, public health, social medicine, and other disciplines. The objective of this study is to explore the effect and importance of the community practice of Master of Public Health graduates on community residents’ health during the Coronavirus Disease 2019 epidemic.
This study used a prospective study design. A total of 152 participants with age ≥ 60 years were selected using a multistage sampling method from Hangzhou in China. Baseline and endline data were collected using structured questionnaires by face-to-face interviews. All psychological and behavioral measurements were performed using standardized instruments and showed good reliability and validity. A total of 147 participants were included in the analysis. The chi-square and rank sum tests were used to compare the difference between baseline and endline for categorical variables. Binary logistic regression analysis was used to evaluate the association between community practice training and changes in psychology and behavior.
The result of chi-square test showed that the eating habits of participants were different at endline and baseline (p = 0.001). Participants reported that the self-perceived health status from “very good” to “not good” was different between endline and baseline by the rank sum test (p = 0.036). The results of logistic regression analysis showed that community practice training was significantly associated with increased self-efficacy scores and cognitive function, with odd ratios (ORs) of 1.08 (95% CI, 1.04–1.13, p < 0.001) and 0.90 (95% CI, 0.83–0.98, p < 0.013), respectively. The change in eating habits was also statistically significant at endline (p = 0.009).
Community practice training was associated with changes in health behavior and psychology of community residents. Our results suggested enhanced community practice training for students under the Master of Public Health program.
Master of Public Health (MPH) education has started earlier in developed countries, and its main education goal is to pay attention to the learning of public health leadership and practical ability [1–4]. In some countries, part of MPH education is completely undertaken by public health schools, and a small part is completed by community health and community health education departments relying on medical schools, public health schools, or health administrative departments. In addition, MPH education focuses on cultivating the students’ basic knowledge and skills required by public health practices, such as disease prevention and health promotion, and promoting effective management of community health problems to solve health problems [5–8].
The number of MPH students is increasing every year in China, and the proportion of MPH students in some universities has exceeded that of academic degree graduates [9, 10]. Even with the emphasis on practical ability training and practice being a necessary condition for awarding degrees, most practice bases are set up in various medical and health institutions, such as Centers for Disease Control and Prevention, Health Education Centers, and Health Supervision Institutes. Studies showed that more than 90% of MPH students’ practical courses are conducted in the Centers for Disease Control and Prevention, and only 1.9% are completed in community health service institutions. The community is rarely considered as a public health practice base, and the community MPH education system has not been established [11, 12].
Community-based medical education, including public health education, is a style of education that brings practical skills and ethical competencies to students [13]. Community practice can promote the students’ career intentions toward primary care and addressing enormous challenge by aging populations [14, 15]. Since the Corona Virus Disease 2019 (COVID-19) pandemic, the elderly are considered the most vulnerable group due to their susceptibility to COVID-19 and because preventive and management strategies, like social distancing, can have increased effects on the elderly who have a risk for social isolation and loneliness [16–18].
We hypothesize that community practice can develop practice skills and the health of community residents. This study aims to examine whether applied investigation, as an important part of community practical training, may have a beneficial effect on the health of elderly people who live in the community.
A prospective study was designed to investigate the effect of community practice training on the health of the elderly who live in the community. On the basis of empirical study, 152 community residents with age ≥ 60 years were selected from Hangzhou, Zhejiang Province in China during the period of September 2020 to July 2021. Three communities with good organizational and managerial capacities were selected from three subdistricts of West Lake district. Participants were enrolled by community staff members through phone calls.
The practical training lasted for a week. The practical training team consisted of nine students under the Master of Public Health program. The purpose of this study was explained by the research team, and all participants provided written informed consent before participation in this study. If participants were illiterate that the oral informed consents were provided. The study and method of oral informed consent were approved by the Institutional Review Board of the School of Medicine, Zhejiang University (No: ZGL201909-10).
A structured questionnaire was used to investigate the elderly living in the community. The questionnaire was divided into nine parts and comprised 520 items. Before the investigation, we conducted a preliminary investigation to test the validity of the questionnaire. The main content of the questionnaire comprised demographic characteristics, behavior and habits, neurological and social cognition, personality and psychology, community resources, health and perceived health status, social support, adverse events and environmental factors, and community services during the COVID-19 epidemic. The demographic characteristics of participants included age, gender, marital status, income, and education level. Daily behavioral habits were asked from the following aspects: eating habits, tobacco use, alcohol consumption, sleep duration and quality, and physical activity. Personality and psychological factors were evaluated in accordance with the following: self-efficacy, depression, dependency, and eysenck personality. Community resources were divided into four dimensions: environmental, medical, nursing, and welfare resources. Self-reported chronic disease status and self-perceived health level were recorded. All data were collected at baseline and end of observation. Face-to-face structured interviews were conducted by Master of Public Health students who used a standardized interview protocol and a set of responses for recording the responses of participants. The interview time was approximately 45–60 min for most participants, and the interviewer suggested that elderly people who feel tired may take a rest.
Self-efficacy was measured using the Chinese version of General Self-Efficacy Scale (GSES). The GSES consists of 10 items, and 10–40 points may be obtained. High scores represented high levels of self-efficacy. Cognitive function was assessed using the Chinese version of Dementia Assessment Sheet for Community-based Integrated Care System 21 items (DASC-21). The total score was 84 points. A high score indicated poor cognitive function. The 15-item Geriatric Depression Scale was used to identify individuals with depressive symptoms. Dependency personality disorder was identified using the Chinese version of standardized Minnesota Multiphasic Personality Inventory-II. Social support was assessed using the Older American Resources and Services scale. All measurement instruments used in the study showed good reliability and validity.
Statistical analysis was restricted to the 147 participants with complete questionnaires and follow-up survey data. Frequency and percentage were used to describe the general characteristics of the study participants. Survey data at baseline and the end of the observation were compared. Categorical variables were analyzed using the chi-square and rank sum tests, and continuous variables were compared using t-test or Mann–Whitney test. A logistic regression analysis was conducted to identify the association between community practice training and changes in psychology and behavior of participants. Self-efficacy, DASC-21, and dependency scores were divided into “1” and “0” by using the 75th percentile. Outcome variables to be observed were added to the logistic regression model as binary dependent variables. Community practice training was defined as two categorical variables, which were assigned a value of “0” at baseline survey and “1” at the end of observation, and community practice training and other factors were added to the model as independent variables. Reverse validation was performed using continuous variables. All analyses were performed using SAS for Windows (version 9.4).
The baseline characteristics of the participants are shown in Table 1. Among all the participants, 105 (71.4%) were female, and 42 (28.6%) were male. About 45.6% participants were at least 70 years old, and 78.9% of participants reported one or more chronic diseases. Approximately 68.7% of participants reported lower level of education and completed only nine years or less of education. A high proportion of participants (86.4%) also reported physical activity during the COVID-19 epidemic.
| Characteristic variables | n | % |
|---|---|---|
| Gender | ||
| Male | 42 | 28.6 |
| Female | 105 | 71.4 |
| Age (yr.) | ||
| < 70 | 80 | 54.4 |
| ≥70 | 67 | 45.6 |
| Education levels (yr.) | ||
| 0–6 | 18 | 12.2 |
| 7–9 | 83 | 56,5 |
| 10–12 | 38 | 25.9 |
| 12+ | 8 | 5.4 |
| Marital status | ||
| Married | 128 | 87.1 |
| Non-married | 19 | 12.9 |
| Individual income | ||
| ¥0 to 3,999 | 123 | 83.67 |
| ¥4,000 and over | 24 | 16.33 |
| Smoking status | ||
| Yes | 20 | 13.6 |
| No | 127 | 86.4 |
| Alcohol use | ||
| Yes | 48 | 32.6 |
| No | 99 | 67.4 |
| Physical activity | ||
| Yes | 127 | 86.4 |
| No | 20 | 13.6 |
| Chronic disease status | ||
| Yes | 116 | 78.9 |
| No | 31 | 21.1 |
Table 2 shows the changes in behavior and psychology after community practical training. About 37.4% and 21.1% of the participants reported irregular eating habits at baseline and endline, respectively (p = 0.001). About 10.2% and 19.7% of participants were light drinkers at baseline and endline, respectively. By contrast, about 21.8% and 17.0% of participants were moderate to heavy drinkers at baseline and endline, respectively (p = 0.059).
| Category Variables | Baseline survey | Endline survey | |||
|---|---|---|---|---|---|
| n | % | n | % | P | |
| Alcohol use | |||||
| No drinking | 100 | 68.0 | 93 | 63.3 | 0.059 |
| Light drinking | 15 | 10.2 | 29 | 19.7 | |
| Moderate-heavy drinking | 32 | 21,8 | 25 | 17.0 | |
| Eating habits | |||||
| Very regular | 92 | 62.6 | 116 | 78.9 | 0.001 |
| Not very regular | 55 | 37.4 | 31 | 21.1 | |
| Self-perceived health | |||||
| Very good | 11 | 7.5 | 22 | 15.0 | 0.036 |
| Good | 62 | 42.2 | 63 | 42.8 | |
| Ordinary | 56 | 38.1 | 55 | 37.4 | |
| Not good | 18 | 12.2 | 7 | 4.8 | |
| Continuous variables (Mean, SD) | |||||
| Self-efficacy scores | 25.7 | 6.1 | 29.0 | 6.7 | < 0.001 |
| DASC-21 scores | 26.3 | 3.4 | 25.0 | 3.1 | 0.001 |
| DYS scores | 40.5 | 9.4 | 38.5 | 9.9 | 0.079 |
| Depression scores | 1.9 | 2.5 | 2.2 | 2.1 | 0.300 |
| Time of physical activity | 51.6 | 25.6 | 56.5 | 35.0 | 0.203 |
| DASC-21: Dementia Assessment Sheet for Community-based Integrated Care System 21-items. | |||||
| DYS: Dependency scores | |||||
In terms of self-perceived health status, 7.5% and 12.2% participants reported “very good” and “not good”, respectively, at baseline, and these values increased to 15.5% and decreased to 4.8%, respectively, at endline (p = 0.036). Participants had significantly higher self-efficacy scores in the endline survey than in the baseline survey (p < 0.001). By contrast, the DASC-21 scores of participants were 26.3 and 25.0 points at baseline and endline, respectively (p = 0.001).
The association of community practice training with changes in psychology and behavior analyzed by logistic regression analysis is shown in Table 3. Community practice training was significantly associated with increased self-efficacy and decreased DASC-21 scores, with ORs of 1.08 (95% CI = 1.04–1.13, p < 0.001) and 0.90 (95% CI = 0.83–0.98, p < 0.013), respectively. Community practice training was associated with altered eating habits from irregular to very regular, with OR of 1.93 (95% CI = 1.18–3.15, p = 0.009). The association between community practice training and self-perceived health status no longer maintained a significant level after adjustment for gender, education levels, marital status, physical activity, individual income, and social support.
| Variables | Multivariable adjusted | P | ||
|---|---|---|---|---|
| Odds Ratios | 95% CI | |||
| Self-efficacy scores (points) | 1.08 | 1.04 | 1.13 | < 0.001 |
| DASC-21 scores (points) | 0.90 | 0.83 | 0.98 | < 0.013 |
| Eating habits (irregular to very regular) | 1.93 | 1.18 | 3.15 | 0.009 |
| Age (yr) | 1.08 | 1.03 | 1.13 | 0.001 |
| SPH (not good to very good) | 1.19 | 0.86 | 1.66 | 0.285 |
| DYS scores (points) | 1.01 | 0.98 | 1.04 | 0.495 |
| Model adjusted for gender, education levels, marital status, physical activity, individual income and social support. | ||||
| SPH: self-perceived health | ||||
| DASC-21: Dementia Assessment Sheet for Community-based Integrated Care System 21-items. | ||||
| DYS: Dependency scores | ||||
In this work, we have identified that community practice training is significantly associated with changes in behavior and psychology among the elderly living in a community through a prospective study design. After the community practice training, significantly increased self-efficacy and cognitive levels and altered eating habits from irregular to very regular are observed among the elderly.
Community environment and health assessment [19, 20], project planning, survey implementation and evaluation, and direct community practice are the core contents of community public health practice education [21, 22]. Community practice training is also the basis for all public health research, intervention strategy formulation, public health policy implementation, and disaster prevention [23, 24]. Studies showed that applied investigation is also an effective way of health education and health promotion and covers the main contents of practical education and training of community public health [25, 26]. The implementation of the applied investigation needs the comprehensive use of multidisciplinary study methods, such as social medicine, medical statistics, epidemiology, public health, health education, and behavioral medicine and management.
In this study, we have used applied investigation to conduct community diagnosis. Daily living conditions of the elderly living in the community during the COVID-19 epidemic, including their strategies for maintain health, opportunities to obtain medical information, food and drug needs, utilization of health services, frequency of communications with family or friends, and changes in mental health under social isolation status, are collected. In the baseline survey, we have found that the elderly have a high tendency to dependency personality disorders during the COVID-19 epidemic. The elderly have higher utilization frequency of medical services and facilities and increased the demand for health consultation and physical examination services after the outbreak of the COVID-19 epidemic compared with before the outbreak of the COVID-19 epidemic. Subjects have reported highly irregular eating habits, which may be related to the control management of going out during the epidemic. Most of the subjects have reported ordinary or poor self-perceived health status.
In addition, applied investigation is a method and ways of health education. The positive association of education and health is established [27], but inequality in health education is still common especially among the elderly people, who lack educational resources and opportunities than younger people [28, 29]. On the one hand, socioeconomic variations may affect behavior. On the other hand, health resources, like education, may be limited because of the growing frailty among the elderly. This community practical training provides a good opportunity to receive health education for these elderly people. We have observed remarkably improved self-perceived health and eating habits and significantly increased self-efficacy and cognitive levels among the elderly in the endline survey. One reason for convergence may be that long-term environmental exposure can lead to the body and cognition function to adapt gradually to environmental changes, but we can at least recognize that health education based on community practice training has played a role. This result is also confirmed in our further analysis, whereas the changes in self-efficacy, cognitive level, and eating habits at endline are significantly associated with community practice training.
The period of major public health events and disease epidemics is the best time for community diagnosis and implementation of public health projects. These projects can quickly identify public health problems, implement emergency preventive strategy, guide health promotion, and enhance the community comprehensive prevention and control capacity. In this study, the elderly are selected as study subjects due to high risk of disease compared with other age groups and remarkable effect on their daily health behavior and mental health. Changes in behavior and psychology of these elderly people is also easy to observe at endline. The COVID-19 epidemic provides a good opportunity to obtain professional knowledge and practical skills for MPH students. After the community practice training, the students have observed that the psychology and behavior of study participants change into a healthy outcome, thus strengthening their determination and beliefs of participating in community public health work [30].
The main strength of this study is that it is a prospective study, which has a strong power to prove a causal link between community practical training and change in behavioral and psychological health. In addition, we have collected a large number of data. Therefore, we can analyze many health-related factors. This study also has several limitations. First, this study has a relatively small sample size. Although the study is a good community practice training and education project, results are difficult to extrapolate to all people. In addition, due to the epidemic, we have not implemented many health promotion plans and interventions.
In conclusion, this study identified that community practice training, as community education, can develop practice skills and have a beneficial effect on the health of individuals living in the community. Additionally, community practice training may have positive effects on MPH students’ considerations of a career in community public health. We suggest that community practice training is also a good way to promote the health of community residents especially the elderly and vulnerable groups. Community practice training should be further strengthened for MPH students.
MPH: Master of Public Health
COVID-19: Corona Virus Disease 2019
GSES: General Self-Efficacy Scale
DASC-21: Dementia Assessment Sheet for Community-based Integrated Care System-21 items
EPQ: Eysenck Personality Questionnaire
ORs: Odds ratios
CI: Confidence interval
Ethics approval and consent to participate
All participants provided informed consent before participation，and oral informed consent was taken for illiterate participants. The study and method of oral informed consent were approved by the institutional review board at the School of Public Health, Zhejiang University (No: ZGL201909-10), and performed in accordance with the Declaration of Helsinki.
Consent for publication
Not applicable.
Availability of data and materials
The datasets generated and analysed during the current study are not publicly available due to ensure the privacy of participants but are available from the corresponding author on reasonable request.
Competing interests
The authors declare no conflict of interest.
Funding
This work was supported by the Leading Innovative and Entrepreneur Team Introduction Program of Zhejiang (2019R01007) and in part by the Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province (2020E10004).
Authors' contributions
In this paper, YL was the principal investigators and involved in the study design and conception, manuscript preparation. YYP, XWD, and AA performed data collection and analysis.
Acknowledgements
We thank Xiaojun Si, Xia Gao, Dongbin Hu and Xuanting Liu for their assistance with survey set up.