In this report we have evaluated the implementation of a public health community-based service learning programme at the University of Lyon. In this programme medical students were taught the basic concepts of health education and promotion, and then put this knowledge into practice with school pupils. The perception of students was assessed before and after the service learning experience through quantitative and qualitative approaches, as well as observations of participants in schools. Results indicated that the students were satisfied with teaching by interactive seminars, which were considered as more concrete than other forms of instruction. Thus, they gained confidence in their teaching capacities. Their perception of the public health programme evolved during the year, from a negative one – due to the new and compulsory nature of the concept – to a positive one after their action in schools. Following their involvement in community-based service learning, the students began to broaden their understanding of their role as future physicians in promoting and educating people about public health issues, and gained insight into social inequalities in health, health determinants, and health literacy. Students therefore developed professional skills including knowledge, project management, communication, health education, and empathy. Observation of students during their action showed that they had an adequate understanding of public health issues.
This study had certain limitations. For the quantitative approach based on a questionnaire, the most evident limitation is the possible information bias resulting from evaluation of student skills before and after the seminars that were made at the same time. This bias might have overestimated the impact of the seminars, but we believe that the students are capable of evaluating their own progress. In addition, student satisfaction could have been influenced by parameters with no relation to the quality of teaching, such as the friendly nature of the teacher or the students’ interest in the subject, but this point is still debated by medical education researchers (7). Concerning the qualitative approach, the limited number of students that were interviewed allowed data saturation, but may not be representative of the entire year group. There are also strengths that are of note, for instance, there was a high response rate for the quantitative approach (90.6%) which ensured representative answers (8). Furthermore, the interviews confirmed the high level of satisfaction of the students with the seminars, and the observations demonstrated that students acquired adequate health education skills. Methodological triangulation was also a strength of our study, whereby qualitative results were confirmed by quantitative data.
The delivery of undergraduate medical education in public health is a worldwide challenge, and diverse designs for the organisation of curriculum to ensure effective public health education have been reported (9–11). Integration of national public health problems into the training of medical students at the University of Lyon occurs very gradually: students receive theoretical training on health education only in the third year of medicine and fourth year of midwifery. However, the training programme for medical students in public health issues is much greater in many other countries. For instance, at the Ege University medical school in Turkey, the first three years of training includes 100 hours of lectures, 18 sessions of integrated case discussions, and 83 hours per student of group activities related to public health; the latter are composed of problem-solving sessions that include critical appraisal of health data, social determinants of health, and health promotion (12). In addition, students in their second year work in primary health centres under the supervision of trained general practitioners for three half-day periods, and third-year students visit the same centres for seven days (12).
In the US, medical schools have experimented with service learning as an additional component to medical education for students (13). For example, in Arkansas a service learning experience was attempted with a vulnerable population (the homeless) for student nurses, the aim of which was to acquire favourable advocacy for this group, to change the nurses’ initial attitudes and perception, and ultimately improve the health of disadvantaged populations (14). These experiences allowed students to use their academic knowledge and skills in a specific social context (15) and led to an improvement of students’ academic results, a decrease in the students’ fear of populations they did not know, an increase in empathy, and also had a positive effect on leadership skills (13, 14, 16). These outcomes are in agreement with that results presented herein.
The UK takes this a step further since as of 2018 newly qualified physicians are trained to apply the principles of sustainable healthcare to medical practice (17). This focuses on the improvement of health and better delivery of healthcare, rather than late intervention in diseases, resulting in benefits to patients and to the environment in which human health depends. This approach emphasises that future physicians should not only integrate prevention and health promotion into their public health roles, but also the dimension of sustainable development (18). This goes beyond the French programme described here but could be of interest in the future.