Harnessing the potential of family adoption program mandates and beyond: An institutional case study

INTRODUCTION

The family adoption program (FAP) outlined in GMER 2023 and 2024 has been an integral part of the current competency-based medical education (CBME) curriculum for over half a decade now.^[1-3] It was envisaged to serve as a dual tool for student experiential learning and community engagement in India where public health curriculum is not very robust but at the same time, most crucial.^[4]

The structure of the FAP was built upon the principles of community-based educational design to develop the core competencies of empathy and communication, understanding the dynamics of rural setup, cultural competence, community engagement, understanding social determinants of health, and fulfilling social responsibility in the form of environmental protection and sustenance activities.^[5] To deliver these outcomes, the departments of community medicine were placed at the hub which would be involved in need assessment and program designing, curriculum development and delivery, competency mapping, community engagement, interdisciplinary collaboration, health promotion and disease prevention, implementation and assessment, advocacy and policy issues, and evaluating program outcomes.^[5,6] Hence, the integration of FAP into CBME-based curriculum represents transformative approaches at micro, meso, and macro levels of the framework.^[7]

Since its inception, various educationists and researchers have reported their experiences, highlighting the practices, challenges, and also some solutions thereof. There also have been publications on reporting of best practices and lessons learned so as to achieve a tri-level alignment through FAP.^[4] Toward harmonizing the efforts placed for the successful implementation of FAP and providing a discussion forum, a national-level initiative was also launched by National Medical Commission (NMC) under the aegis of which 3 publications were released on September 26, 2023, at NMC headquarters in New Delhi. These publications showcased activities, achievements, and reflections on FAP pan-India.^[8-10]

However, since FAP is a program to stay, the complete evaluation of the evolution needs to be reflected by all institutes implementing FAP, to explain the context (organizational, curricular, and community-based) elements that make FAP more educational and health-promotional in addition to documenting compliance with NMC mandates. This is much more needed to give a clear picture for further successful sustenance of the program and make the required modifications so as to provide us with a further roadmap to follow.

MATERIAL AND METHODS

The study was planned as a mixed-methods study using both quantitative and qualitative approaches to data collection which were simultaneously integrated to fit into the framework of the logic model of program evaluation. The study was done in a private medical college over a period of 1 year after approval from the research and ethics committees. Informed written consent was obtained from all participants. The study population included all MBBS students from batch 2021, 2022, 2023, and 2024, all community medicine and allied departments faculty involved in FAP and representatives of adopted families and their community leaders. For students and faculty, universal sampling was adopted, while for adopted families, purposive sampling was done to have representation from all villages. For selecting program performance indicators, the logic model was used to classify inputs, activities, outputs, outcomes, and impact data. Survey questionnaire for obtaining feedback from students and community was designed after a literature review and was peer-reviewed by experts for validation. For obtaining open feedback from students, faculty, and community leaders, focus group discussions (FGDs) and IDI guides were also peer reviewed and validated. Document analysis was done for reviewing the institutional FAP guidelines and implementation documents, logbooks, and portfolios of students and field activity reports of the department. A survey was done using self-administered structured questionnaires for students and interviewer administered for community representatives to collect quantitative information regarding experiences and perceptions of FAP. For exploring the depth of the experiences and perceptions, FGDs were conducted with students (4 groups of 8–10 participants) and faculty (2 groups of 8 participants each). Structured in-depth interviews were held with community leaders (2 from each village = 8). Program outcome data for quantitative metrics such as students’ attendance and performances, and health records for community such as screening rates and coverages were obtained from program records. Quantitative data analysis of survey responses was on Likert scale and numerical metrics were analyzed as frequencies and percentages through Microsoft Excel. For qualitative data, transcripts of FGDs and interviews were manually analyzed using a thematic approach to generate codes, categories, and themes.

RESULTS

The study targeted to review the past 4 years of FAP implementation. Methodological mapping to evaluate the program has been done using the Logic Model Framework [Figure 1], and the results have been analyzed [Table 1].

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Figure 1: Logic model evaluation of family adoption program.

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As per the NMC guidelines, four villages were adopted successively each year (Tungwali, Nathana, Lehra Mohabbat, and Mehraj) which is now planned to be continued in a cyclic fashion for the next Batches. A total of 2,079 families amounting to 10,202 individuals have been covered under FAP.

For planning, training, and actual implementation of FAP, a significant number of faculty and student hours was invested. Faculty-student mentoring sessions consume around 154 h annually. Around 10 health camps and 75 home visits per year were conducted.

As per output [Table 2], the educational output in the form of minimum of 03 family adoptions per student was achieved as per NMC norms. An average of two health camps per village was organized successfully every year. Screening of 497 individuals for diabetes and 6442 for hypertension was carried out. Anthropometric measurements for 6960 individuals were documented. These screenings were accompanied by 21 educational sessions which included individual and group sessions. The high attendance rate of students during FAP (reaching 94.8%) indicated good student engagement in the program.

Outcomes were analyzed as perceptions and impact on various stakeholders.

Community

FAP was perceived as being very helpful by the community [Figure 2 and Table 6]. While 74% reported a high impact on their knowledge of healthcare accessibility, 72% also reported high improvement in doctor–patient relationship. 55% community members were highly satisfied with the students’ role and contribution to their families and community through various activities such as health camps, referral consultations, and health counseling sessions.

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Figure 2: Community responses for seeking doctor’s consultation before and after family adoption program.

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Table 6: Community’s perception of FAP.

Perceived impact of FAP on various parameters	Low (%)	Medium (%)	High (%)
Knowledge related to healthcare services (n=116)	4 (3.45)	30 (25.86)	82 (70.69)
Knowledge related to accessibility to healthcare services (n=116)	2 (1.72)	28 (24.14)	86 (74.14)
Patient–doctor relationship (n=116)	4 (3.45)	28 (24.14)	84 (72.41)
Level of satisfaction related to students’ role in FAP (n=116)	4 (3.45)	48 (41.38)	64 (55.17)

FAP: Family adoption program

Figure 3 represents the strengths and challenges from various stakeholders after triangulation of data from all sources. On in-depth discussion and analysis of responses, it is proposed that additional CBME facets can be exploited and utilized under FAP. Figure 4 represents the wide opportunities for its branchification and implementation. Figure 5 shows the ripple effect of FAP on students, faculty, community and institution in terms of academic benefits and community engagement.

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Figure 3: Strengths and challenges of the family adoption program.

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Figure 4: Additional competency-based medical education components explored during the family adoption program. FAP: Family adoption program. AIT: Aligned and integrated topics, LDP: Learner doctor program, AETCOM: Attitude, Ethics and Communication, ECE: Early clinical exposure.

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Figure 5: Ripple effect of family adoption program.

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DISCUSSION

The implementation of FAP at every Institute demands an evaluation so as to gauge their own compliance with the mandate as well as to create a meaningful educational impact. A structured evaluation was reported from Assam using mixed methods similar to our study, which also focuses on utilizing various data collection methods so as to provide a comprehensive picture of the whole program.^[11] Study by Shah and Lotliker^[12] provided us with a snapshot of the scenario at a few medical colleges in India. The main findings of the study highlight the differences in the input and processes of the FAP, where the number of families allotted did not comply with 5 or 3 as laid down by NMC guidelines, justifying the logistical issues in the allotment of families. The challenges reported regarding manpower shortage, transport facilities, logistics at implementation sites, and insufficient support from government bodies as well as the community were highlighted. Similar issues related to enormous inputs to be arranged for FAP have been reported from studies of many other authors.^[13-16] The findings of our study also correlate with the high amount of basic requirements in terms of manpower, money, and materials to be invested in FAP. The significant investment in terms of faculty hours, student hours, and involvement of field workers, large amount of budget was invested in terms of transport as well as the conduct of health camps, which accounted for direct costs. Indirect costs also involved the subsidized rates being offered to the referred patients from the field practice area. This calls for a large amount of planning at the and administrative and logistic end for the sustenance of FAP program.

A proper plan in the timetable schedule with the fixing of hours for every batch was achieved as per the NMC mandate. This finding was supported by other studies such as Shah Lotliker, Landge et al., Arumugam et al., and Kowmudi et al.^{[12,14,17,18]} who also emphasized that proper planning, coordination and support are necessary for a successful program. A detailed planning process was shared by Shikha et al.^[16] who focused on the detailed activities and TL methods along with step-wise flowchart of the methodology adopted for FAP. These planning activities are very crucial as also reflected by the Sewagram curriculum and adopted by many other Institutions such as AIIMS under Family Health Adoption Program which emphasize a residential and longitudinal planning to be a part of FAP.

Assessments of students by the authors were conducted through logbooks and portfolios. Very few studies have reported the use of documentation in logbooks, and none of the study has reported the use of a portfolio for FAP. Probably ours is the only institute which has introduced the longitudinal learning and assessment portfolio^[19] for FAP evaluation and this has been documented as emerging best practices as reported in a position paper by Shah et al.^[4]

Conduction of health camps and health education sessions was reported as an important component by almost all the authors who had reported on input needs for FAP. Studies related to outputs have documented screening of NCD cases and also referrals for beneficiaries.^[20] The provision of University Priority Health card for patients referred from FAP areas has also been reported, a similar initiative in the form of smart cards provided in our Institute.^[20] This emphasizes the need for referral linkage and the advantage being offered to the adopted families and calls for support from hospital management and authorities in case of private stakeholders. This forms a considerable budget under corporate social responsibility as envisaged by the guidelines of higher educational institutions in addition to the logistic investment for outreach camps. This would also cater to the problem reported by Reshmi et al.^[15], Shikha et al.^[16], and Yalamanchili et al.^[21] who feel it is a challenge when the families ask what benefit they will receive, thus enhancing the acceptability of FAP by the community.

Outcomes of IMGs in the form of academic and professional growth were reported by the students.^[13] The understanding of community health, empathy, communication, practical skills, team collaboration, and personal growth has been reported as positive outcomes. In addition, leadership skills, increased research inclination, early clinical exposure, and Attitude, Ethics and Communication (AETCOM) were reported.^[14,20] Furthermore, identification of cases related to AIT blocks such as hypertension, tuberculosis, anemia, and other non-communicable diseases positively added to the learning. Environmental wellness coincided with the findings from Priyaranjan et al.^[22] leading to improved awareness of the community and environmental system. Overall satisfaction was reported to be high and also reported academic improvement and FAP program satisfaction. ^{[15,20,21,23]} These findings are almost similar to the agreements reported in our study. However, despite FAP, only 39% students in our study were motivated to choose a community health-related career.

Studies have been conducted to collect the reflections of students and other stakeholders after undergoing FAP.^[17,18] The key findings here were related to outcomes and impact which supported the fact that the students had an opportunity to develop their communication skills and teamwork.

Different views on the timing of introducing students to FAP have been received from various studies with some agreeing and some demanding a delayed timing.^[23] A study from Mysore reported that many of the students did not agree to the exposure of students to FAP in 1^st year, as they were not very familiar and could not offer much to the family, as they were still themselves not very sure of the correct scientific knowledge. They were unable to build trust with family, leading to poor experience. Half of them reported having no idea of what changes they were supposed to bring about in their families, due to which most of the activities were only limited to generic data collection, lacking depth. However, the present scenario cannot be decided by the institutes as the NMC guidelines on FAP mention introduction in 1^st year itself. Alternatively, planning activities on improving acceptability of students in the community are required to be strengthened.

Many strengths, weaknesses, opportunities and challenges (SWOC) studies have contributed to understanding various aspects of this program, which overlap with the findings of the current study. Individualization of SWOC areas has been noticed in various studies, which calls for local action; at the same time, a few areas need to be streamlined at the NMC policy level. Shikha et al.^[16] presented their experience and SWOC analysis of 1 year of FAP activities. They emphasized and provided a detailed flow chart and list of activities which were a part of their FAP program which led to their success. This would enable the students to understand the cultural context and to understand people’s needs in terms of health and develop their own interpersonal skills. This would also help them feel more confident and provide the finest exposure to serving as community health doctors. Development of leadership skills, AETCOM, and community exposure were the main strengths. The opportunities of community diagnosis and treatment leading to the achievement of the goal of health for all need to be exploited. The threats of resistance, language barriers, time, feasibility, and cultural issues need to be properly addressed. Allocation of adequate amounts of resources and working on logistics and timetables needs to be privatized for the successful implementation of FAP.

Similarly, a study from Assam^[11] emphasized the need for comprehensive program evaluation and formulation of standard operating modules to strengthen the FAP at various institutes. This emphasizes the need for program evaluation by every Institute undergoing FAP and by pulling up the findings from Pan-India to develop a standardized module for implementation of which lays out the intricate details and solutions to overcome the challenges faced by the majority. Similar to our study, most of their participants agreed to the policy decision of introducing FAP, which would benefit the students to gain knowledge, skills, attitude, and communication relevant for IMGs, thereby helping them to understand community health and social structures. This would also provide an appropriate early clinical exposure here, helping them to understand the health awareness and health-seeking behavior of the family. The benefits were reported by the medical students as well as the community, who also reported their benefits in terms of routine health checkups, health advice, and social assistance under schemes such as Ayushman Bharat and awareness regarding the same. At the same time, the community also reported issues with students invading too much into their families during working hours, which was also reported by the students as a reason for non-cooperation by the family. They also recommended a late start of FAP beyond year 1 and restriction on the number of families to be adopted and changing the timings of the visits. Their recommendations included the development of student assessment tools to assess their learning from this program. This has been taken care of by the present authors by using portfolios for learning as well as assessment of FAP.

Shikha et al.^[16] suggested cyclical adoption of the families after one batch has finished, and the same is adopted as a part of the plan at our institute. Hence, the villages are adopted in a cyclical nature, with the new batch of students replacing the outgoing batch students’ families. This would prevent the family from becoming orphaned and hence provide Continuum care services.

Ganganahalli et al.^[24] proposed the use of the module for structured community-based teaching and learning during FAP. The basic structure of the module suggested aligns with the activities, teaching, learning methods, and assessment methods being utilized in our institute. However, having a unified structured module for FAP throughout India will help in the standardization of the program delivery.

CONCLUSION

The evaluation of FAP at the Institutional level provides a complete picture of the inputs, activities, processes, outputs and outcomes as well as impact. These indicators – both qualitative and quantitative – provide a comparison for what was planned, what were actual implementation scenarios, and what was achieved and what could not happen as per plan. Since these insights provide a ground framework, every institute must adopt a system of evaluation for future sustenance of the program in their institutes as well as provide feedback to the regulatory bodies to achieve its desired goals.