Education for Health Volume 28, Issue 2 (August 2015)
CONTENTS Editorial Co‑Editors Notes 28:2
Michael Glasser, Donald Pathman...................................................................................................................................... 116
Original Research Articles Residents’ and Attendings’ Perceptions of a Night Float System in an Internal Medicine Program in Canada Anurag Saxena, Loni Desanghere, Robert P. Skomro, Thomas W. Wilson........................................................................ 118
Group Work: Facilitating the Learning of International and Domestic Undergraduate Nursing Students Julie Shaw, Creina Mitchell, Letitia Del Fabbro................................................................................................................... 124
Improving Health Literacy of Women about Iron Deficiency Anemia and Civic Responsibility of Students through Service Learning Rukhsana Aslam Ayub, Tara Jaffery, Faisal Aziz, Muneeb Rahmat.................................................................................... 130
Brief Communications Application of Kern’s Six‑step Approach to Curriculum Development by Global Health Residents Leigh R. Sweet, Debra L. Palazzi....................................................................................................................................... 138
Higher Acceptance Rates for Abstracts Written in English at a National Research Student Meeting in a Non‑English Speaking Country Afshin Khani, Amin Zarghami, Fatemeh Izadpanah, Hamid Mahdizadeh, Leila Golestanifar............................................. 142
Comment Ongoing Faculty Development for Peer Tutors: A Widely Neglected Need Gihan Jayasinghe, Rebecca Jayasinghe, Dason E. Evans................................................................................................ 145
Letters to the Editor Hand Hygiene and Health Care Hierarchy by Year of Medical Education Vic Sahai, Karen Eden, Shari Glustein................................................................................................................................ 148
Medical Students Hanging by a Thread Sonal Pruthi, Vineet Gupta, Ashish Goel............................................................................................................................ 150
Knowledge, Attitude and Practices of Evidence‑based Medicine among Sudanese Medical Doctors Hatim Sid Ahmed, Elsadig Yousif Mohamed, Sawsan Mustafa Abdalla, Khalid Altohami Madani, Feroze Kaliyadan......................................................................................................................... 152
Evidence‑based Practice among Physiotherapy Practitioners in Mumbai, India Vrushali P. Panhale, Bharati Bellare.................................................................................................................................... 154
Distance Training of Medical Laboratory Professionals in Sub‑Saharan Africa: Concern over Assessment Method Ezekiel U. Nwose, Phillip T. Bwititi...................................................................................................................................... 156
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Original Research Article
Improving Health Literacy of Women about Iron Deficiency Anemia and Civic Responsibility of Students through Service Learning Rukhsana Aslam Ayub1, Tara Jaffery2, Faisal Aziz3, Muneeb Rahmat4 Department of Medical Education, Fatima Memorial Hospital Medical and Dental College, Shadman, Lahore, 2Department of Internal Medicine, Shifa College of Medicine, Shifa Tameer-e-Millat University Islamabad, Pakistan, 3Institute of Public Health, College of Medicine and Health Sciences, University, Al Ain, United Arab Emirates, 4Department of Planning and Development, Fatima Memorial System, Shadman, Lahore, Pakistan 1
ABSTRACT Background: Service‑learning (S‑L) is an educational approach that integrates community service with academic learning. S‑L helps educate youth about their civic role and responsibility in society, and empowers them to tackle societal problems, strengthening communities through civic engagement. The objectives of this study were to demonstrate the effectiveness of S‑L in fostering civic responsibility and communication skills in college students and to increase health literacy regarding iron‑deficiency anemia (IDA) among both students and community women. Methods: This interventional exploratory study used a mixed methods approach. Thirteen first‑year students from a women’s college participated in the project. The authors held small interactive group sessions to teach the students about IDA and communication skills. A questionnaire measured the students’ perceived knowledge about civic responsibility, communication skills, and IDA. The students then developed and delivered a health education campaign for sixty five community women and measured changes in the women’s health literacy about IDA. A focus group discussion was conducted to collect students’ reflections after the S‑L experience. The changes in the civic responsibility and communication skills were determined by Wilcoxon rank test, while health literacy in women by a McNemar test. Results: Students showed significant improvement in all three constructs of civic responsibility and in perceptions of their communication skills. Increases in civic responsibility and in acquisition of knowledge emerged as the main themes of the focus group discussion with students. The community women showed substantial improvement in health literacy of IDA. Discussion: In this study, S‑L achieves two purposes: (a) Increases students’ knowledge of health topics, their sense of civic responsibility and improves their communication skills, and (b) educates women in the community about common and preventable health issues. Keywords: Civic responsibility, health literacy, iron deficiency anemia, service learning
Background Developing countries like Pakistan face a host of social, economic and health‑related problems, and much of their limited resources are spent on managing high morbidity and mortality caused by chronic diseases, many of which are easily preventable.[1] The burden of responsibility of improving the health of the population, however, cannot Access this article online Quick Response Code: Website: www.educationforhealth.net
DOI: 10.4103/1357-6283.170122
be the sole responsibility of the government. One strategy to increase societal responsibility for health is to increase awareness in youth about their civic role in society. There is clear evidence that social change to improve health outcomes can be brought about through student engagement with the community.[2,3] Educational strategies that provide students with the opportunity to practice what they learn in real‑life situations have been shown to be an effective way to increase social awareness. Service learning (S‑L) is defined as “a teaching and learning strategy that integrates meaningful community service with academic instruction and reflection to enrich the learning experience, teach civic responsibility, and strengthen communities.”[2] For this study, we focused on S‑L as a strategy to improve the health literacy of women in the community
Address for correspondence: Dr. Rukhsana Aslam Ayub, House No. 17, Street 13, Sector H, Phase 2, DHA, Islamabad, Pakistan. E‑mail: rukhsana117@hotmail.com 130
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about iron‑deficiency anemia (IDA), which is highly prevalent the world over,[4] including Pakistani women. The main causes of IDA are dietary deficiency, multi‑parity, worm infestation, poor iron absorption and lack of health services.[5] Oral iron supplementation is widely used for treating IDA, but side effects lead to poor compliance.[6,7] The estimated prevalence of IDA in Pakistan among children is 50.9%, leading to impaired school performance.[8,9] Among women of reproductive age (WRA) in Pakistan, the estimated prevalence of IDA is 27.9%.[8] IDA has a profound impact on this major work forcegroup, reducing women’swork capacity, bringing serious social and economic consequences to families and impeding national development.[7,8,10] IDA also leads to major health problems among WRA such as poor pregnancy outcome.[7,8,11,12] Increasing awareness of WRA about the causes, effects and prevention of IDA through health education campaigns has shown to be effective in combating this highly prevalent yet easily preventable condition.[6,13,14] Two of the main hurdles Pakistan faces in improving the health of its population are the inadequate number of healthcare personnel and the overall low adult literacy rate of 55% (67% for men, 42% for women) which hinders effective health education and disease prevention.[15‑17] An individual’s literacy level has been shown to positively correlate with health literacy, making it easier to impart health information in populations with higher literacy rates.[18‑20] Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health‑related decisions.”[21,22] People with low health literacy face great risks; they experience unnecessary illness and disability,[23] are poor users of preventive care, and are unable to use print‑only material effectively.[19] For such settings other methods, like pamphlets with simple graphics, may be employed.[24] These problems are present in developed countries like the United States as well, and new and innovative techniques are thus needed to meet healthcare needs of communities with lower literacy rates.[3,25] One approach that is being increasingly used in the US is Service Learning (S‑L) – creating a volunteer work force comprised of competent and energetic undergraduate college students who assist those engaged in public health.[25,26] S‑L has its roots from John Dewey, who identified the interaction of knowledge and skills with experience as central to learning.[2,27,28] Effective S‑L programs are designed to equally benefit the provider and the recipient of service, and to focus on both the quality of the service and the learning.[29] To maximize the benefit of S‑L, students must have time and opportunity to reflect critically on their service experience. This reflection helps clarify the learner’s meaning of the Education for Health • Volume 28 • Issue 2 (August 2015)
experience and leads to change in their thinking.[2,28,30,31] In Pakistan, there are very few educational programs that provide relevance of learning in the context of real life situations. Pakistani public and private educational institutions rely on classroom teaching with little exposure to community lifestyle. This is why, in view of the aforementioned problems Pakistan is facing, service learning becomes a highly relevant teaching and learning strategy. This paper presents the results of an exploratory, mixed methods S‑L intervention where students were engaged with the community in a health education campaign. Both the students and the women community participants benefited as they were educated about causes, effects, and prevention of IDA. Through interaction with the community, the students became skilled communicators and also developed a greater sense of civic responsibility.
Methods Student participants The Principal Investigator described the S‑L project to 40 first‑year students (freshmen) and ten faculty members in a public Girls’ Degree College1. Thirteen students volunteered to participate in the six‑week project, conducted in the summer of 2010, and received certificates at the end. The college assigned two teachers for training and facilitating the project. Approval for the project was granted from the Ethical Review Board of Girls’ Degree Collegei. Phase I (before actual field visit) We developed a 30‑item questionnaire to assess health literacy of students and the community women on three dimensions before and after training: Sources of iron, causes of IDA, and signs and symptoms of IDA. The content of questionnaire was finalized through literature review[32‑34] and by consulting two medical specialists and a gynecologist. The questionnaire was translated in Urdu for the community women. After completing the pre‑test, students learned about IDA in six sessions lasting for up to 3 hours each. The students were considered health literate if they scored 80% on the post‑test in identifying meat, spinach and lentils as important dietary sources of iron, diets insufficient in meat, worm infestation, and multiple child births as important causes of IDA,[32,33] pallor, tiredness, and shortness of breath as main ‑symptoms of IDA,[34] and juices containing Vitamin C as major facilitators of iron absorption.[33] We pilot tested the Urdu version of the questionnaire on 30 housekeeping women of the same socio‑economic and demographic background as the target women. Afterwards, i 1 Girl’s Degree College is the standard nomenclature used in Pakistan to describe ‘women’s college’.
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inter‑item reliability of the tool was determined by Cronbach’s alpha coefficients for each dimension: Sources of iron = 0.94, causes of IDA = 0.87 and signs and symptoms of IDA = 0.78. The piloting resulted in a few modifications in the Urdu questionnaire and helped students select educational strategies easily understood by community women. The authors also conducted a baseline survey of the students’ perceptions about civic responsibility using the 24‑item civic responsibility survey (CRS) version K12, level 3 instrument that has been used extensively. [35‑37] It uses a six‑point Likert scale (strongly disagree = 1 to strongly agree = 6) to measure perceptions about civic responsibility in three constructs: Connectedness to community; civic awareness and attitudes; and civic action and efficacy (overall Cronbach alpha = 0.93, and each construct = 0.63, 0.88 and 0.85 respectively). [35] We measured the students’ perception of their communication skills through the Self‑Perceived Communication Competence (SPCC) Scale.[38] This instrument has inter‑item reliability (alpha = 0.85) and strong face validity.[39,40] It measures oral communication skills across four contexts (public speaking, talking in large groups, talking in small groups, talking in dyads) and communicating with three types of receivers (strangers, acquaintances and friends). Phase II (actual field visit) To deliver training about IDA, we recruited all 65 women receiving vocational training from a non‑governmental organization (NGO). An eight‑hour long session was organized at the place provided by the NGO to promote interaction between students (n = 13) and women. Each student was assigned a small group of five to six women and they assessed the women’s baseline knowledge of IDA through the pre‑test. Afterwards, they conducted their educational intervention using pictorial pamphlets, posters, a short play and a question and answer session. After one month, students re‑administered the IDA knowledge questionnaire to 53 women out of the total 65 who participated in the baseline survey and intervention. Phase III (post‑intervention student reflection and changes in perception of civic engagement and communication skills) A college faculty member (not directly involved in the S‑L project) conducted a focus group discussion (FGD) with students (attended by all but one student, who was sick) to gather detailed information about the experiences and changes in the perception of civic learning and communication skills that occurred throughout the process of service learning. Further, it enabled students to reflect and evaluate their perceptions and behavior towards their own learning needs and of the community. The focus group included questions such as; ‘How this service learning project has changed you as a person?’, ‘What do you feel about the community where you delivered the service learning program?’ (See appendix for the 132
complete FGD guide). The authors re‑administered the CRS and the SPCC scale to the students. Data collection and analysis Data from the instruments were entered in SPSS version 17 and analyzed using Stata version 12. We used the Wilcoxon sign rank test (z‑score <1.96, P value <0.05) to measure the median difference in the perception of civic responsibility and average increase in SPCC in students (z‑score <1.96, P < 0.05), as the sample size was low and distribution was non‑normal. We applied the McNemar test (McNemar exact chi square >3.84 and P < 0.05) to measure the difference in proportion of women with knowledge about IDA before and after the health education intervention. The Principal Investigator (PI) recorded and transcribed the focus group discussion. The transcription was analyzed, coded and categorized independently by two researchers using an inductive approach. Final agreement on themes was reached by comparison of independently done thematic analysis. Any disagreement on themes was discussed until consensus was achieved.[41] Member check was done with some focus group participants who reviewed the themes for validity. The PI analyzed and categorized the data based on the agreed themes and also selected student quotes to highlight important themes.
Results Changes in student perceptions about civic responsibility and communication skills associated with the S‑L project; The 13 students showed significant increase in their perceptions of civic responsibility after survey across all three constructs: “Connection to community,” “civic awareness and attitudes,” and “civic action and efficacy” [Table 1]. The median score of connection to the community increased significantly (z = −3.19, P < 0.001) from 4 to 5.5. Similarly, median sores of civic awareness and attitudes (z = −2.44, P = 0.016) increased from 4.5 to 5.5, and civic action increased significantly (z = −2.85, P = 0.004) from 3 to 5.1. Table 1: Students’ responses on civic responsibility survey (version K 12 level 3) (n=13) Civic responsibility constructs
Preintervention score (n=13)
Postintervention score (n=13)
Wilcoxon rank test
Median Minimum- Median Minimum- Z≤1.96 maximum maximum (P<0.05) Overall 4.0 2-5.5 5.0 4.5-6.0 −2.82 (0.005) Connection to the community 4.0a 1.0-5.0 5.5 4.5-6.0 −3.19 (0.001) Civic awareness and attitudes 4.5 3-6.0 5.5 4.5-6.0 −2.44 (0.016) Civic action and efficacy 3.0 1.5-5.0 5.1 4.0-6.0 −2.85 (0.004) Wilcoxon sign rank test was applied to compare pre‑ and post‑intervention scores of civic responsibility. Z = Wilcoxon Z score ≤1.96 and P<0.05 were was considered as statistically significant for Wilcoxon rank test
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Communication skills The 13 students also showed statistically significant increase in their self‑perceived overall communication competency score, with an average increase from 68.5 to 78.6 (P < 0.001) before and after the S‑L. This increase was related to five of the seven constructs, including: Public speaking (P = 0.006), meeting (P = 0.023), speaking in groups (P = 0.038), speaking in dyads (P = 0.024), and speaking with acquaintances (P = 0.01) [Figure 1]. The changes in communicating with strangers (P = 0.06) and friends (P = 0.06) were not significant. Increase in proportion of community women’s health literacy about IDA Overall, there was a clear increase in the proportion of community women (n = 53) knowledge in all three elements of IDA. The knowledge about causes of IDA increased significantly (chi = 23.5, P < 0.001) from 32.1% (17) to 83.0% (44), sources of iron (chi = 18.6, P < 0.001) from 49.1% (26) to 96.1% (48) and signs and symptoms of IDA (chi = 22.5, P < 0.001) from 41.5% (22) to 90.6% (48) after the health education intervention [Table 2]. The health literacy of IDA among the women was compared before and after health education according to education status [Table 2]. Most of the 53 community women in the study were 15 to 25 years old (53.4%, 31), while 41.5% (22) were 26‑46 years old. Of the 53 women, about one‑third of the women were educated less than high school (33.9%, 18) and three‑fifths (66.1%, 35) equal to or more than high school. There was no statistically significant difference in gain in knowledge after health education with respect to age groups in all three components of knowledge about IDA [Table 2]. However, there was a clear association of educational level and gain in awareness of IDA with the health education intervention. The women educated less than high school (n = 18) showed the least gain. Only the proportion knowledgeable about the causes of IDA increased significantly (chi = 5.4, P = 0.039) from 38.8% (7) to 77.7% (14) after education. In contrast, substantial gains in all three elements of IDA awareness occurred with the
Figure 1: Pre‑ and post‑comparison of self‑perceived communication competency norms of students (n = 13)
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women (n = 35) who were educated high school and above. The proportion of women with knowledge about causes of IDA significantly increased (chi = 18.2, P < 0.001) from 28.5% (10) to 85.6% (30), symptoms of IDA increased (chi = 22.2, P < 0.001) from 31.4% (11) to 94.3% (33) and proportion of women knowledgeable in dietary sources of iron substantially improved from 54.0% (19) to 97.1% (34) (chi = 15.0, P < 0.001). Impact of the S‑L project on students Five themes emerged from qualitative analysis of the focus group discussion held with the students after completion of the S‑L project. The first theme, service‑learning increases civic responsibility and/or motivation to do community service, was communicated by all 12 students who were able to participate in the follow‑up focus group discussion. Typical comments included: “…I would definitely take part in such a project because you should help people regardless of their background” and “…I am responsible to care for my country.” The second theme, service‑learning increases acquisition of new knowledge, was expressed by 11 of the focus group participants. Students reflected that studying about an important health issue helped them to increase their own knowledge, and this was enhanced by disseminating information to others: “It was a wonderful experience; we told Table 2: Pre‑ and post‑health education intervention scores on awareness of IDA among women according to age and education status (n=53) Awareness of IDA
Overall (n=53) Causes of IDA Dietary sources of iron Signs and symptoms of IDA Age groups (n=53) 15-25 years (n=31) Causes of IDA Dietary sources of iron Signs and symptoms of IDA 26-45 years (n=22) Causes of IDA Dietary sources of iron Signs and symptoms of IDA Educational status (n=53) <High school (n=18) Causes of IDA Dietary sources of iron Signs and symptoms of IDA ≥High school (n=35) Causes of IDA Dietary sources of iron Signs and symptoms of IDA
Frequency (%)
McNemar test*
Preintervention
Postintervention
Chi >3.84 (P<0.05)
17 (32.1) 26 (49.1) 22 (41.5)
44 (83.0) 48 (90.6) 48 (90.6)
23.5 (<0.001) 18.6 (<0.001) 22.5 (<0.001)
8 (25.8) 16 (51.6) 9 (29.0)
25 (80.6) 27 (87.1) 28 (90.3)
17.0 (<0.001) 9.3 (0.003) 17.2 (<0.001)
9 (40.9) 10 (45.4) 13 (59.1)
19 (86.4) 21 (95.4) 20 (90.9)
7.1 (0.012) 9.3 (0.003) 5.4 (0.039)
7 (38.8) 7 (38.8) 11 (61.1)
14 (77.7) 14 (77.7) 15 (83.3)
5.4 (0.039) 4.5 (0.065) 2.7 (0.218)
10 (28.5) 19 (54.0) 11 (31.4)
30 (85.6) 34 (97.1) 33 (94.3)
18.2 (<0.001) 15.0 (0.001) 20.2 (<0.001)
McNemar test was applied to compare the pre‑ and post‑intervention scores on IDA. Chi = McNemar exact, Chi‑square score >3.84 and P<0.05 were considered as statistically significant. IDA = Iron deficiency anemia
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people who didn’t know about iron deficiency and in the process increased our own knowledge too.” Another student noted that this experience was an eye opener for her: “We learnt how a lot of women, rich or poor, don’t know about their dietary needs and symptoms of deficiencies.” The third theme was ‘improved communication skills’, noted by nine students. The students appreciated the opportunity to practice their communication skills: “The most important thing for me was learning how to interact with people. How to talk to them and how to inform them about iron deficiency.” The fourth and fifth themes were noted by one‑half of the focus group participants (6 each). Students remarked that they learned about ‘the diverse lifestyles of communities’. The hands‑on exposure helped students to connect with reality, discovering the health problems and level of health knowledge of the community: “I have gained a lot of information about how people in the poor segments of society are living.” Additionally, students commented that they experienced a sense of satisfaction after participating in the S‑L project: “‑‑‑and the satisfaction of changing people’s life is a great feeling.” Both the participating faculty members were sent an open‑ended questionnaire. They were very enthusiastic about this new educational approach. Typical comments were: “I feel happy as now I have a way through which I can change the way my students think in addition to learning the course.” “I can teach so much of my Biology syllabus through Service–Learning that I am very excited but I need help.”
Discussion
The literature has shown that health education programs for the community which pay attention to the needs of the particular community are more likely to succeed.[43] In this context, the education level of the community is an important factor to be kept in mind while designing health education programs. In addition, the language used for providing health education as well as an understanding of common biases and misconceptions related to the particular health problem in that community are relevant.[43] The initial phase of our study included translation of the IDA questionnaire in Urdu, the local language of the community, and piloting this questionnaire on women from same socio‑economic and demographic background. We involved the students participating in the project in translation and pilot testing the questionnaire after they had completed the IDA workshop. This strategy familiarized students to common terms and biases regarding IDA in the community. As students reflected on this experience, they were able to develop health education strategies according to the needs of the community. Health literacy is much more than the ability to read health information. Many conventionally well‑educated people may be challenged by low health literacy.[23] In order to help those with poor health literacy to make the right choices and decisions, it is important for them to have conversations with those providing health care and education.[44] An interesting phenomenon which emerged from the student reflections was the use of multiple educational strategies to educate WRA ‑‑ pictorial pamphlets, posters, a short play and a question and answer session related to IDA in small groups during tea. Our study showed a similar and significant increase in –Health Literacy regarding IDA in WRA of both age groups, 15 to 25 years and 26 to 46 years, perhaps related to the use of multiple strategies to promote learning.
This exploratory study established the feasibility of S‑L to promote health literacy about IDA in Pakistani women. S‑L is a powerful pedagogy for teaching public health and developing public health literacy.[2,25,42] The S‑L provided benefits to both the college students and community women. Community women gained health literacy about several aspects of IDA, which was maintained for at least one month. The women college students gained knowledge about IDA, skills in communication, and increased civic responsibility.
An individual’s literacy level has been shown to positively correlate with health literacy, making it easier to impart health information in populations with higher literacy rates.[18] In our study, there was a clear association with educational level and gain in awareness of IDA with the health education intervention. The women with less than high school level showed the least gain.
Although, S‑L is not a new concept, there are only few studies demonstrating actual improvement in health literacy.[2,42] The pedagogical principles underpinning S‑Lare the engagement of learners with the community to address community needs, and structured opportunity for reflection built into the project to facilitate the desired learning outcomes. In our study, the desired learning outcomes for the students included learning about IDA, and improving communication skills and civic responsibility. Our objective for the community was to demonstrate improvement in Health literacy related to IDA in WRA.
Kolb defines experiential learning as “the process whereby knowledge is created through the transformation of experience.”[45] The students went through a process of learning by concrete experience, reflective observation, abstract conceptualization and active experimentation. By participating in the S‑L project, ‑ the students showed more willingness to serve the community and worked to help them. A major theme which emerged from the focus group discussion was acquisition of new knowledge. The students applied the knowledge about an important public health issue to a practical experience. Various studies using S‑L report
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similar improvement in critical thinking, problem‑solving and interpersonal skills along with development of civic responsibility,[3,30,46‑48] as well as improved communication skills.[30,49,50] The students showed improved scores on the SPCC scale for all of the contexts and types of receivers except for the ability to talk to friends and strangers. The results with friends could be due to the fact that the students already rated themselves initially quite high regarding their ability to talk to friends (86.2% average). These results show that in future projects it will be important to put more emphasis on improving the students’ ability to talk to strangers. Through the FGD, it became apparent that for many students there was correction of their own misconceptions about an easily preventable disease, and imparting this knowledge to others enhanced their own learning. Thus, S‑L programs improve students’ self‑worth[51] and the students also expressed satisfaction that they could actually make a difference to society.
Conclusion
Overall, the women in the community learned about a health issue that is important for WRA, and built links with college students belonging to segments of society which are often perceived as elite and thus indifferent to the plight of less fortunate communities. Similar to the findings of Brown[3] and Narsavage et al.,[52] the real life exposure to the community women resulted in the students feeling connectedness and greater attachment to the community. The interaction with people of different ages and socio‑economic status increased their awareness and understanding of common issues faced by the community. This was reflected in the themes of the focus group discussion as students reported learning about the diverse lifestyles of communities and a better understanding about the communities’ social problems.
This study was begun as a project for Dr. Ayub’s Fellowship with the Foundation for Advancement of International Medical Education and Research (FAIMER), and we would like to thank Zareen Zaidi, MD, Stewert Mennin, PhD, and Tony Laduca, PhD who were very helpful in the early phases. We would like to thank Dr. Page Morahan, PhD for her mentorship to the authors in completing the manuscript for publication, and Gwen Martin, BA for her editorial assistance.
To our knowledge, this study was the first one that used service learning in community settings of Pakistan. This exploratory study has enabled us to identify the potential for a health workforce extension model in the country. However, this study also had some limitations. Regarding the college students, the S‑L project involved volunteers who were already motivated to take part, which may have resulted in a selection bias as well as in remarkable increase in health literacy. Also, the students assessed their own knowledge, and there may be subjectivity in the assessment. The students noted issues with scheduling. However they were ready to participate in future projects if scheduling could be optimized. On the community side, there was limited follow‑up with the community (at one month after the education intervention), because the S‑L project was done during summer break and the students needed to start classes. Ideally, we would have had a longer follow‑up at three months or more after the S‑L intervention. Education for Health • Volume 28 • Issue 2 (August 2015)
S‑L is a unique approach to experiential education where student participation in carefully structured activities and provision of opportunities for reflection lead to development of civic responsibility perceptions in addition to academic learning and better communication skills. Service learning projects like this study can serve to fill the gap in the public health workforce in meeting basic public health needs of the community in a resource poor country like Pakistan. The process and lessons learned from this study have led to the development of student electives program in the school because the students themselves advocated for this strategy to be taken up in a more comprehensive manner. Further, various health literacy projects tackling awareness of hepatitis B and C and AIDS viral infections are in progress.
Acknowledgements
References 1.
2. 3. 4. 5. 6.
7. 8.
9.
Lashari T. Pakistan’s National Health Policy: Quest for a Vision. 1st ed. Islamabad, Pakistan: Health Policy Unit; 2004. Available from: http://www.brandimage.com.pk/ow_userfiles/plugins/forum/ attachment_82_524bb9c967e9c.pdf. [Last accessed on 2014 Apr 03]. Cashman SB, Seifer SD. Service‑learning: An integral part of undergraduate public health. Am J Prev Med 2008;35:273‑8. Brown B, Heaton PC, Wall A. A service‑learning elective to promote enhanced understanding of civic, cultural, and social issues and health disparities in pharmacy. Am J Pharm Educ 2007;71:9. Friedman AJ, Chen Z, Ford P, Johnson CA, Lopez AM, Shander A, et al. Iron deficiency anemia in women across the life span. J Womens Health (Larchmt) 2012;21:1282‑9. Awan MM, Akbar MA, Khan MI. A study of anemia in pregnant women of railway colony, Multan. Pak J Med Res 2004;43:11‑4. Kalimbira AA, Mtimuni BM, Chilima DM. Maternal knowledge and practices related to anaemia and iron supplementation in rural Malawi: A cross‑sectional study. Afr J Food Agric Nutr Dev 2009;9:550‑64. Khalafallah AA, Dennis AE. Iron deficiency anaemia in pregnancy and postpartum: Pathophysiology and effect of oral versus intravenous iron therapy. J Pregnancy 2012;2012:630519. WHO. Worldwide Prevalence of Anaemia 1993‑2005. WHO Global Database on Anemia. Geneva, Switzerland: World Health Organization; 2008. Available from: http://www. whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf. [Last accessed on 2014 May 02]. Abe E, Omo‑Aghoja LO. Maternal mortality at the Central Hospital, Benin City Nigeria: A ten year review. Afr J Reprod Health 2008;12:17‑26.
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Ayub, et al.: Using service learning to improve health literacy and civic responsibility 10. Grantham‑McGregor S, Ani C. A review of studies on the effect of iron deficiency on cognitive development in children. J Nutr 2001;131:649S‑66S. 11. Zimmermann MB, Hurrell RF. Nutritional iron deficiency. Lancet 2007;370:511‑20. 12. Haidar J. Prevalence of anaemia, deficiencies of iron and folic acid and their determinants in Ethiopian women. J Health Popul Nutr 2010;28:359‑68. 13. Ny P, Dejin‑Karlsson E, Udén G, Greiner T. Health education to prevent anemia among women of reproductive age in Southern India. Health Care Women Int 2006;27:131‑44. 14. Hassan AE, Kamal MM, Fetohy EM, Turky GM. Health education program for mothers of children suffering from iron deficiency anemia in United Arab Emirates. J Egypt Public Health Assoc 2005;80:525‑45. 15. Pakistan Social and Living Standards Measurement Survey 2011‑2012. Government of Pakistan, Statistics Division: Pakistan Bureau of Statistics; 2012. Available from: http://www.pbs.gov.pk/ content/pakistan‑social‑and‑living‑standards‑measurement‑survey‑ pslm‑2010‑11‑provincial‑district. [Last accessed on 2014 Jun 06]. 16. Governemnet of Pakistan. Pakistan Demographic Survey 2001. Islamabad, Pakistan: Pakistan Bureau of Statistics; 2003. Available from: http://www.pbs.gov.pk/content/ pakistan‑demographic‑survey‑2001. [Last accessed on 2014 Mar 06]. 17. Safeer RS, Keenan J. Health literacy: The gap between physicians and patients. Am Fam Physician 2005;72:463‑8. 18. Zarcadoolas C, Pleasant A, Greer DS. Understanding health literacy: An expanded model. Health Promot Int 2005;20:195‑203. 19. McCray AT. Promoting health literacy. J Am Med Inform Assoc 2005;12:152‑63. 20. Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000;15:259‑67. 21. Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med 2011;26:474‑9. 22. Kirsch IS, Jugeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. National Center for Education Statistics; 2002. Available from: http://www.nces.ed.gov/pubs93/93275.pdf. [Last accessed on 2014 Apr 23]. 23. Beaulieu A, Lewendon K, Torres C, DeChello L. Improving Health Literacy in Connecticut: A Prescription for Healthy Lives and Communities. UCHC Graduate School Presentations. 2006. Available from: http://www.digitalcommons.uconn.edu/uchcgs_ presentations/4. [Last accessed on 2014 Mar 15]. 24. Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician 1996;53:205‑11. 25. Bajracharya SM. Community‑based health education intervention: A service‑learning approach. J Oxf Round Table 2007;2007(3):1-11. 26. Seifer SD. Service‑learning: Community‑campus partnerships for health professions education. Acad Med 1998;73:273‑7. 27. Jacoby B. Service‑learning in Higher Education: Concepts and Practices. 1st ed. San Fancisco: Jossey‑Bass, Wiley and Sons Inc.; 1996. p. 380. 28. Giles J, Dwight E, Eyler J. The theoretical roots of service‑learning in John Dewey: Toward a theory of service learning. Mick J Community Serv Learn 1994;1:77‑85. 29. Furco A. Service‑Learning: A Balanced Approach to Experiential Education. Corporation for National Service; 2‑6, 1996. Available from: http://www.shsu.edu/academics/cce/documents/Service_ Learning_Balanced_Approach_To_Experimental_Education.pdf.
136
[Last accessed on 2014 Mar 08]. 30. Martinez‑Mier EA, Soto‑Rojas AE, Stelzner SM, Lorant DE, Riner ME, Yoder KM. An international, multidisciplinary, service‑learning program: An option in the dental school curriculum. Educ Health (Abingdon) 2011;24:259. 31. Eyler J. Reflection: Linking service and learning‑linking students and communities. J Soc Issues 2002;58:517‑34. 32. Jamil KM, Rahman AS, Bardhan PK, Khan AI, Chowdhury F, Sarker SA, et al. Micronutrients and anaemia. J Health Popul Nutr 2008;26:340‑55. 33. Bhargava A, Bouis HE, Scrimshaw NS. Dietary intakes and socioeconomic factors are associated with the hemoglobin concentration of Bangladeshi women. J Nutr 2001;131:758‑64. 34. Zhu A, Kaneshiro M, Kaunitz JD. Evaluation and treatment of iron deficiency anemia: A gastroenterological perspective. Dig Dis Sci 2010;55:548‑59. 35. Furco A, Muller P, Ammon MS. Civic Responsibility Survey for K‑12 Students Engaged in Service‑Learning. California, Berkeley: Service‑Learning Research and Development Center, University of California; 1998. Available from: http://www.peecworks.org/peec/ peec_inst/01795CBE‑001D0211.0/furcosurvey%20civicrespons. pdf. [Last accessed on 2014 Jun 03]. 36. Ammon MS, Fureo A, Bernadette C, Middaugh E. Service‑learning in California: A Profile of the Calserve Service‑Learning Partnerships (1997‑2000). University of California, Berkeley; 2002. Report No. 10. Available from: http://www.digitalcommons. unomaha.edu/slcepartnerships/10. [Last accessed on 2014 Apr 17]. 37. Stewart T. Honours service‑learning and civic responsibility. Int J First Year High Educ 2012;3:49‑60. 38. McCroskey JC, McCroskey LL. Self‑report as an Approach for Measuring Communication Competence; 1988. p. 108‑13. Available from: http://www.jamescmccroskey.com/publications/143. pdf. [Last accessed on 2014 Jun 24]. 39. Burroughs NF, Marie V, McCroskey JC. Relationships of Self‑perceived Communication Competence and Communication Apprehension with Willingness to Communicate: A Comparison With First and Second Languages in Micronesia. Report No. 3; 2003. p. 230‑9. Available from: http://www.jamescmccroskey.com/ publications/202.pdf. [Last accessed on 2014 Mar 16]. 40. Blood GW, Blood IM, Tellis G, Gabel R. Communication apprehension and self‑perceived communication competence in adolescents who stutter. J Fluency Disord 2001;26:161‑78. 41. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 2nd ed. London, New Delhi: Sage Publications, Inc.; 2007. p. 414. 42. Tappe MK, Galer‑Unti RA. Health educators’ role in promoting health literacy and advocacy for the 21st century. J Sch Health 2001;71:477‑82. 43. Averill NJ, Sallee JM, Robinson JT, McFarlin JM, Montgomery AA, Burkhardt GA, et al. A first‑year community‑based service learning elective: Design, implementation, and reflection. Teach Learn Med 2007;19:47‑54. 44. Flecky K, Gitlow L. Service‑Learning in Occupational Therapy Education. Massachusetts; Burlington MA: Jones and Bartlett Publishers; 2010. p. 336. 45. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. 1st ed. Upper Saddle River, NJ: Prentice Hall; 1983. p. 256. 46. Gallini SM, Moely BE. Service‑learning and engagement, academic challenge, and retention. Mick J Community Serv Learn 2003;10:5‑14. 47. Gomez B. Service‑learning: Every Child a Citizen. Education Commission of the States. Report No. IP‑99‑1; 1999. p. 1‑15.
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Ayub, et al.: Using service learning to improve health literacy and civic responsibility Available from: http://www.files.eric.ed.gov/fulltext/ED445961. pdf. [Last accessed on 2014 Jun 24]. 48. Ahmad AD, Jabor MK, Buntat Y, Musta’mal AH. Potential of Service‑Learning on Students’ Interpersonal Skills Development in Technical and Vocational Education Asian Social Science 2014;10:21. 49. Meili R, Fuller D, Lydiate J. Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service‑learning project. Med Teach 2011;33:659‑66. [Last accessed on 2014 May 16]. 50. Eyler J, Giles DE. Where’s the Learning in Service‑Learning? 1st ed. San Francisco: Jossey‑Bass, Wiley and Sons Inc.; 1999.
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51. Lee CL. Integrating service‑learning in an undergraduate family and consumer sciences adolescent development course. J Fam Consum Sci Educ 2009;27:46‑51. 52. Narsavage GL, Lindell D, Chen YJ, Savrin C, Duffy E. A community engagement initiative: Service‑learning in graduate nursing education. J Nurs Educ 2002;41:457‑61.
How to cite this article: Ayub RA, Jaffery T, Aziz F, Rahmat M. Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning. Educ Health 2015;28:130-7. Source of Support: Nil. Conflict of Interest: None declared.
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