Medical students' reflection on the family planning services at primary health clinics in Malaysia.

CONTEXT: Family planning is crucial for everyone within the reproductive age to promote the health and welfare of every member of the family. For the medical students, it is essential to have core knowledge, understanding of family planning concept, and competency in communication skills with the patients. The final-year medical students are posted in Maternal and Child Health Clinics for 3 weeks to gain the knowledge and practical experiences on the primary healthcare in the community. AIMS: The aim of this study was to explore the experiences of final-year medical students on family planning services offered at community clinics in Malaysia. SETTINGS AND
DESIGN: This was qualitative study. SUBJECTS AND METHODS: This qualitative study used the data of the students' reflection written in the case reports on family planning. Coding, identification of subthemes, and themes were done by two researchers independently using RQDA software. STATISTICAL ANALYSIS USED: Thematic analysis.
RESULTS: Final-year medical students who had exposure to the clinical services at primary care clinic, regarding Malay word (Klinik Kesihatan) gained the learning opportunities during family planning session such as learning by observation, clerking, and counseling the patients, understanding the barriers to utilizing services and learning for their self-improvement. These learning opportunities lead to developing the positive attitudes on their learning experiences and the positive attitudes toward the concept and services of family planning.
CONCLUSIONS: To have the better understanding of family planning services and provide the better care to the community in the future, the clinical exposure at the primary care clinics should be promoted for medical students in Malaysia.

Introduction

Family planning assists the couples and individuals to understand their right in making the decision for their family and responsibility regarding their decision on the number and timing of the pregnancies.[1] Family planning services were introduced to Malaysia since 1930.[2] Since thereafter, the intensified strategies were used to improve the public awareness and utilization by collaborating Ministry of Health (MOH) and nongovernment organizations.[3] The scope of family planning goes beyond the contraception, including sex education, marriage-counseling, advice on sterility, birth control, providing adoption services, etc.[4] Although there was an improvement of contraception prevalence rate of all methods from 32% in 2004 to 41.7% in 2015, it is still low compared to the other Asian countries.[13] The health-care providers at the primary healthcare centers, Klinik Kesihatan (KK), are strengthening the capacities to provide the effective and efficient family planning services to the community.

The medical students who pass the professional examination (Phase II Stage I) on completion of semester 7 in the study institution will enter into the clinical postings. The clinical postings of different disciplines are arranged during semester 8, 9, and Maternal and Child Health (MCH) posting is one of them. The medical students are posted in MCH Unit at KK for 3 weeks to integrate their theory knowledge and practical experiences. The exit criteria for the MCH posting are the students who fulfill the attendance requirement of 90% of all contact teaching sessions, and pass the end of posting examination which include Multiple Choice Questions, Modified Essay Question, and portfolio assessment. The family planning service is part of the primary health-care program, and therefore, the students are able to gain the knowledge, clinical skills, and professional attitudes on that service to be competent medical doctors in their career. To augment their learning process, it is important to explore their experiences, strength, and areas to improve in the future.[5]

Reflection is a way for students to express their experience throughout the learning process.[5] It has been using in the professional field since the 1930s to enhance their own individual and lifelong learning process.[6] The clinical experience is essential for the medical students during their study period. Reflection on the clinical experience is crucial to become the active learning process, in which they incorporate their experience to preexisting knowledge to develop the expended knowledge.[7] Therefore, the students were assigned to write the reflection on their experience on family planning services in the MCH posting.

During the clinical posting, the students may have various experiences in the new environment. According to the AMEE medical education guideline (No 23), the students’ perception on their learning environment is considered as climate.[8] Reflective writing on the students’ experiences on the learning environment is a strategy to measure the climate in the medical education.[9] The author also encouraged faculties to conduct the climate studies and apply the findings for the development of curriculum.[8] Therefore, authors studied the obtainable students’ reflections to explore their perceptions on the learning environment. This study aimed to explore the experiences of final-year medical students on family planning services offered at community clinics in Malaysia.

Subjects and Methods

This study intended to reveal the medical students’ experience and attitude toward the family planning services at KK in Malaysia. The final-year medical students have the opportunity to learn at KK, and therefore, we selected them as the study participants. The students were assigned to write a family planning case report at the end of the 3-week posting as part of their portfolio assessment. At the end of the case report, they were instructed to write their reflection in that case and their experiences on the family planning services in KK.

Study design

This study analyzed the qualitative data of the students’ reflection on the family planning services. A total of 54 final-year medical students’ reflective writing after their MCH posting at KK in Malaysia were included in this study.

Data analysis

The reflection sections at the end of the family planning case sheets were extracted and separately saved in text document files. The qualitative data of 54 students’ reflective writings were imported to RQDA software. Thematic analysis was used to develop themes by comparing their similarities and differences in their writings. Generation of coding, defining and naming subthemes, and themes were done by two researchers independently using R package for computer assisted qualitative data analysis (RQDA) software.

Ethical approval

Ethical approval to analyze the qualitative data of students’ reflection was obtained from the Research Ethical Committee of the institution.

Results

Learning at the primary health care centers provide the valuable practices, skills, and understanding of the family planning concept to the medical students. As the students are in their final-year, they have sound knowledge on theory; however, understanding to the patients and development of professional communication with the other health-care personals can be improved through their exposure in the clinic setting. The qualitative analysis of 54 students’ reflection revealed their learning experiences and attitude during their MCH posting.

Three salient themes emerged from the qualitative data analysis, which were (1) Learning during the family planning session in KK, (2) Students’ attitude on learning experiences during the family planning session, and (3) Students’ attitude toward the family planning concepts and the family planning services [Figure 1].

Figure 1

Conceptual framework of students’ reflection on family planning services at primary health centers in Malaysia

Learning during family planning session in Klinik Kesihatan

Learning by observation

This study revealed the learning process of students when they were in the primary healthcare clinics. By observing the family planning counseling at KK, they developed insight on the professional communication and importance of building rapport with the patients:

“After watching the counseling procedure by experienced nurses, I learned that effective counseling should be based on the establishment of trust and respect between the patient and counselor” (A52).

Learning by clerking and counseling

The students’ admitted that clerking the women and attending the counseling session at KK helped them to improve their family planning knowledge to apply in the future:

“This case allows me to learn more about the contraceptive method available in the KK setting, which should be important when I start practicing in the future” (A45).

Learning about barriers for women

When the students had real conversations with the patients in KK, they realized the barriers for the women to access and utilize the family planning services, especially for birth spacing. They have the better understanding about the misconception among women in Malaysia and revealed in their reflection:

“Based on my clinical observation, there is a very low level of awareness about family planning and contraception among Malaysians. In spite of the high percentage of pregnant women who receive antenatal care (and hence, counseling regarding family planning and contraception), a lot of Malaysians are still unwilling to use contraceptives. This can largely be attributed to religious interference and personal misconceptions regarding contraception” (A50).

The students acquired the autonomy and role of women in making decision for their family. Although the women are entitled to have autonomy, some are still lucking and overwhelmed by their spouses in making decision:

“Some women, on the other hand, want to take contraceptive methods but are prohibited by their husbands. I think that women should have autonomy on their body and the decision should be made by them” (A13).

Insight on consequences of the family planning services

The long-term impact of these services aims to achieve the targets for Sustainable Development Goals (SDGs) to have good health and wellbeing of the individuals. The students’ reflection echoed their insight on the long-term impact of the family planning services as followings:

“A part from that, I realize that family planning is not only for a family or individually but also important in reducing infant mortality. Thus, we need to create awareness among the family in Malaysia on how is important this family planning for their future child as well as for the mother herself” (A19).

“I should not take sexual health and education lightly from now on, as this topic is very important in achieving the 3rd goal of Sustainable Developmental Goals in 2030” (A10).

Learning for improvement

Reflection is the metacognitive process by improving the learner's understating before, during, and after their experience.[7] Therefore, reflective writing helps the students to augment their future learning activities.[6] In this study, the students admitted themselves about the areas for improvement in the future:

“I had a chance to learn about communication in which I was lacking and need more improvement for me to become a good doctor in the future” (A22).

Students’ attitude on learning experiences during family planning session

Appreciation

When the students were learning in the clinics, they perceived the better understanding on the role of health-care personals such as nurses and doctors in the primary health-care setting. The students’ revealed that they appreciated the nurses’ teaching sessions, observing the family planning counseling sessions, and getting the chance of hands-on practice in the family planning service experiences.

“I am very glad that the sister in charge of KK Bukit Rambai explained to us how the family planning services are provided in our country. She had given us the guidelines on how mothers are advised, educated, and given contraceptive methods for the family planning” (A3).

Self-satisfaction

During their MCH posting, the students built up their competency and confidence over time. They were satisfied their working and learning process and illustrated their feelings:

“The patient was really friendly and kind enough to share her personal information with me. I was really happy to give her an overview of the contraceptives available before she was counseled by the nurse in charge. The patient told me before going back that my overview eased her counseling process and boosted her confidence level in making a final decision. Her words truly made my day and lifted my spirit to be a good practitioner in the future” (A49).

Students’ attitude toward family planning concepts and family planning services

Attitude toward family planning concepts

Through their clinical experience, the students revealed their attitudes toward the family planning concepts, as it is the reproductive right for all the women, can offer benefit to mother, family, and society.

“At the same time, one should respect the decision of the women concerned. Although family planning is an effective way to improve the health and quality of life of women, we cannot decide what is right or wrong for the women themselves. The choices made by them should be respected” (A28).

Apart from the contraception, the students developed the understanding toward the broader scope and nature of the family planning services in Malaysia:

“The most obvious and glaring thing that I have learnt during this time was that “family planning” is a term that encompasses a lot more than only birth control. There is a lot that goes into it” (A1).

As the students learned during their posting, they had a positive attitude toward the benefits of family planning through their reality clinic setting:

“From this exposure about counseling of family planning, I deeply felt the importance of family planning to a woman and also the whole family. Family planning is a very vital aspect in building a good and healthy family as this will allow the couple to prepare mentally, physically, and financially for the next pregnancy should they plan for having next pregnancy. As an example, the patient's household income is only RM 1000.00, in a practical view of perspective; family planning can reduce the burden of the family” (A36).

Moreover, some students suggested improving the usage of contraception among Malaysians and aware of the unmet needs which should not be ignored in the health sector.

“The Government shall try to introduce these family planning services into the community through mass communication, media, and newspaper. Every mother has the right to know about the family planning services available in Malaysia” (A3).

Attitude toward family planning services

The students are at the center of the clinical teaching process and their positive attitude toward the providing services can motivate them to achieve their goals. They appreciated the effort of MOH Malaysia services, which are providing free at the good timing for the women in Malaysia.

“I also realized that MOH is doing a great job by providing free contraceptive methods to couples and they also offer family planning advice to pregnant mothers as early as during their third trimester and continue even during their postnatal visits. This provides them adequate time to discuss with their partners regarding their contraceptive method of choice which both of them would be compliance to. Moreover, the four contraceptive methods are offered free to these couples and they do not have to worry about the financial problems” (A17).

In their reflection, the students mentioned the positive attitude toward health-care personals on their professionalism to the patients in KK:

“I will strive to emulate KD Bukit Piatu health-care professionals selfless passion and should better communicate with couples. Counseling should please both, linking morbidities to each method's pros and cons for optimal solutions” (A20).

Discussion

The effective clinical skills training for medical students is the essential goal for medical institutions all around the world.[9] It is crucial for the final-year medical students to acquire the proper clinical knowledge before getting to the housemanship phase in Malaysia. MCH Clinics at the KK are the ideal places for the students to learn about the family planning services due to the small group training and learning from the health-care personal with the real patients in the community.

Active observation and participation in clinical learning will stimulate the deep learning process and knows how to perform proper clinical skills.[10] In this study, the students mentioned that through active observation at KK, they learnt that effective counseling session was based on the establishment of trust and respect between the patients and health-care providers. Active participations in the clinic services such as clerking and observing counseling sessions could improve the students’ knowledge on family planning and contraception methods. After seeing and clerking to women coming for contraception, the students came to know the practical benefits and had the positive attitude toward the practice of birth spacing. Smith et al. have also mentioned in their study that the clinical rotation shaped the medical students’ attitudes toward the family planning and contraception usage.[11]

Some students in the study described their understanding of the barriers for women to use the contraception such as fear of side effects, insufficient knowledge on family planning, and religious interference. Although intensive strategies of family planning are implementing in Malaysia, misconception about the consequences of contraceptive methods are still barriers to adopt the modern methods.[12] The students’ reflection in this study is in line with some Malaysian studies which reported that poor knowledge on family planning was also a barrier among the women.[212]

Insight on consequences of family planning services

As a long-term impact, the family planning services play an important to reduce the maternal and child mortality regarding achieving the SDGs. Acquisition of knowledge on benefits and long-term impact of family planning is similar to the findings of a qualitative study conducted with the medical students in Chicago.[11]

According to Hargreaves, reflection should be assimilated in the students’ lifelong learning to achieve the high level of professional competency.[13] Through their reflective writing, the students admitted that communication skills with the patients and deep understating of choosing the contraception methods were areas for improvement in the future. The literature supporting that if the students are aware of their weakness and strength in their study process, they have higher chance to get the achievement.[14]

In their journey to become medical doctors, the clinical training environment, the mentor and preceptors have influential in the development of soft skills that cannot be taught in the theory teaching. The students, in this study, appreciated the communication skills of the nurses and inspired their selfless passion on the patients. This finding supported the study of nursing students where the positive workplace relationship between the registered nurse and the students make a difference while constructing their own schema.[15] The study of medical students also found out that the relationship with their supervisors has an important influence on their learning in the clinical context.[16]

As the students were learning the realities in the primary health care setting, they appreciated the chances of hands-on practice and the new experiences in family planning services. “Participation in Practice” has been recognized as the essential dimension of clinical teaching which has been evolved from the passive observation of the performance in the clinical context.[1718] In this study, some students had the opportunity to participate in family planning counseling and stated their appreciation toward their participation and experiences.

Through the MCH posting, the students had continuous exposure to the family planning services, which led to building up their confidence in counseling and caring for the patients. The students who had the opportunity to participate in the clinic counseling services felt ultimate satisfaction and increase their confidence to be good practitioners in the future. Qualitative studies of medical students mentioned that they have gained self-confidence when they participated in the family planning services and the workplace experience at primary health care centers built up their professional development.[1116]

Family planning and usage of contraception are the reproductive right for all the women. The scope of family planning is not only limiting the family size but also including sterility education, sexual education, and genetic counseling.[4] In this study, the students mentioned that they perceived the understanding of the broader scope of family planning and developed the positive attitudes on it during their posting. This finding was in line with the qualitative study of medical students in Chicago in which they mention of getting experience and enhancing knowledge of family planning topics during their clinical rotation.[11]

Throughout the MCH clinical posting, the students had the opportunity to learn the benefits of family planning for the women, children, the family, and reduction of undesirable public health consequences such as unintended pregnancy, abortion, and child abandonment. Knowing the benefits encouraged the students to learn more about family planning to provide the better service for the community.

On the other hand, they also recognized the role of patients, especially for the women in using contraception. All women should have autonomy to make their own decision; however, some might still need to receive permission from their spouse. Similar findings had revealed that husband-wife communication is essential to use the modern contraception methods in qualitative studies of women conducted in Malaysia.[1920] Since the students are aware of the unmet needs and barriers, they shared their suggestions to expand the utilization of family planning services, such as the provision of health education to the community through mass communication, media, and newspaper. Some qualitative studies had also suggested improvement of counseling and promoting the campaigns.[212]

The impact of health care fees in the middle and low-income countries had been systematically reviewed and revealed that introducing or increasing the fees were significantly reduce the utilization of health care services.[21] In Malaysia, the Government is providing the free services for contraception to enhance the utilization. The students’ revealed their positive attitude toward the timing and free services that are offering at KK.

Moreover, the students witnessed the selfless passion of the health care personals such as doctors and nurses in counseling the patients, managing individually, and disseminating the family planning knowledge to the community. This surrounding clinical setting and the positive attitudes toward the other health care personals have a high influence on their learning process throughout their way to become the medical doctor. A recent qualitative study in this institution also revealed the students’ the positive attitudes toward the team work spirit among the healthcare personals and dedicated mentors at the health clinics.[22] Moreover, the similar findings exposed in an Australian study conducted among the nursing students, in which they admitted that the admirable manners of their registered nurse facilitate their learning.[15]

This study has some limitations, as it was a qualitative study of students’ reflection only at a private medical institution in Malaysia. The context of this study was focused at MCH Clinics in KK so that it did not cover the experiences at the other clinical settings. Nonetheless, this study could provide experiences, attitudes, and views of final-year medical students so that further qualitative studies should be conducted to explore the medical students’ experience in a wider range of clinical settings in Malaysia.

This study revealed that the final-year medical students improved their knowledge by learning, observing, and practicing hands-on experiences in KK. Their constructive learning process led to having the positive attitude toward the real clinical experiences. All of these factors favor them to develop confident in their profession and leading to be the competent medical doctors. Therefore, encouraging the clinical exposure at the primary health clinics will promote the development of professional skills among the medical students in Malaysia.

Conclusions

This study disclosed the medical students’ experiences on the family planning services during the MCH posting in Malaysia. The students received the learning opportunities by various methods such as observation, clerking, and counseling to the patients in MCH clinics. Through these opportunities, the students expanded their knowledge, improved the clinical and communication skills, gained insight toward the family planning services, and recognized the barriers for the Malaysia women to utilize the modern contraception methods. Reflective writing enhanced the students’ awareness on the areas for improvement in their individual learning process. It also revealed their attitudes toward their learning experiences and services provided by the health clinics. This positive climate of the learning environment will encourage their learning process and develop confident in their medical profession, which might lead to the achievement and success in their future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.