Effectiveness of preventive medicine education and its determinants among medical students in Malaysia

Abstract

Preventive medicine has been incorporated in the medical school curriculum, but its effectiveness and the factors that affect it are yet to be widely looked into in the context of Malaysia. We aimed to measure the familiarity with, perception about the importance to learn, and the ability to practice preventive medicine as well as its determinants among the medical students in Malaysia. Thus, a cross sectional study was conducted through an anonymous online survey among 387 randomly selected final year medical students of four large public medical schools in Malaysia from March to September 2014. Of the total sample, only 340 (response rate 87.8%) gave a written informed consent and took part in the survey. The familiarity of the sample with preventive medicine was measured in 19 preventive medicine areas, and their perception about the importance of preventive medicine and their ability to practice it were gauged on a Likert scale (low score indicates disagreement and high indicates agreement). Descriptive statistical analysis was performed, followed by logistic regression. The mean age of the respondents was 23.7 (SD 0.77) years, and 61.2% (n = 208) of them were females. Results showed that 22.9% of the sample (n = 78) had a low familiarity with preventive medicine, whereas 76.8% (n = 261) had a high familiarity. The study sample specified that among all the preventive medicine subjects, screening and control as well as smoking cessation and immunization are “extremely important to learn.” In univariable analysis, being a female, medical school, family size, and perception about the importance to learn preventive medicine were associated with the ability to practice it. In multivariable analysis, the perception towards the importance to learn preventive medicine was the only significant determinant: aOR (adjusted odds ratio) for those who “agreed” 17.28 (95% CI aOR 4.44 – 67.26, P<0.001) and for “strongly agreed” 35.87 (95% CI aOR 8.04 – 159.87, P<0.001). Considering these findings, the familiarity of medical students with preventive medicine should be increased. The perception about the importance to learn preventive medicine is a strong determinant for the ability to practice it.

Keywords

preventive medicine / medical school / medical students

Introduction

Importance of preventive medicine

Disease prevention is the cornerstone in maximizing the health and quality of life of individuals and populations, and it is the most effective approach for reducing morbidity and mortality [ 1]. The incidence of diseases and their risk factors can be reduced if physicians advise their patients about preventive measures [ 2]. Preventive medicine physicians can help health centers provide a new array of community-based preventive services, which go beyond the traditional primary care, to improve public health [ 3]. These specialists are unique because they can understand and reduce the risks of diseases, disabilities, and death in individuals and population groups [ 4].

Role of preventive medicine in the management of non-communicable diseases (NCDs)

The continued shift of communicable diseases to NCDs today is greater than that in previous decades, leading to premature deaths and disability [ 5]. The key risk factors responsible for this global trend include high blood pressure, tobacco smoking and second-hand smoke exposure, high body mass index, physical inactivity, alcohol use, and diet low in fruits and vegetables but high in sodium and saturated fats [ 5– 7]. The global burden of NCDs constitutes a major public health challenge that may undermine the social and economic developments of any country. Nonetheless, the occurrence of NCDs and their risk factors can be prevented. The role of preventive medicine in managing NCDs is important as evidenced by the US national health priorities that aim to prevent and detect chronic diseases early for slowing down disease progression, mitigate complications to optimize quality of life, and decrease the demand for medical services among others [ 8]. The United Nations and the World Health Organization (WHO) have also emphasized the significance of integrating preventive approach into primary healthcare [ 9].

NCDs burden in Malaysia

NCDs are becoming prevalent in Malaysia given that an increasing number of people suffer from heart diseases, hypertension, kidney disease, macro vascular disease, cerebrovascular disease, and diabetes in this age of industrialization and urbanization [10]. From 1986 to 2006, the prevalence of hypertension and diabetes increased from 14.4% to 32.2% and from 6.3% to 11.5%, respectively; in 2002, 71% of deaths in Malaysia were caused by chronic diseases [ 11].

Preventive medicine education in Malaysia

In Malaysia, 32 public and private medical colleges, 40 programs, and 378 qualifications are recognized by the Malaysian Medical Council (MMC). This council claims that an average of 3500 medical doctors are annually produced by the country. All medical schools in Malaysia should include “rural health and preventive medicine” in their curriculum. This subject requires the students to undergo a training period of one to four weeks during which they are assigned to a rural health center where they should also conduct a small research on the rural community [ 12].

Rationale of the study

The determinants of preventive medical practice should further be understood considering its importance. Most studies on preventive medical care were conducted in developed countries such as the US by reviewing previous literature [ 13– 15]. Preventive medicine is a relatively new field in the medical practice in Malaysia. Research on preventive medicine in the Malaysian context has been focused on certain topics, including lifestyle practices of university students [ 16], breast self-examination [ 17], skin cancer prevention [ 18], colorectal cancer screening [ 19], lung cancer prevention [ 20], and cervical cancer screening [ 21, 22].

A previous research determined that the Public Health course, which involves preventive medicine training on smoking cessation, weight management, and cardiovascular diseases, has been successfully implemented by pharmacy schools in Malaysia [ 23]. This study particularly looked into the performance of the students on quizzes and coursework and analyzed their perception about the contribution of Public Health to their career as pharmacist [ 23]. To the best of our knowledge, the contributions of integrating preventive medicine into medical school curriculum to the preventive medicine practice of young doctors are yet to be investigated in Malaysia. Thus, further research should be performed to extend the existing literature on the preventive medical education and its effect in the Malaysian context.

In this study, we aimed to evaluate the effectiveness of preventive medicine content in the curriculum in terms of the familiarity with it, perception about its importance, and the attitude to practice it among the medical students of selected public medical universities in Malaysia.

Materials and methods

Study design and setting

This cross sectional study was conducted from March to September 2014 at Universiti Kebangsaan Malaysia (UKM), University of Malaya (UM), Universiti Teknologi MARA (UiTM), and Universiti Putra Malaysia (UPM).

Study population

The final year medical students (Malay, Chinese, Indian race, or minorities) who agreed to participate willingly and submitted a written informed consent were included in the study. The medical students of the universities other than the selected public universities in Malaysia were excluded.

Sample size and sampling technique

The WHO sample size software (WHO, Geneva) was used to determine the sample size. The results showed that the study should include at least 322 medical students; 93% was the anticipated proportion that would provide positive feedback (satisfaction) on the preventive medicine curriculum [ 24] with a confidence level of 95% and a relative precision of 3%. Considering the 20% loss to follow-up/drop-out rate, the sample size was increased to at least 387 participants. Given that the four universities had a total of 670 final year medical students, the sample size of 387 represented 57.7% of the total number of students. The students were selected from the universities through the probability proportional to size (PPS) sampling and were chosen from each university randomly.

Data collection tool

A well-structured, pre-tested, and self-administered online questionnaire was used for data collection. To the best of our knowledge, no standard validated questionnaire was available to measure the effectiveness of preventive medicine content in the curriculum in terms of the familiarity with it, perception about its importance, and the attitude to practice it among medical students; hence, we developed a questionnaire based on the study of Scott et al. [ 25] The instrument was developed through our collaboration with committee members, medical students, and an external survey researcher, and it was reviewed by experts for content validity. The questionnaire comprised four main variables explained in the succeeding paragraphs.

Socio-demographic data

For this variable, the age, gender, institution, nationality, urban or rural residence, parents’ education, parents’ profession of being a doctor, family size, and monthly household income of the respondents were inquired.

Familiarity with preventive medicine

The familiarity of the respondents with preventive medicine was measured through 19 preventive medicine areas related to the curriculum, including poison control education, health counseling, cancer detection education, preventive health physical screening, substances abuse counseling education, weight reduction education, smoking cessation, personal hygiene education, stress management education, nutrition counseling, occupational health and safety education, exercise/physical fitness programs, genetic counseling, risk factor analysis, family planning, immunization, personal counseling, sexually transmitted disease prevention, and blood pressure screening and control as it is one of the primary prevention strategy for cardiovascular disease prevention. The respondents were asked how many instructions have they received in these areas at their respective medical schools using scores from 0 to 3 (0: none; 1: very little; 2: some; 3: a lot), which were re-coded to 0 (none) and 1 (categories 1, 2, and 3 combined). These re-coded scores were summed to obtain an overall score (0–19). The distribution of the index score was highly skewed; thus, the overall score was re-coded into two levels through median split (median= 19) (i.e., low familiarity (score<19) and high familiarity (score= 19)) and was used as an outcome variable [ 26]. One question was asked about the satisfaction of the respondents with the amount of training in preventive medicine provided by their schools. This question had five response options, namely, (0) very dissatisfied, (1) dissatisfied, (2) neither satisfied nor dissatisfied, (3) satisfied, and (4) very satisfied. The total score for this question was re-coded into a dichotomous item through median split (median= 3) (i.e., no/low satisfaction (score<3) and high satisfaction (score= 3)) and was used as an outcome variable.

Perception about the importance of preventive medicine

This variable looked into how the respondents perceive the importance of learning the areas of preventive medicine mentioned above. Each of these items had five response options, including (0) not at all important, (1) not very important, (2) somewhat important, (3) very important, and (4) extremely important. Each item was re-coded to 0 (not at all important and not very important) and 1 (somewhat important, very important, and extremely important). A general question on the perception toward the importance of learning preventive medicine was also asked and was coded as 0 (strongly disagree), 1 (neither agree nor disagree), 2 (agree), and 3 (strongly agree).

Attitude toward the ability to practice preventive medicine

The students were asked if they can provide preventive medicine services. The responses were coded as 0 (strongly disagree), 1 (neither agree nor disagree), 2 (agree), and 3 (strongly agree). Each item was re-coded into a 0 (strongly disagree and neither agree nor disagree) and 1 (agree and strongly agree).

The questionnaire link was dispatched to the students through e-mail and Facebook. The online webpage was designed in a manner that only when the students agreed to participate in the online survey by giving a written informed consent will the questionnaire appear to be answered. The participants were reminded frequently to participate in the online survey until the required response rate was obtained.

Statistical analysis

Descriptive statistics were computed: mean and standard deviation (±SD) for continuous variables and frequency and percentage for categorical variables. The factors associated with the ability to practice preventive medicine were determined through logistic regression analyses. The variables in the univariable model with a P-value of<0.05 were included in the multivariable model. No collinearity was observed between the independent variables included in the multivariable model. The factors in multivariable regression with a P-value of<0.05 were considered significant. The crude odds ratio (cOR) and 95% confidence interval (CI cOR) of the univariable model were calculated, and the adjusted odds ratio (aOR) and 95% CI aOR of the multivariable model were determined. Statistical analyses were conducted on SPSS version 17 (SPSS Inc., Chicago).

Results

Of the 387 participants, 340 responded with a response rate of 87.8%.

Socio-demographic profile

The mean age of the respondents was 23.7 (SD 0.77) years, and 61.2% of them (n = 208) were females. Among the sample, 77.6% (n = 264) live in urban areas, whereas 22.4% (n = 76) are rural residents. With regard to the educational background of the respondents’ parents, 45.9% (n = 156) of the sample have fathers whose education level is tertiary, and 48.8% (n = 166) have mothers who completed their secondary education. The family size of the 57.3% of the sample have five to seven members (n = 195), and 32.4% (n = 110) have a monthly household income of 3000 to 6000 Malaysian Ringgit (MR). Table 1 shows the baseline characteristics of the study participants.

Familiarity with preventive medicine

Of all the respondents, 22.9% (n = 78) have a low familiarity with preventive medicine, whereas 76.8% (n = 261) are significantly familiar with the subject. Lack of familiarity was observed in many subjects of preventive medicine (Fig. 1). Out of the 265 participants who responded on the question of satisfaction with the amount of training in preventive medicine provided at their medical school, 95.5% (n = 253) are not satisfied or have low satisfaction, whereas only 4.5% (n = 12) are highly satisfied.

Perception about the importance to learn preventive medicine

Among the 336 medical students who replied to the question about the importance of learning preventive medicine, 4.8% (n = 16) neither agreed nor disagreed, 42.3% (n = 142) agreed, and 53% (n = 178) strongly agreed. Fig. 2 elaborates the perception of the respondents toward preventive medicine.

Attitude to practice preventive medicine and its determinants

When asked about their ability to practice preventive medicine, 10.4% of the 336 students who responded (n = 35) disagreed or were neutral, whereas 89.6% (n = 301) agreed or strongly agreed. In the univariable analysis, being a female, medical school, family size, and perception about the importance of learning preventive medicine were statistically associated with the ability to practice preventive medicine. In the multivariable analysis, the odds of practicing preventive medicine among those who agreed that preventive medicine is important to learn was 17.28 (95% CI 4.44 – 67.26) and for those who strongly agreed 35.87 (95% CI 8.04 – 159.87) compared with those who did not agree or were neutral, adjusting for gender, medical school, and family size (Table 2).

Discussion

This study determined that the majority of the medical students are satisfied with the amount of training in preventive medicine they have received at their respective medical colleges, and approximately two thirds of them are highly familiar with it. In addition, half of the students strongly agree that preventive medicine should be learned, and these are the ones who are most likely to practice it.

The curriculum at medical schools forms the basis of imparting general professional education and should provide students with opportunities to enhance their knowledge, skills, and attitude to practice medicine ethically and effectively [ 27]. For this reason, the medical curriculum needs to be upgraded regularly to include new knowledge based on evidence and on various needs of the hour [ 27]. The population worldwide continuously increases so are the risk factors of diseases, especially NCDs. Preventive medicine aims to identify and control the risk factors of diseases instead of the diseases themselves [ 28]. Hence, the incorporation of an effective preventive medicine curriculum in the areas identified in this study can play a pivotal role in preventing the risk factors of NCDs.

More than 89% of the respondents are familiar with the preventive medicine courses evaluated in this study. This finding shows that the preventive medicine education in the public sector medical colleges of Malaysia is sufficient, implying a positive direction in the education and training of preventive medicine, especially in a developing country. This observation, however, contradicts the comment of Levy and Wegman (2012) on the insufficiency of public health and preventive medicine education and training in the US and Canadian medical curriculums [ 29]. A study (2010) analyzed the knowledge of female medical students of the National University Malaysia about cervical cancer prevention and reported low to intermediate grades of knowledge for cervical cancer and its prevention, respectively [ 22]. In the current study, 99.1% of the respondents are familiar with cancer detection and screening (Fig. 1). Despite the progress made in preventive medicine education, the preventive medical curriculum in Malaysia needs further development in the fields of poison control, genetic counseling, and risk factor analysis, which are not greatly known by the medical students according to the research findings.

The positive response toward the importance of learning preventive medicine in all 19 areas probed ranged from 94% to 100% (Fig. 2). In particular, 98.8% of the students believe that nutrition counseling should be thoroughly understood. This figure is almost 50% higher than that reported by Spencer et al. who looked into the senior year medical students in the US [ 13]. In addition, 53% of the research respondents strongly agreed that preventive medicine is important. This finding is comparable to the perception of British and Polish general physicians, of which 55% and 54% respectively reported that health promotion is extremely relevant [ 30].

The perception of the medical students toward preventive medicine reflects their motivation to learn such [ 31]. This perception in turn strongly predicts the ability of the students to practice preventive medicine, suggesting a dose-response relationship. In other words, when a student is highly motivated to learn preventive medicine and significantly values its importance, he/she is inclined to practice it. This proposition supports the finding of Amodio, who reported on cognitive theory of the coordinated effects of motivation, perception, and behavior [ 31]. To enhance the practice of preventive medicine, the motivation of medical students to perceive its importance should be improved. The theory and practice of motivational science, as it applies to the andragogy in general educational settings, is not as simple as it seems for medical education because it is determined by the multiple internal and external factors of an individual and the interplay of complex forces between them [ 32]. Nevertheless, efforts can be made to understand these factors and implement them in medical education [ 31]. One approach to do so is through “experience-based learning,” which incorporates “supported participation,” that reinforces the clinical practice of medical students [ 33]. Reflection in learning, meaning orientation, and cross-year tutoring have been positively associated with the autonomous motivation of medical students [ 34] and can therefore be utilized by medical educators to further encourage the students to learn about preventive medicine.

Strengths

• Though the sample represents 57.7% of the total number of final year medical students in the selected universities (n = 670), the response rate of the selected participants was 87.8% (340/387). This figure is beyond the sample size of 322 (without drop-out rate) to meet the power of the study, thereby maintaining the internal validity of the study.

• Malaysia has 11 public sector medical colleges. This study was conducted in four universities, representing 36.4% of the public sector medical colleges. The multicenter approach of this study increases its external validity, making the results generalizable to the public sector medical students of Malaysia.

• Clustering effect may have occurred in this study when the medical students from the same medical college have the same perception and attitudes. The perception about the importance of preventive medicine is associated with the ability to practice it even after the clusters (i.e., the “medical colleges” in the final multivariable model) were adjusted. Hence, the clustering effect was addressed in this study.

Limitations

• This study relied on subjective findings; no objective observations were made.

• Private medical colleges were not considered in this study.

• The CIs of the odds ratio for the perception about the importance to learn preventive medicine were large because the sample size was calculated based only on the familiarity with the preventive medicine education that may have been less for determining the factors affecting the ability to practice preventive medicine. Despite this limitation, this study provides relevant insights into the factors that may affect the ability to practice preventive medicine in clinical profession. Further research can be conducted with a large sample size based on this study.

• The ability to practice preventive medicine while at medical school and after medical school was not observed or measured objectively. Thus, this study failed to establish the association between the ability to practice preventive medicine while at school and after leaving school.

• This study did not ask the respondents about their interest in pursuing a career in preventive medicine. This component may have been an interesting effectiveness measure.

Conclusions

This study determined that approximately one fifth of the medical students in Malaysia are not significantly familiar with preventive medicine. Effective strategies should accordingly be developed to address this issue. When students highly perceive the importance to learn preventive medicine, they will further be inclined to practice it. This observation underlines the need to embed the motivational approach toward the importance of preventive medicine at medical colleges.

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