So far, the global burden of non-communicable chronic diseases represented by hypertension, coronary heart disease, stroke and diabetes, etc. has been a significant public health concern as a result from accelerated ageing of the population around the world [1,2,3]. Uncontrolled chronic diseases are closely associated with diverse severe co-morbidities and adverse outcomes. According to the World Health Organization estimates, in 2016, approximately 40.5 million people died of non-communicable chronic diseases, which accounted for 71% of the total worldwide deaths within year [4]. Long-term and comprehensive health-care interventions associated with chronic diseases including population-based prevention, primary and secondary prevention for high-risk individuals via multi-drug therapy, co-morbidity management, and treatment of acute cases, etc. caused heavy financial burdens for patients and nations, which posed a formidable challenge especially for resource-limited developing countries [5,6,7]. In China, it was estimated that nearly 75% of the elderly population aged 60 and over had at least one kind of chronic disease [1, 6], and chronic diseases contributed to about 70% of the total national health expenditures [5]. So far, a multi-tiered healthcare system including tertiary hospitals, secondary hospitals, and primary care facilities with an emphasis on the role of primary care facilities (e.g. community health centers) has been globally accepted as a cost-effective and sustainable way for managing chronic diseases [2, 3, 5, 8, 9]. In China, community-based primary care is currently the first level of contact for chronic disease patients into the health system, and often acts as the principal avenue for chronic disease management through the provision of community-focused, affordable, comprehensive, family-oriented, long-term and continuous care closer to home [3, 5].
Among the comprehensive management strategies for chronic diseases, the effective daily self-management support has been accepted as one of essential components for high-quality chronic disease management [10]. Chronic disease self-management approaches included a package of behavioural interventions addressing the medical, physical, emotional, social and related challenges posed by the chronic diseases, aiming to improve health-related attitude and quality of life, as well as to reduce chronic disease-related complications and mortality. Successful self-management experience on health behaviors and lifestyle intervention such as diet, routinized physical activity, medication, and attendance at follow-up appointments has been demonstrated to be consistent with better health outcomes [11]. Accordingly, chronic disease self-management education via effective health communication among the patients and the health-care providers is necessary to support and improve patients’ self-efficacy, knowledge, self-care skills, and adherence to recommended self-care behaviors [12]. For patients with chronic diseases, the community-based primary care system is the frontline responsible for health education service to support chronic disease self-management [9]. Under the direction of community health educators, patients can ensure their treatment adherence, make lifestyle adjustments, make decisions on management options and actions, identify possible challenges and solve them as early as possible [9]. According to the Basic Public Health Services launched by Chinese central government in 2009, health education as one of the most important programs has been requested to be freely provided for all community residents in response to their needs by community health centers [12].
Despite the increasing recognition of the importance of community-based primary care in chronic disease management especially in health education service, studies conducted in different countries point out that the lack of health providers is one of the most important barriers for community health centers to provide quality primary care for chronic disease patients [13,14,15,16]. Similar to most countries in the world, China is currently facing the transformation from the traditional hospital-centric healthcare system to the community-based primary healthcare model. Accordingly, the shortage of community health professionals has been considered as a key issue hindering the development of primary care in China [16]. In fact, under the current circumstance, community health education is often performed by community nurses as part-time workers [5, 6]. It appears to be difficult to attract enough qualified health educators in community health institutions within a short period of time, due to the constraints of the current working conditions, income and training cycle, etc.
Based on their vibrancy, acquired professional knowledge and skills, as well as their awareness of local cultural customs, medical students have been well-accepted as a force multiplier for the community-based health service [17,18,19,20]. For example, medical students were involved in a student-led community-based prevention program for falls, which has been demonstrated to potentially enhance the sustainability of the program and reduce program costs [17]. Our team previously recruited undergraduate students from medical and other health professions to participate in household visits for community residents suffering from diabetes aiming to increase diabetes self-management education [18]. Through a team-based model, medical students can channel their energy and passions to elevate the community health in any way they can [18, 19]. Especially as the current COVID-19 pandemic has challenged and, in many cases, exceeded the capacity of healthcare systems worldwide, more and more medical students have engaged in patient care–related community services, and contributed greatly to improve community public health [19, 20]. Student-led health clinics offer valuable and potential cost-saving opportunities for meeting the health care needs of residents especially in underserved communities while also for student professional learning [21, 22].
As an interactive learning tool in experiential education engaging students in human-centered service-learning activities to address community needs as well as develop students’ professional value and knowledge, the community service learning (CSL) has achieved broad acceptance among medical schools and educators [18, 23,24,25,26,27,28]. So far, the positive educational effects of CSL have been demonstrated at all levels of learning for the cognitive, affective, and psychomotor domains [27]. Through providing an authentic sociocultural context for medical professional education, CSL allows medical students to gain exposure to primary care and social justice, flexibly apply classroom knowledge in real life, and strengthen their learning, professionalism, communication and problem-solving skills, civic and social responsibility as well as sense of community [25,26,27,28]. Especially for health professions previously being therapy-oriented, there is more emphasis now on prevention and primary care via improving life styles and eliminating risk factors having adverse effects on public health. Accordingly, in order to serve the educational needs of modern medicine in the twenty-first Century, integrating community service into student projects provides opportunities for medical students to gain competency in public health, preventive practice and social service through the learning experience of actually delivering health care to community residents in need [27, 28]. As for medical students, personal experience of contact with real patients is certainly an integral component of their professional learning. Traditionally, most medical student contact with patients occurs during their clinical placements in teaching hospitals. CSL offers students especially at preclinical stage the additional benefits such as a focus on person rather than disease, and a clear presentation of the influence of social factors on health care [29]. However, the above pedagogic advantages of CSL programmes were considered and addressed mainly in terms of student dimensions. Attitudes from other stakeholders (e.g. faculty members as instructors, patients as beneficiaries) regarding their involvement in CSL as stakeholders have gone largely unexplored [27]. Therefore, the present study aimed to determine whether a gap exists among the attitudes of the involved stakeholders, including students, faculty and patients, towards the CSL-based medical student-led community health education service to support chronic disease self-management. The findings would better support the future CSL activities in medical education as well as the community health service practices for patients with chronic diseases.
