Responding to change in a medical student rural community service: Insights from activity theory

Introduction: Medical students have voluntarily initiated service-learning programmes with the aim of providing assistance to medically underserved communities, especially within remote indigenous villages. However, their values and goals have been challenged because rural health care demands have changed considerably since the introduction of integrated delivery system (IDS) programmes, that is, programmes that integrate local health care providers with outreach services provided by contracted hospitals. Our study aimed to explore how a health care service-learning group negotiates its position and how it responds to the tension of IDS implementation and changes in rural health care demand. Methods: Medical students who have been engaged in building or operating the health care service-learning group of one university in Taiwan were invited to participate in the study. We used cultural–historical activity theory (CHAT) to help us interpret the interactions between students, indigenous communities and the public health sectors and to understand the evolution of the service-learning relationship and its effectiveness. Results: Eighteen participants were recruited for in-depth interviews. The implementation of IDS programmes brought change to the rural community and challenges to students' service learning. Utilising cultural–historical activity theory, we highlighted points of fragmentation within the system. This tension lead to medical students' personal conflict and also served as an impetus for change and learning. Flexible goal setting and coping ability were considered critical to the sustainability and maintenance of students' value systems. Conclusions: IDS implementation can upset the balance of rural health care supply and demand, resulting in accumulating tensions within and between activity systems. Those contradictions exposed medical students to an expansive learning cycle, resulting in transformational change and learning. Under the context of IDS programmes, health care service-learning can create a ‘win-win’ situation. Not merely medical students but also community residents gain benefits. This result may be extrapolated to health care service-learning programmes with similar context.