The Benefits of a Heart Health Service Learning Opportunity for First-Year Medical Students

Abstract

Service learning across medical schools is non-standardized and the skills that they learn can vary. Project HEART, a volunteer-based outreach program focused on teaching cardiovascular health and cardiopulmonary resuscitation (CPR) at public high schools, was implemented to encourage greater community engagement and equilibrate skill acquisition across different service projects. This pilot study characterized the benefits of providing service learning opportunities to first-year medical students. First-year medical students at a single institution were recruited to Project HEART. Following service sessions, all students completed a retrospective pre/post survey. They provided self-reported scores on a five-point Likert-type scale, grading their didactic and communication skills before and after the event. Subjective feelings of community engagement were also queried. Overall, 30 students were recruited across nine different community programs. Following participation, significantly increased confidence was seen in performing hands-only CPR (p < 0.001), public speaking (p = 0.003), teaching effectively (p < 0.001), and explaining medical terminology to laypersons (p < 0.001). Volunteers had an increased sense of community engagement (p < 0.001) and 17/30 students expressed greater consideration towards specializing in cardiology, primary care, or entering academia after participation. The study supported the proposal that service learning may promote self-determined altruism, positively influence perceptions of community stewardship, and have positive subjective benefits on medical student education.

1. Introduction

Cardiovascular disease is the leading cause of death in Hawai‘i [1]. On the island of O‘ahu alone, more than 1000 cardiac arrests occur each year with only approximately 10% of people surviving such an event [2]. As such, the importance of cardiopulmonary resuscitation (CPR) is monumental. However, only a third of hospital cardiac arrests (OHCA) in the state receive adequate intervention with bystander CPR [2]. Additionally, children of racial minorities are less likely to receive bystander CPR than White children [3]. Amongst Hawaii’s majority racial minority population [4], such disparities need to be addressed. We believe that expanding CPR training and the overall knowledge of cardiovascular health would be the first step towards a healthier community.

Project HEART (Heal, Exercise & Rescue Together) was established to spread awareness of cardiovascular disease and provide hands-only CPR workshops to public high school students. At the same time, it operated as a service learning opportunity, engaging medical students in both health advocacy and longitudinal community engagement. Service learning, in general, has been shown to have numerous benefits towards medical student education. Engaging in community health projects early in a student’s medical career can improve future civic involvement, communication, empathy, compassion, intra- and interpersonal skills, and teaching capacity, as well as the ability to identify and address healthcare needs of underserved populations [5,6,7,8,9,10,11,12,13,14,15]. With all of these benefits attributable to service learning, it is hard to distinguish the strengths of one program as opposed to another. Also, required service learning curricula may compel students to work on a project which may not teach them the skills they would like to learn through such experiences. The implementation of optional service learning opportunities may help to offset the heterogeneity of varied service learning curricula among self-motivated students.

The purpose of this pilot study was to assess whether the implementation of an optional teaching-based service learning opportunity with underserved communities would help supplement a community service-based medical school curriculum through self-reported measurements of learning. Project HEART’s potential benefits in teaching viable and useful skills to early-career medical students in order to offset the heterogeneity of service learning projects within a single institution were measured and analyzed.

2. Materials and Methods

First-year medical students (MS1s) were recruited through a university-affiliated email listserv and assigned to teach a one-hour Project HEART workshop. The workshops were held at local public schools on O‘ahu (i.e., Roosevelt, Kalani, and Farrington) and targeted high school students on healthcare academy tracks, specialized high school curricula for students interested in future healthcare careers. Public high schools were selected as data showed that in 2023–2024 approximately 55% of public school students were identified as disadvantaged, ranging from economic disadvantages to being English as a Second Language learners [16]. Prior to participation, medical student volunteers signed consent forms confirming their participation in the study and underwent a brief orientation to review the curriculum and learning objectives. During the workshops, MS1s guided students through a 30 min clinical problem-based learning case which covered heart physiology and cardiovascular disease basics. The remaining 30 min were dedicated to hands-only CPR training without certification (see Supplemental File S1). After teaching once, MS1s completed a retrospective pre/post survey, providing self-reported scores on a five-point Likert scale (1 = not comfortable at all, 2 = slightly comfortable, 3 = moderately comfortable, 4 = very comfortable, and 5 = extremely comfortable) to evaluate their confidence in didactic and communication skills, as well as subjective degree of community involvement. A retrospective approach enabled students to assess their perceptions at both time points using a consistent internal standard, leading to a more accurate characterization of outcomes [17]. The survey also evaluated their interest in particular medical subspecialties aligned with the curriculum by asking if participants were more likely to consider specializing in cardiology, primary care, rural medicine, or medical education following study participation, and if so, which specialty.

Data Analysis

A Shapiro–Wilk test was used to evaluate the normality of the data set. This was carried out due to the small sample size and self-selected participants, which led to concerns that the population would not be normally distributed. Since normality was not demonstrated, a non-parametric Wilcoxon signed-rank test was used to evaluate the difference between pre- and post-participation responses with significance set at a p-value < 0.05.

3. Results

A total of 30 students volunteered to teach Project HEART workshops during the 2022–23 school year. Self-reported confidence in performing hands-only CPR, public speaking, teaching effectively, and explaining medical terminology to laypersons improved significantly after they led the workshops (see

Table 1. Mean self-reported learning outcomes before and after Project HEART participation.

Learning Outcome	Before	After	p-Value
Ability to Perform Effective CPR	2.67 ± 1.06	4.23 ± 0.82	<0.001 *
Public Speaking	3.50 ± 0.97	4.17 ± 0.87	0.003 *
Teach Effectively	3.43 ± 1.10	4.00 ± 0.83	<0.001 *
Translate Medical Topics to “Layperson” Terminology	3.87 ± 0.90	4.23 ± 0.68	<0.001 *
Current Level of Community Involvement	3.47 ± 0.78	4.10 ± 0.71	<0.001 *

CPR = cardiopulmonary resuscitation. Significance was set at a p-value < 0.05 and any significant values are indicated by *.

). Additionally, 17 out of 30 students (57%) expressed greater consideration towards specializing in either cardiology, primary care, or participating in medical education in the future. Feedback was collected and categorized into the following themes: 15 out of 30 students (50%) enjoyed facilitating small group learning and observing the students’ enthusiasm and learning progress. Around 8 out of 30 students (27%) valued the chance to make an impact in their community, and another 8 out of 30 (27%) emphasized connecting with students on a personal level, sharing experiences, and providing mentorship opportunities.

4. Discussion

The growing diverse population within the United States demands for a greater degree of culturally competent medical care [5]. Service learning, a seamless combination of community-centered advocacy and medical education, represents a promising tool to address this need [18]. Examples include student-run health clinics, health-promotion projects, and community service work after a natural disaster [6]. However, despite this demand, a 2019 Association of American Medical Colleges survey found that only 43 medical schools had service learning as a required part of their curriculum, and only a handful of schools employed required service learning across multiple years of school [5,19]. The Project HEART initiative recruited a cohort of 30 students participating across a single school year to face this challenge. While the program’s community advocacy focus was to teach about cardiac health and CPR, there was a clear intention to develop crucial intra- and interpersonal skills amongst participating medical students.

Overall, the pilot study identified significant self-reported increases in self-determined ability to perform effective CPR, comfort with public speaking, confidence in teaching effectively, competency in explaining complex medical topics using digestible terminology, motivation to participate in future community service/education, willingness to contribute to the betterment of their community, and a deepened sense of community involvement. These results support previous literature on the ability of medical students to teach CPR while simultaneously benefiting educationally from such experiences [20,21]. However, while there have been several other student-run programs focused on CPR training alone [19,20], this was one of the first studies which utilized problem-based learning with supplemental hands-only CPR training to educate high schoolers on cardiovascular health and OHCA readiness. This study was also one of the first to record student-reported variables focused on communication and teaching beyond the focus on CPR training. Additionally, our analysis was able to note the impact of a heart health-focused community initiative on medical student consideration in specialization, with 57% of students expressing a greater consideration towards specializing in cardiology, primary care, or medical education after participation in Project HEART.

MS1s at our institution have the option to enroll in community health electives but the learning opportunities vary greatly depending on which elective they join. A secondary analysis of the cohort revealed that 43% of students prior to joining Project HEART rated their level of community involvement and impact at either a 1/5 or 2/5. Following participation, only 3% said their motivation to participate in future community service/education was at a 2/5 or lower, with all other students showing an increased interest with a rating of 3/5 or higher. Furthermore, students identified common themes after participating, with “connecting with the students”, “sharing experiences”, “providing mentorship”, and “making an impact on their community” being the most notable. Such findings align with prior research on how community-based education has been shown to support the further development of traits like altruism and dutifulness [22,23].

This study describes one of the first service learning projects that employs problem-based learning and CPR education with self-reported outcomes to simultaneously educate vulnerable communities and promote medical education. However, the specific focus of this project may limit the generalizability of our findings to that of other service learning initiatives. Additionally, Project HEART was centered on self-motivated students who chose to enroll in our program. This cohort of students likely have some degree of bias associated with their perceptions of their community involvement, which is likely to skew the findings, though it is unclear to what degree. The data were collected with a retrospective pre/post survey, which is useful for identifying when learning had occurred in each of the queried topics, but is limited by not being able to accurately quantify how much learning had changed compared to an objective tool. The study’s smaller sample size and lack of longitudinal follow up with participants also make it difficult to determine the long-term benefits of Project HEART. The smaller sample size in particular is one of the main limitations of this study. Following MS1s into their clerkship years and having them reflect on lessons from Project HEART may elucidate whether the skills they develop impact their patient care. Looking ahead further, assessing the involvement of medical students who participated in this study and their future contributions to community service, CPR instruction, or the impact this had on their careers would also be valuable. Furthermore, future studies may find it useful to survey the high school students to determine the community impact of this project.

5. Conclusions

This pilot study largely supports the idea that service learning can promote self-determined altruism and community engagement and have positive benefits on medical student education. Additionally, it shows that a heart health-focused initiative seeking to prevent future cardiac events and increase awareness of CPR training is viable, and can contribute to self-reported intra- and interpersonal skill development among medical students.