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 Table of Contents  
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 130-137

Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning

1 Dep artment of Medical Education, Fatima Memorial Hospital Medical and Dental College, Shadman, Lahore, Pakistan
2 Department of Internal Medicine, Shifa College of Medicine, Shifa Tameer-e-Millat University Islamabad, Pakistan
3 Institute of Public Health, College of Medicine and Health Sciences, University, Al Ain, United Arab Emirates
4 Department of Planning and Development, Fatima Memorial System, Shadman, Lahore, Pakistan

Date of Web Publication21-Nov-2015

Correspondence Address:
Rukhsana Aslam Ayub
House No. 17, Street 13, Sector H, Phase 2, DHA, Islamabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.170122

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Background: Service-learning (S-L) is an educational approach that integrates community service with academic learning. S-L helps educate youth about their civic role and responsibility in society, and empowers them to tackle societal problems, strengthening communities through civic engagement. The objectives of this study were to demonstrate the effectiveness of S-L in fostering civic responsibility and communication skills in college students and to increase health literacy regarding iron-deficiency anemia (IDA) among both students and community women. Methods: This interventional exploratory study used a mixed methods approach. Thirteen first-year students from a women's college participated in the project. The authors held small interactive group sessions to teach the students about IDA and communication skills. A questionnaire measured the students' perceived knowledge about civic responsibility, communication skills, and IDA. The students then developed and delivered a health education campaign for sixty five community women and measured changes in the women's health literacy about IDA. A focus group discussion was conducted to collect students' reflections after the S-L experience. The changes in the civic responsibility and communication skills were determined by Wilcoxon rank test, while health literacy in women by a McNemar test. Results: Students showed significant improvement in all three constructs of civic responsibility and in perceptions of their communication skills. Increases in civic responsibility and in acquisition of knowledge emerged as the main themes of the focus group discussion with students. The community women showed substantial improvement in health literacy of IDA. Discussion: In this study, S-L achieves two purposes: (a) Increases students' knowledge of health topics, their sense of civic responsibility and improves their communication skills, and (b) educates women in the community about common and preventable health issues.

Keywords: Civic responsibility, health literacy, iron deficiency anemia, service learning

How to cite this article:
Ayub RA, Jaffery T, Aziz F, Rahmat M. Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning. Educ Health 2015;28:130-7

How to cite this URL:
Ayub RA, Jaffery T, Aziz F, Rahmat M. Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning. Educ Health [serial online] 2015 [cited 2022 Oct 7];28:130-7. Available from:

  Background Top

Developing countries like Pakistan face a host of social, economic and health-related problems, and much of their limited resources are spent on managing high morbidity and mortality caused by chronic diseases, many of which are easily preventable.[1] The burden of responsibility of improving the health of the population, however, cannot be the sole responsibility of the government. One strategy to increase societal responsibility for health is to increase awareness in youth about their civic role in society. There is clear evidence that social change to improve health outcomes can be brought about through student engagement with the community.[2],[3]

Educational strategies that provide students with the opportunity to practice what they learn in real-life situations have been shown to be an effective way to increase social awareness. Service learning (S-L) is defined as "a teaching and learning strategy that integrates meaningful community service with academic instruction and reflection to enrich the learning experience, teach civic responsibility, and strengthen communities."[2] For this study, we focused on S-L as a strategy to improve the health literacy of women in the community about iron-deficiency anemia (IDA), which is highly prevalent the world over,[4] including Pakistani women.

The main causes of IDA are dietary deficiency, multi-parity, worm infestation, poor iron absorption and lack of health services.[5] Oral iron supplementation is widely used for treating IDA, but side effects lead to poor compliance.[6],[7] The estimated prevalence of IDA in Pakistan among children is 50.9%, leading to impaired school performance.[8],[9] Among women of reproductive age (WRA) in Pakistan, the estimated prevalence of IDA is 27.9%.[8] IDA has a profound impact on this major work forcegroup, reducing women'swork capacity, bringing serious social and economic consequences to families and impeding national development.[7],[8],[10] IDA also leads to major health problems among WRA such as poor pregnancy outcome.[7],[8],[11],[12] Increasing awareness of WRA about the causes, effects and prevention of IDA through health education campaigns has shown to be effective in combating this highly prevalent yet easily preventable condition.[6],[13],[14]

Two of the main hurdles Pakistan faces in improving the health of its population are the inadequate number of healthcare personnel and the overall low adult literacy rate of 55% (67% for men, 42% for women) which hinders effective health education and disease prevention.[15],[16],[17] An individual's literacy level has been shown to positively correlate with health literacy, making it easier to impart health information in populations with higher literacy rates.[18],[19],[20] Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health-related decisions."[21],[22]

People with low health literacy face great risks; they experience unnecessary illness and disability,[23] are poor users of preventive care, and are unable to use print-only material effectively.[19] For such settings other methods, like pamphlets with simple graphics, may be employed.[24] These problems are present in developed countries like the United States as well, and new and innovative techniques are thus needed to meet healthcare needs of communities with lower literacy rates.[3],[25] One approach that is being increasingly used in the US is Service Learning (S-L) – creating a volunteer work force comprised of competent and energetic undergraduate college students who assist those engaged in public health.[25],[26]

S-L has its roots from John Dewey, who identified the interaction of knowledge and skills with experience as central to learning.[2],[27],[28] Effective S-L programs are designed to equally benefit the provider and the recipient of service, and to focus on both the quality of the service and the learning.[29] To maximize the benefit of S-L, students must have time and opportunity to reflect critically on their service experience. This reflection helps clarify the learner's meaning of the experience and leads to change in their thinking.[2],[28],[30],[31] In Pakistan, there are very few educational programs that provide relevance of learning in the context of real life situations. Pakistani public and private educational institutions rely on classroom teaching with little exposure to community lifestyle. This is why, in view of the aforementioned problems Pakistan is facing, service learning becomes a highly relevant teaching and learning strategy.

This paper presents the results of an exploratory, mixed methods S-L intervention where students were engaged with the community in a health education campaign. Both the students and the women community participants benefited as they were educated about causes, effects, and prevention of IDA. Through interaction with the community, the students became skilled communicators and also developed a greater sense of civic responsibility.

  Methods Top

Student participants

The Principal Investigator described the S-L project to 40first-year students (freshmen) and ten faculty members in a public Girls' Degree College 1. Thirteen students volunteered to participate in the six-week project, conducted in the summer of 2010, and received certificates at the end. The college assigned two teachers for training and facilitating the project. Approval for the project was granted from the Ethical Review Board of Girls' Degree College i.

Phase I (before actual field visit)

We developed a 30-item questionnaire to assess health literacy of students and the community women on three dimensions before and after training: Sources of iron, causes of IDA, and signs and symptoms of IDA. The content of questionnaire was finalized through literature review [32],[33],[34] and by consulting two medical specialists and a gynecologist. The questionnaire was translated in Urdu for the community women. After completing the pre-test, students learned about IDA in six sessions lasting for up to 3 hours each. The students were considered health literate if they scored 80% on the post-test in identifying meat, spinach and lentils as important dietary sources of iron, diets insufficient in meat, worm infestation, and multiple child births as important causes of IDA,[32],[33] pallor, tiredness, and shortness of breath as main -symptoms of IDA,[34] and juices containing Vitamin C as major facilitators of iron absorption.[33]

We pilot tested the Urdu version of the questionnaire on 30 housekeeping women of the same socio-economic and demographic background as the target women. Afterwards, inter-item reliability of the tool was determined by Cronbach's alpha coefficients for each dimension: Sources of iron = 0.94, causes of IDA = 0.87 and signs and symptoms of IDA = 0.78. The piloting resulted in a few modifications in the Urdu questionnaire and helped students select educational strategies easily understood by community women.

The authors also conducted a baseline survey of the students' perceptions about civic responsibility using the 24-item civic responsibility survey (CRS) version K12, level 3 instrument that has been used extensively.[35],[36],[37] It uses a six-point Likert scale (strongly disagree = 1 to strongly agree = 6) to measure perceptions about civic responsibility in three constructs: Connectedness to community; civic awareness and attitudes; and civic action and efficacy (overall Cronbach alpha = 0.93, and each construct = 0.63, 0.88 and 0.85 respectively).[35] We measured the students' perception of their communication skills through the Self-Perceived Communication Competence (SPCC) Scale.[38] This instrument has inter-item reliability (alpha = 0.85) and strong face validity.[39],[40] It measures oral communication skills across four contexts (public speaking, talking in large groups, talking in small groups, talking in dyads) and communicating with three types of receivers (strangers, acquaintances and friends).

Phase II (actual field visit)

To deliver training about IDA, we recruited all 65 women receiving vocational training from a non-governmental organization (NGO). An eight-hour long session was organized at the place provided by the NGO to promote interaction between students (n = 13) and women. Each student was assigned a small group of five to six women and they assessed the women's baseline knowledge of IDA through the pre-test. Afterwards, they conducted their educational intervention using pictorial pamphlets, posters, a short play and a question and answer session. After one month, students re-administered the IDA knowledge questionnaire to 53 women out of the total 65 who participated in the baseline survey and intervention.

Phase III (post-intervention student reflection and changes in perception of civic engagement and communication skills)

A college faculty member (not directly involved in the S-L project) conducted a focus group discussion (FGD) with students (attended by all but one student, who was sick) to gather detailed information about the experiences and changes in the perception of civic learning and communication skills that occurred throughout the process of service learning. Further, it enabled students to reflect and evaluate their perceptions and behavior towards their own learning needs and of the community. The focus group included questions such as; 'How this service learning project has changed you as a person?', 'What do you feel about the community where you delivered the service learning program?' (See appendix for the complete FGD guide). The authors re-administered the CRS and the SPCC scale to the students.

Data collection and analysis

Data from the instruments were entered in SPSS version 17 and analyzed using Stata version 12. We used the Wilcoxon sign rank test (z-score <1.96, P value <0.05) to measure the median difference in the perception of civic responsibility and average increase in SPCC in students (z-score <1.96, P < 0.05), as the sample size was low and distribution was non-normal. We applied the McNemar test (McNemar exact chi square >3.84 and P < 0.05) to measure the difference in proportion of women with knowledge about IDA before and after the health education intervention.

The Principal Investigator (PI) recorded and transcribed the focus group discussion. The transcription was analyzed, coded and categorized independently by two researchers using an inductive approach. Final agreement on themes was reached by comparison of independently done thematic analysis. Any disagreement on themes was discussed until consensus was achieved.[41] Member check was done with some focus group participants who reviewed the themes for validity. The PI analyzed and categorized the data based on the agreed themes and also selected student quotes to highlight important themes.

  Results Top

Changes in student perceptions about civic responsibility and communication skills associated with the S-L project; The 13 students showed significant increase in their perceptions of civic responsibility after survey across all three constructs: "Connection to community," "civic awareness and attitudes," and "civic action and efficacy" [Table 1]. The median score of connection to the community increased significantly (z = −3.19, P < 0.001) from 4 to 5.5. Similarly, median sores of civic awareness and attitudes (z = −2.44, P = 0.016) increased from 4.5 to 5.5, and civic action increased significantly (z = −2.85, P = 0.004) from 3 to 5.1.
Table 1: Students' responses on civic responsibility survey (version K 12 level 3) (n=13)

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Communication skills

The 13 students also showed statistically significant increase in their self-perceived overall communication competency score, with an average increase from 68.5 to 78.6 (P < 0.001) before and after the S-L. This increase was related to five of the seven constructs, including: Public speaking (P = 0.006), meeting (P = 0.023), speaking in groups (P = 0.038), speaking in dyads (P = 0.024), and speaking with acquaintances (P = 0.01) [Figure 1]. The changes in communicating with strangers (P = 0.06) and friends (P = 0.06) were not significant.
Figure 1: Pre- and post-comparison of self-perceived communication competency norms of students (n=13)

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Increase in proportion of community women's health literacy about IDA

Overall, there was a clear increase in the proportion of community women (n = 53) knowledge in all three elements of IDA. The knowledge about causes of IDA increased significantly (chi = 23.5, P < 0.001) from 32.1% (17) to 83.0% (44), sources of iron (chi = 18.6, P < 0.001) from 49.1% (26) to 96.1% (48) and signs and symptoms of IDA (chi = 22.5, P < 0.001) from 41.5% (22) to 90.6% (48) after the health education intervention [Table 2].
Table 2: Pre- and post-health education intervention scores on awareness of IDA among women according to age and education status (n=53)

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The health literacy of IDA among the women was compared before and after health education according to education status [Table 2]. Most of the 53 community women in the study were 15 to 25 years old (53.4%, 31), while 41.5% (22) were 26-46 years old. Of the 53 women, about one-third of the women were educated less than high school (33.9%, 18) and three-fifths (66.1%, 35) equal to or more than high school.

There was no statistically significant difference in gain in knowledge after health education with respect to age groups in all three components of knowledge about IDA [Table 2]. However, there was a clear association of educational level and gain in awareness of IDA with the health education intervention. The women educated less than high school (n = 18) showed the least gain. Only the proportion knowledgeable about the causes of IDA increased significantly (chi = 5.4, P = 0.039) from 38.8% (7) to 77.7% (14) after education. In contrast, substantial gains in all three elements of IDA awareness occurred with the women (n = 35) who were educated high school and above. The proportion of women with knowledge about causes of IDA significantly increased (chi = 18.2, P < 0.001) from 28.5% (10) to 85.6% (30), symptoms of IDA increased (chi = 22.2, P < 0.001) from 31.4% (11) to 94.3% (33) and proportion of women knowledgeable in dietary sources of iron substantially improved from 54.0% (19) to 97.1% (34) (chi = 15.0, P < 0.001).

Impact of the S-L project on students

Five themes emerged from qualitative analysis of the focus group discussion held with the students after completion of the S-L project. The first theme, service-learning increases civic responsibility and/or motivation to do community service, was communicated by all 12 students who were able to participate in the follow-up focus group discussion. Typical comments included: "…I would definitely take part in such a project because you should help people regardless of their background" and "…I am responsible to care for my country." The second theme, service-learning increases acquisition of new knowledge, was expressed by 11 of the focus group participants. Students reflected that studying about an important health issue helped them to increase their own knowledge, and this was enhanced by disseminating information to others: "It was a wonderful experience; we told people who didn't know about iron deficiency and in the process increased our own knowledge too." Another student noted that this experience was an eye opener for her: "We learnt how a lot of women, rich or poor, don't know about their dietary needs and symptoms of deficiencies."

The third theme was 'improved communication skills', noted by nine students. The students appreciated the opportunity to practice their communication skills: "The most important thing for me was learning how to interact with people. How to talk to them and how to inform them about iron deficiency." The fourth and fifth themes were noted by one-half of the focus group participants (6 each). Students remarked that they learned about 'the diverse lifestyles of communities'. The hands-on exposure helped students to connect with reality, discovering the health problems and level of health knowledge of the community: "I have gained a lot of information about how people in the poor segments of society are living." Additionally, students commented that they experienced a sense of satisfaction after participating in the S-L project: "---and the satisfaction of changing people's life is a great feeling."

Both the participating faculty members were sent an open-ended questionnaire. They were very enthusiastic about this new educational approach. Typical comments were:

"I feel happy as now I have a way through which I can change the way my students think in addition to learning the course." "I can teach so much of my Biology syllabus through Service–Learning that I am very excited but I need help."

  Discussion Top

This exploratory study established the feasibility of S-L to promote health literacy about IDA in Pakistani women. S-L is a powerful pedagogy for teaching public health and developing public health literacy.[2],[25],[42] The S-L provided benefits to both the college students and community women. Community women gained health literacy about several aspects of IDA, which was maintained for at least one month. The women college students gained knowledge about IDA, skills in communication, and increased civic responsibility.

Although, S-L is not a new concept, there are only few studies demonstrating actual improvement in health literacy.[2],[42] The pedagogical principles underpinning S-Lare the engagement of learners with the community to address community needs, and structured opportunity for reflection built into the project to facilitate the desired learning outcomes. In our study, the desired learning outcomes for the students included learning about IDA, and improving communication skills and civic responsibility. Our objective for the community was to demonstrate improvement in Health literacy related to IDA in WRA.

The literature has shown that health education programs for the community which pay attention to the needs of the particular community are more likely to succeed.[43] In this context, the education level of the community is an important factor to be kept in mind while designing health education programs. In addition, the language used for providing health education as well as an understanding of common biases and misconceptions related to the particular health problem in that community are relevant.[43] The initial phase of our study included translation of the IDA questionnaire in Urdu, the local language of the community, and piloting this questionnaire on women from same socio-economic and demographic background. We involved the students participating in the project in translation and pilot testing the questionnaire after they had completed the IDA workshop. This strategy familiarized students to common terms and biases regarding IDA in the community. As students reflected on this experience, they were able to develop health education strategies according to the needs of the community.

Health literacy is much more than the ability to read health information. Many conventionally well-educated people may be challenged by low health literacy.[23] In order to help those with poor health literacy to make the right choices and decisions, it is important for them to have conversations with those providing health care and education.[44] An interesting phenomenon which emerged from the student reflections was the use of multiple educational strategies to educate WRA -- pictorial pamphlets, posters, a short play and a question and answer session related to IDA in small groups during tea. Our study showed a similar and significant increase in –Health Literacy regarding IDA in WRA of both age groups, 15 to 25 years and 26 to 46 years, perhaps related to the use of multiple strategies to promote learning.

An individual's literacy level has been shown to positively correlate with health literacy, making it easier to impart health information in populations with higher literacy rates.[18] In our study, there was a clear association with educational level and gain in awareness of IDA with the health education intervention. The women with less than high school level showed the least gain.

Kolb defines experiential learning as "the process whereby knowledge is created through the transformation of experience."[45] The students went through a process of learning by concrete experience, reflective observation, abstract conceptualization and active experimentation. By participating in the S-L project, - the students showed more willingness to serve the community and worked to help them. A major theme which emerged from the focus group discussion was acquisition of new knowledge. The students applied the knowledge about an important public health issue to a practical experience. Various studies using S-L report similar improvement in critical thinking, problem-solving and interpersonal skills along with development of civic responsibility,[3],[30],[46],[47],[48] as well as improved communication skills.[30],[49],[50] The students showed improved scores on the SPCC scale for all of the contexts and types of receivers except for the ability to talk to friends and strangers. The results with friends could be due to the fact that the students already rated themselves initially quite high regarding their ability to talk to friends (86.2% average). These results show that in future projects it will be important to put more emphasis on improving the students' ability to talk to strangers. Through the FGD, it became apparent that for many students there was correction of their own misconceptions about an easily preventable disease, and imparting this knowledge to others enhanced their own learning. Thus, S-L programs improve students' self-worth [51] and the students also expressed satisfaction that they could actually make a difference to society.

Overall, the women in the community learned about a health issue that is important for WRA, and built links with college students belonging to segments of society which are often perceived as elite and thus indifferent to the plight of less fortunate communities. Similar to the findings of Brown [3] and Narsavage et al.,[52] the real life exposure to the community women resulted in the students feeling connectedness and greater attachment to the community. The interaction with people of different ages and socio-economic status increased their awareness and understanding of common issues faced by the community. This was reflected in the themes of the focus group discussion as students reported learning about the diverse lifestyles of communities and a better understanding about the communities' social problems.

To our knowledge, this study was the first one that used service learning in community settings of Pakistan. This exploratory study has enabled us to identify the potential for a health workforce extension model in the country. However, this study also had some limitations. Regarding the college students, the S-L project involved volunteers who were already motivated to take part, which may have resulted in a selection bias as well as in remarkable increase in health literacy. Also, the students assessed their own knowledge, and there may be subjectivity in the assessment. The students noted issues with scheduling. However they were ready to participate in future projects if scheduling could be optimized. On the community side, there was limited follow-up with the community (at one month after the education intervention), because the S-L project was done during summer break and the students needed to start classes. Ideally, we would have had a longer follow-up at three months or more after the S-L intervention.

  Conclusion Top

S-L is a unique approach to experiential education where student participation in carefully structured activities and provision of opportunities for reflection lead to development of civic responsibility perceptions in addition to academic learning and better communication skills. Service learning projects like this study can serve to fill the gap in the public health workforce in meeting basic public health needs of the community in a resource poor country like Pakistan. The process and lessons learned from this study have led to the development of student electives program in the school because the students themselves advocated for this strategy to be taken up in a more comprehensive manner. Further, various health literacy projects tackling awareness of hepatitis B and C and AIDS viral infections are in progress.

  Acknowledgements Top

This study was begun as a project for Dr. Ayub's Fellowship with the Foundation for Advancement of International Medical Education and Research (FAIMER), and we would like to thank Zareen Zaidi, MD, Stewert Mennin, PhD, and Tony Laduca, PhD who were very helpful in the early phases. We would like to thank Dr. Page Morahan, PhD for her mentorship to the authors in completing the manuscript for publication, and Gwen Martin, BA for her editorial assistance.

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