Introduction
Aside from facilitating the development of fieldspecific competence, higher education institutions are tasked with producing ready-to-work graduates (employability) by equipping them with generic skills and an awareness of contextual issues relevant to their profession [1]. In the healthcare sector, these issues often center on closing the gap of health inequity, as emphasized in the Sustainable Development Goals (SDGs), which recognize various sociocultural and environmental factors influencing society’s health and well-being [2-5]. Future healthcare workers are expected to be aware of and capable of responding to the challenges posed by these factors, collectively referred to as the Social Determinants of Health (SDoH). They are also expected to act as catalysts for change by initiating and fostering meaningful improvements in the healthcare sector as part of their professional responsibilities [6]. Health profession education institutions play a critical role in preparing students to meet these expectations.
Despite rigorous attempts to reduce the health inequity gap, it remains a prominent challenge faced by underdeveloped or developing countries, including Indonesia [7,8]. Most health disparity issues are typically profoundly rooted in the community and thus require creative and innovative solutions to break the status quo. Particular in the Indonesian context, access to healthcare, poor sanitation, and unhealthy behaviors are three major issues that contribute to health inequity [9-12]. Despite being major health inequity issues, healthcare infrastructure and affordability contribute only 39%–52% to the variability index scores hindering societal access to healthcare in remote areas and big cities in Indonesia, respectively [12]. This indicates the presence of other pervasive and unknown factors—such as sociocultural norms, beliefs, and practices [13,14]—that contribute to the persistence of health inequities in Indonesia.
A standardized guideline for teaching health equity does not currently exist. However, there is a consensus on the key topics that should be included in the health equity curriculum. These topics encompass the social environment, built environment, access to care, and forces and system [15]. Many medical schools in the United States employ short, one-time, didactic, participatory, and experiential learning approaches, often involving students to engage in a specific project, to teach health equity [16]. The absence of standardized health equity curricula has resulted in significant variations in what, when, and how health equity topics are taught to students [17].
The integration of health equity topics into medical school curricula in Indonesia varies significantly across institutions and is often confined to discussions of biopsychosocial factors influencing health, typically delivered using traditional didactic lectures aimed at preparing students to provide holistic patient care [18,19]. Nevertheless, the scope of health equity education in Indonesia—focused on topics such as clinical epidemiology, environmental health, health systems, and national health programs—remains comparatively narrow, overlooking other aspects that largely contribute to the real-world health challenges within Indonesian communities, such as the social and built environment and access to care [20,21].
In a country with vast demographic, geographic, and sociocultural diversity, more attention should be given to developing students’ ability to identify and respond to existing health inequity issues, which include creative problem-solving skills, collaboration and team working skills, as well as futures thinking skills. Traditional didactic methods frequently lack the capacity to foster critical thinking, empathy, and practical problem-solving skills required to address complex health inequity issues. Project-based learning (PjBL) offers a promising alternative by exposing students to real-world challenges and encouraging active engagement with these issues. Grounded in social constructivism, experiential learning, and situated learning, this educational strategy provides students with an opportunity to engage in meaningful learning by creating concrete and applicable products that correspond to real-world challenges, thereby bridging their theoretical knowledge with situational awareness and understanding when addressing health inequities [22,23].
To date, the use of PjBL in Indonesian medical education has been very limited because of its resourceintensive nature. This study was intended to showcase the value of PjBL, particularly in teaching health equity, by exploring students’ experiences during a PjBL course, which was designed around the core theme of achieving health equity. Specifically, we aimed to answer the question “How does PjBL influence students’ perception and understanding of health equity?” by examining what they learned, how the course changed their outlook on their future professional roles, and which topics most influenced these shifts.
Methods
This study used a qualitative phenomenology approach [24]. We specifically designed a 4-week elective PjBL course centered on identifying and addressing health inequities in surrounding communities by incorporating active learning. This course was one of six elective courses offered to fourth-year preclinical students at a private medical school in Jakarta, Indonesia during the 2021 and 2022 academic year. Course enrollment was based on students’ preferences.
1. Course design
The underlying theme of this course was “Achieving Health Equity through Interprofessional Collaboration.” We named it the “Medical Education Course” (ME course) to reflect the incorporation of various medical education topics as foundational knowledge in developing the health equity project. We employed active learning methods as the primary educational strategies in this course to highlight PjBL’s distinct advantages over traditional didactic lectures. These methods included flipped classrooms, interactive discussions, mentoring sessions, working group activities, hands-on workshops, and skills laboratories. Furthermore, we encouraged students to independently design their own health equity projects— determining the resources required, engaging key community stakeholders, and accounting for local SDoH while addressing prevalent health issues. All projects were carried out in groups of four to five students with the support of one or two mentors. Each mentor was briefed on the expected learning outcomes and study objectives. Mentors with less than 5 years of teaching experience were paired with senior teaching faculty, while mentors with 5–10 years of teaching experience mentored their groups individually. Throughout the 4 weeks of this course, students engaged regularly in a series of working group sessions with mentors to develop their project. During the working group session, students could discuss their progress on the project and any related problems. The mentors were briefed to limit their interventions as much as possible to optimize students’ active participation during their learning in this PjBL method.
To help students in developing their projects, we introduced and explored seven key topics, which can be further categorized into three main categories: (1) foundations of health equity topics, including terminologies and definitions, SDoH, and health inequity issues in Indonesia; (2) medical education topics, including adult learning, personal and community education (including introduction to telemedicine), interprofessional collaboration, professionalism and professional identity; and (3) general topics that support students in completing the project, such as communication (including effective mass communication and intergenerational dialogue), futures thinking, and agent of change. These key topics were delivered through lectures and interactive learning activities, ensuring that students could integrate these concepts into their project designs. An overview of the course structure, including key learning topics, is presented in Fig. 1.
At the end of the course, students were asked to reflect on their most memorable learning experiences and what they had learned. Specifically, students were asked to address the following three trigger questions: (1) What is/are the lesson(s) that you learned after attending this course? Relate what you have learned to your personal experiences and professional roles and responsibilities as a future agent of change in the healthcare sector; (2) Are there any changes in your outlook after taking this course? If so, what are the changes? If not, please explain why; and (3) Which topic(s) and study material(s) significantly change(s) your views or was/were the most memorable for you? In discussing these topics, relate them to your personal experiences and expectations.
2. Study participants
There were 65 fourth-year undergraduate medical students who enrolled in this course: 29 students (18 female; 11 male) in 2021 and 36 students (31 female; five male) in 2022. At the beginning of the course, we introduced the study and obtained informed consent from the students who chose to participate. This study was approved by the School of Medicine and Health Sciences Ethics Committee of Atma Jaya Catholic University of Indonesia (EC no., 01/04/KEP-FKUAJ/2022).
3. Data collection and analysis
To capture students’ experiences during the PjBL course, we asked students to write a 500-word reflective writing, which we subsequently analyzed using a deductive approach to thematic analysis [24,25]. A deductive approach enabled us to align our findings with the conceptual and theoretical framework underpinning the PjBL approach, as well as the aim of the study [26]. A total of 65 reflective writings were included in this study. Question 1 of the reflective writing assignment was designed to capture students’ learning experiences during the ME course, while questions 2 and 3 aimed to identify any changes in students’ outlook following the course and examine the processes driving those changes.
Initially, we developed a codebook based on our understanding of the topic, which was further refined by conducting a preliminary review of the entire data to grasp the essence of the students’ perspectives, as shown in the reflective writings. After identifying the quotes that closely reflected the meaning of each code in the codebook, we grouped them into categories that best represented the overarching idea of each code group. Two raters coded each reflective writing based on the codebook while adding new codes that had not been covered in the codebook when necessary. All raters (N.P., Gi.A., E.R., C.D.K., Gr.A.) regularly compared the codes and categories with the original data, maintaining a critical awareness of their theoretical assumptions about PjBL to ensure an accurate reflection of students’ voices regarding their experiences. An interrater meeting was held to discuss any disagreement regarding the coded quotes.
A total of 259 meaningful quotes were obtained. One of the 259 quotes did not reach complete agreement between the raters and was thus excluded from the analysis (interrater agreement 99.62%). We conducted member checking by returning the analysis results to each student and asking for their approval.
4. Researcher positionality
Two authors (N.P. and Gi.A.) were assistant professors, while C.D.K. and Gr.A. were teaching assistants at the medical school in which this research was conducted. Three authors (N.P., Gi.A., and E.R.) were involved in designing the PjBL course and delivered the medical education topics. All authors were involved in the teaching and learning process as mentors. We acknowledge that our personal and professional background, including our direct engagement with the participants during the PjBL course, may have influenced the data collection process and our interpretation of the data. Several steps were taken to mitigate potential conflicts and biases. We assured the students that their participation in this study was voluntary and that they could choose to drop out of the study at any time without any consequences. Two raters were assigned to code each reflective writing during the coding process. All raters consistently referred to the original transcript and met regularly for interrater meetings. Through these measures, we critically examined how our positionalities could influence our analysis and refined it to authentically represent the students’ experiences.
Results
Data analysis revealed 27 codes that were further categorized into four categories: character (eight codes), role (four codes), competence (nine codes), and learning experience (six codes). A complete list of categories, codes, and definitions obtained from the data analysis is presented in Table 1.
Three major themes emerged from the data analysis: (1) key learning experiences during the ME course; (2) the curated topics, encompassing both theoretical and practical aspects of health equity, medical education, communication, and futures thinking and agent of change, facilitated students’ understanding of health inequities and physicians’ roles, particularly in addressing health inequities in Indonesia; and (3) the influence of the ME course on students’ outlook and beliefs. A detailed explanation of each theme is provided below. Note that Supplement 1 presents a summary of the students’ quotes referred to in this section.
1. Key learning experiences during the medical education course
Students described numerous memorable learning experiences during the ME course, noting how these experiences influenced them as individuals, medical students, and future physicians. We identified five key learning experiences: active learning, role-modeling, collaborative learning, comprehensive learning, and affective learning.
One student highlighted how the ME course design encouraged them to “read [the class materials] in advance” as well as to actively “seeking information, giving opinions, …and learning independently” (Q252). This experience aligns with the flipped classroom activities integrated into the course, which promoted active learning by requiring students to complete individual or group pre-meeting assignments before attending classroom sessions. These assignments subtly compelled students to review the materials beforehand, enabling the course instructor to conduct two-way discussions rather than a traditional one-way lecture.
Another student reflected on how the reading assignment from agent of change topic influenced their perception. According to this student, reading about the success of a group of “…great women” in founding and expanding their non-profit organization and the success stories of doctors who worked in telemedicine served as a powerful role-modeling experience (Q219, Q251). Particularly, these stories made them realize that “… everyone can take part [to create] changes, regardless of their origin and background” and inspired them to “…more disciplined and diligent in pursuing [my] medical training” (Q251). These excerpts suggest a role-modeling experience, wherein the character from the reading assignment served as a role model by exhibiting certain characteristics, values, or behaviors that students find compelling and therefore wish to adopt.
One distinct characteristic of the ME course is its emphasis on collaborative group projects. One student noted that it was their first collaborative learning experience during their 3 years of undergraduate education. They also mentioned that this learning approach gave them opportunities to develop their teamwork skills by meeting and working closely with other group members (Q207).
The field trip activity to a nursing home, which was a part of the community education topic, gave students an opportunity to interact with the surrounding communities and observe their actual living conditions. One student felt touched by listening to the stories of how those “…elderly people ended up in that nursing home” (Q247). Being exposed to real-life health problems faced by people around might leave a deep impression that potentially moves them to “…take an active part” in solving existing health problems (Q246). This indicates that this activity could engage the students emotionally, which aligns with the concept of affective learning.
Each topic taught in this course acted as “building blocks” to support students in their journey to becoming future professional physicians. For example, one student mentioned that they “…studied various topics that helped improve [their] learning performance as a student and doctor later such as learning theory, multimedia learning, interprofessional collaboration, online personal education, and communication” (Q253). Another student mentioned that the “…professional identity [topic] … made [them] realize how important it is to know [their] identity …[to] better understand what [their] responsibilities” (Q255). These findings indicate that the ME course helped students comprehensively develop their capacity to become better physicians in the future. Particularly, a student noted that the ME course “…prepared [them] to become a doctor who is braver in facing every challenge that will be faced later” (Q255).
2. The curated topics in the ME course facilitated students’ understanding of health inequities and physicians’ roles
All seven key topics covered in the ME course were memorable and had a substantial impact on students’ personal and professional development (Fig. 1). During the first week, we introduced the foundations of health equity as a “trigger” to engage students with the central theme of the ME course. Delivered through flipped learning and working group activities, this topic provided the foundational knowledge necessary for developing their health equity projects. One student noted that they “… realized that health equity issues were still rampant in Indonesia” (Q220). They also mentioned several SDoHs that contributed to this situation, such as “…education, employment, urban and rural areas, and gender…” (Q227). In addition, some students highlighted the lack of general skills needed to provide optimal healthcare; for instance, one student mentioned “the lack of physician’s ability to communicate effectively with deaf patients [using sign language]” (Q220), resulting in unequal access to quality healthcare.
While the foundations of health equity topic introduced students to the current condition of health inequities in Indonesia, the general topics prompted them to reflect on their own roles in addressing these challenges. For example, a student noted that the “…agent of change, futures thinking [topics]” encouraged them to “learn that although [they were] only ordinary medical students, [they] must be brave [to] get involved in making breakthroughs, discoveries, or other solutions to create changes for the betterment of [themselves], others, and [their] country” (Q126). This motivation was further reinforced by the topic of professional identity, which compelled students to reflect on the kind of physicians they aspire to be. One student mentioned that the “professional identity [topic] made [them] realized the importance of recognizing [their] own identity … to understand what responsibilities [are expected of them] based on the identity” when responding to a health equity issue (Q255). Gaining clarity on their professional identity enabled students to choose the roles they desired in their future professional lives, thereby influencing how they address challenges or problems in their field of work.
Interpersonal communication, teamwork, and interprofessional collaboration were frequently mentioned by the students in their reflective writing. Few students recognized that effective interpersonal communication is crucial for collaborative activities (Q193, Q198), especially when working with different professions (Q190). One student believed that strong “interprofessional collaboration” practice could “reduce miscommunication incidence between physicians and other health care professionals, which will [positively] affect patient’s health” (Q191). Collaboration across professions and sectors was perceived as essential for improving healthcare service accessibility and implementing community-level changes (Q183, Q185). This topic served as a “reminder” for medical students that “as a physician, [they] could not work by [themselves]” (Q178). Developing interprofessional understanding and skills was deemed necessary for providing “maximal quality healthcare” (Q179).
Telemedicine was mentioned as an alternative for expanding healthcare access because it removes the challenges of traveling long distances to healthcare facilities and reduces associated costs. Nevertheless, effective communication was identified as crucial in telemedicine in one of the students’ reflective writings. Issues caused by poor communication during online consultation might affect both the physician, where they might be having “difficulties in taking history and diagnosing the patient … as they couldn’t be 100% sure that the patient provided accurate information”, and the patient, who might “feel dissatisfied and distrust [toward] the physician” whom they interacted only virtually (Q199).
Although not explicitly listed in the course syllabus, teamwork and managerial skills emerged as additional competencies students gained through group work engagement. Numerous students reflected on their in-group performance and group dynamics, with several remarking that the course challenged them to “go outside [their] safe zone”, where they were compelled to “befriend new people, … talk in front of a crowd” (Q10). On a personal level, the course encouraged one student to overcome their “shyness … to express their opinion in public … become more active and participate in all the planned [learning] activities” (Q202). The shift in students’ behavior was attributed to the course’s design, which required students to interact closely with their group members to complete their project (Q203, Q204, Q206).
Students also reported developing organizational and managerial skills. These abilities were particularly important because the course imposed multiple deadlines, assignments, and learning milestones that required careful coordination (Q231). Moreover, students needed to work with representatives from a chosen community to identify and analyze health disparities (Q232), which was integral to creating a tangible health equity project proposal aligned with the community’s needs.
3. The influence of the ME course on students’ outlook and beliefs
Aside from developing their knowledge on health equity, numerous students described how the ME course influenced their outlook on their professional roles—both as current medical students and future physicians—and beliefs on the kind of physicians they aspire to be in the future. While working on their health equity project, one student reflected on gaining a deeper understanding and awareness of the uneven distribution of healthcare workers in Indonesia and expressed their beliefs that compassion and willingness to address inequities and hardships within communities are essential traits for physicians, particularly to close the gap of health inequity in underserved and marginalized populations. We termed these traits as jiwa sosial, which reflects one’s drive to act and contribute to humanity and society. Several students also described their desires and plans to address health inequities in Indonesia once they become a professional physician (Q102, Q108, Q109), such as building a mobile, free-to-access hospital that offers good quality services to low-income people (Q105) and building a community-based social institution that could cover patient’s needs (Q101).
In addition to jiwa sosial, students reported other characteristics and traits through their engagement in the learning process of the ME course, including innovative, self-reflective, and lifelong learning. Working together in a group in developing a health equity project as well as the guided reflection activity seemed to have fostered these characteristics, as noted by numerous students who learned to appreciate each individual’s unique identity and characteristics (Q97), challenged themselves to “…express ideas that might seemed impossible at first or have the courage to apply futures thinking” (Q80), and practiced self-reflection by reviewing their past mistake(s), future goal(s), and life purpose(s) not only as individuals but also as professionals (Q1, Q46, Q48). In particular, the students wrote that “… reflecting upon oneself is not a simple task” (Q27), but it was “…a crucial part in achieving selfconsciousness, self-regulation, and practicing life-long learning” (Q53).
The most significant impact of the ME course on students’ outlook was its ability to trigger a paradigm shift regarding the role of physicians, particularly in addressing health inequities in Indonesia. Several students highlighted that physicians are not only expected to provide care and promote health but also to exhibit a strong sense of responsibility, confidence, and leadership qualities (Q8, Q72, Q85, Q139). One student reflected that, through the course, they realized that as a future healthcare worker, they are “…demanded to be able to make a good decision on the fly” and that “…many different aspects need to be taken into consideration when making a decision” (Q159). Moreover, many students expressed their readiness to act as agents of change. Some noted that creating change does not require being famous or influential; instead, they could begin by making small yet meaningful differences in the lives of those around them (Q133, Q141).
Discussion
The PjBL approach focuses on a key question or problem that structures students’ learning activities [27]. In this study, we asked students to identify at least one health inequity issue in their surrounding communities as a trigger for learning about health equity. We then examined students’ experiences of learning health equity through a PjBL approach to illustrate its pedagogical value. The findings indicate that PjBL fosters a variety of key learning experiences not commonly offered by traditional lectures, which remain as the primary instructional method in Indonesian medical schools. The key learning experiences offered by PjBL include active learning, collaborative learning, role modeling, affective learning, and comprehensive learning. Each learning activity provides different learning experiences. For example, flipped classroom and structured working group sessions with mentors provide students with active learning experiences. Guided by experienced medical instructors, these sessions provided the support and feedback required to enhance both general and content-specific competencies. Mentoring activities also fostered a supportive environment that enabled students to gain insights into professional and personal challenges, thereby reinforcing their professional identity as future physicians [28]. Furthermore, these sessions created opportunities for open and critical discussions about current student capacities, the expectations they will face as fully qualified physicians, and strategies to bridge any gaps between the two. Such reflective processes may underlie the paradigm shift in students’ personal beliefs, ultimately shaping their professional identity [29]. Working group sessions also provide students with collaborative learning experiences that give them opportunities to learn from one another. Through engaging in working group sessions, students learn about managerial skills, teamwork, communication skills, leadership, and responsibility, all of which are critical capacities to engage in interprofessional collaboration practices in the future [30].
The ME course we developed utilized “project component” model, which is a PjBL model that focuses on developing problem-solving skills using real-world issues as triggers for learning [27]. We provided students with foundational knowledge that we deemed necessary to complete their health equity project using flipped classroom. To some extent, these activities allowed students to gain a deeper understanding of the existing health inequities in Indonesia and the various factors that contribute to them. However, it was the field trip activity that fostered the characteristics necessary to address health inequities, such as confidence, self-reflective, life-long learning, leadership, innovative, responsible, respectful, and ‘jiwa sosial ’. By allowing students to directly observe and interact with communities experiencing health disparities, this experience elicited a deeper emotional response to the challenges at hand, which aligns with the concept of affective learning [31].
Health disparities encompass sociocultural, economic, political, and other factors that create barriers for marginalized and underprivileged populations from receiving good quality healthcare [32]. These factors are highly contextual, and understanding how they contribute to health inequities can be challenging for medical students because of their cross-disciplinary nature [33]. This study suggests that PjBL provides medical students with opportunities for learning by doing through authentic engagements with health inequity issues. Informed by constructivism, experiential learning, and situated learning, PjBL shows promise as a method for teaching an inherently contextual topic like health equity.
Moreover, the findings suggest that medical students require more than conceptual knowledge of health equity to effectively address health inequities. A combination of general and discipline-specific knowledge and skills is essential for developing their capacities to tackle these challenges. Exposure to cross-disciplinary subjects—such as those presented in this course—may better prepare medical students to confront complex and systemic health problems in society upon graduation.
Although this study did not introduce a novel approach to teaching health equity, it provides valuable insights into students’ experiences with PjBL. Furthermore, it highlights the importance of incorporating cross-disciplinary topics and developing students’ generic skills to enhance their capacity for addressing health inequities. Due to its qualitative design—which we deemed most appropriate for exploring students’ experiences and illustrating the value of PjBL in the Indonesian context—this study does not measure PjBL’s effectiveness in teaching health equity. Future research is needed to provide additional evidence supporting the use of PjBL to teach health equity in Indonesia.
In conclusion, this study described how the ME course, specifically designed using the PjBL approach and active learning methods, developed students’ knowledge on health equity and influenced their perspectives and abilities to address health inequity issues in Indonesia. By employing the PjBL model, students engaged in active, collaborative, and affective learning, which helped them develop the critical skills and attitudes necessary for addressing health inequities. This approach, coupled with cross-disciplinary topics like health equity fundamentals, agent of change principles, and futures thinking, broadened students’ awareness of inequities and prepared them to respond more compassionately and innovatively to real-world challenges.
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