Identifying and articulating the student experience in the Intercalated Enrichment Year

Background Benefits of intercalation during an undergraduate medical degree are well-recognized. The University of Hong Kong implemented a compulsory Enrichment Year (EY) in its Bachelor of Medicine and Bachelor of Surgery degree programme (MBBS) in 2016. In their third year of study, students could work on an area of interest in any of three programme categories (i) intercalation/ university exchange (IC); (ii) research (RA); (iii) service/ humanitarian work (SH). This study aimed to explore the barriers, enablers, and overall student learning experiences from the first cohort of EY students in order to inform future development of the EY. Methods An exploratory sequential mixed-method study in 2019-20. Twenty students were purposively selected to attend three semi-structured focus group interviews. Conventional thematic analysis was employed and results assisted the design of a cross-sectional questionnaire. Sixty-three students completed the questionnaire. ANOVA or chi-square test was used to compare the difference in student’s characteristics, barriers, enablers and perspectives on EY between programme categories. Adjusting student’s characteristics, logistic regressions were conducted to identify the effect of programme categories on the EY experience. Results Most students (95% in the questionnaire) agreed that EY was worthwhile and more rewarding than expected. EY was positively regarded for enhancing personal growth and interpersonal relationships. The main barriers were financial difficulties, scholarship issues and insufficient information beforehand. A few students had practical (i.e. accommodation, cultural adaptation) problems. Potential enablers included better financial support, more efficient information exchange and fewer assignments and preparation tasks. Similar barriers were encountered by students across all three categories of EY activities. Conclusions Personal growth was the most important benefit of the EY. Barriers were consistent with those identified in the literature except for cultural adaptation, which could be related to Hong Kong’s unique historical context. Financial limitation was the most concerning barrier, as it could result in unequal access to educational opportunities. Better and timely access to scholarships and other funding sources need to be considered. Trial registration Ethics approval was obtained from the local Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 19-585). Supplementary Information The online version contains supplementary material available at 10.1186/s12909-022-03303-z.


Introduction
Intercalation, or sometimes known as gap year or transition year, is common among undergraduate medicine programs around the world [1][2][3][4][5][6]. There is a long history of voluntary intercalated enrichment events, in the form of self-directed courses or research projects in between a medical degree from Australia and the United Kingdom [7][8][9][10]. They typically take place in between the preclinical and clinical years of study to allow medical students to pursue self-directed learning experience and further personal development in either medical or non-medical fields.
Undertaking an optional intercalated degree showed positive effects on academic performance through the development of deeper learning styles and long-term career outcomes among medical undergraduate students [11]. Similarly, improved learning strategies, increased level of motivation and short-term academic performance were among some of the associated benefits reported by previous studies [12][13][14]. Aiming to offer similar benefits to its students, the LKS Faculty of Medicine of the University of Hong Kong (HKUMed) introduced a one-year, credit-bearing, compulsory Enrichment Year (EY) in between the preclinical and clinical years of its six-year Bachelor Medicine and Bachelor of Surgery degree programme (MBBS) in 2016.
Considering its credit-bearing nature and incorporation into the medical curriculum, HKUMed's EY was not designed to simply be a gap year. Instead, it aimed to offer students the means to take charge of their learning and tailor activities to their interests. Students had to choose and plan a local or overseas learning activity under one of the following programme categories: (i) intercalation or exchange programme (IC), (ii) research attachment (RA) or (iii) service and humanitarian work (SH).
Whilst there might be benefits associated with voluntary intercalation, it was unclear whether such benefits could be achieved with a compulsory curriculum [15]. Drawbacks such as cultural impact and financial difficulties affecting students' experience have been shown to be barriers rather than enablers of the learning experience [15][16][17][18][19][20][21][22][23][24][25][26]. It was also unclear whether such barriers identified in studies conducted in western countries could be applicable to students from an Asian background. The lack of data on students' perspective of their experience during intercalation, was the impetus to undertake this study in Hong Kong to explore undergraduate medical students' perceptions of the EY and to identify the barriers and enablers to optimise the learning experience in different types of EY activities.

Methods
Medical students in the EY undertook two semesterbased or a full-year EY activity that fell under one or any combination of the following three categories: (1) Intercalation or exchange (IC). Students could choose inter-or intra-faculty electives, minor options, or intercalated degrees at the home university or partner institutions, or opt to take courses through the university's worldwide exchange programme; (2) Research attachment (RA). Students could apply for the 1-year Master of Research in Medicine (MResMed) degree or choose an attachment with principal investigators from Faculty of Medicine in the University of Hong Kong. These attachments began with a 2-week foundational course on basic research skills and ethics, followed by laboratory, clinical or public health research under the supervision of the PI. (3) Service and humanitarian work (SH). Students selected from a roster of local and overseas nongovernmental organizations (NGO) who were Faculty partners or self-initiated work with Facultyapproved organizations that engaged in community health promotion, humanitarian relief missions or other service programmes that helped disadvantaged populations. Prior to starting the SH work, all students were required to take a 2-week preparatory course on Global Health that addressed issues such as cultural competency and safety.
As a mandatory, credit-bearing year of study, all students in EY were assessed according to their chosen activity, namely on their final course grades in the IC, and on their academic output and learning attitude for RA and SH. In addition, all students were assessed on a final poster presentation based on their EY as well as experience-sharing in the EY online learning community. Scholarships and financial assistance schemes were available to all students.

Keywords:
Intercalation enrichment year, Undergraduate medicine curriculum, Learning experience, Mixed-method study

Study design
An exploratory sequential mixed-method design including focus group interviews and subsequently, a cross-sectional questionnaire was used. Students admitted to the MBBS program at HKUMed in 2016/2017 were required to undertake activities to fulfil the EY requirements in 2018/2019, their third year of study. There was a total of 206 medical students (103 female and 103 male) who participated in the EY. Over 90% of students were of Chinese ethnicity. This cohort formed the target population for the study.
Ethics approval was obtained from the local Institutional Review Board of The University of Hong Kong/ Hospital Authority Hong Kong West Cluster (UW 19-585).

Phase I: qualitative stage
Focus group interviews were conducted in September 2019 to explore in-depth student perceptions regarding their learning experience during their EY. Participants were grouped based on their sex, programme duration, programme application methods, category representativeness (i.e. IC, RA or SH), academic outcomes, financial and scholarship status so that students with different characteristics could be represented in each group. To obtain an adequate sample for each category, 3 focus groups of 6 to 7 participants each were recruited to reach saturation of responses, whereby repetitive findings were seen.
Questions on the participants' views on barriers, enablers and their overall perceptions of the EY were discussed. A preliminary semi-structured interview guide (Supplementary Table 1) was used. Two to four independent facilitators led the interview in Cantonese and/ or English. The interviews were audio-taped and transcribed verbatim, with field notes to record non-verbal responses. Summaries were written by two facilitators and compared. A conventional qualitative content analysis method was used to analyse the interview transcripts [27]. Coding categories were inductively derived from the transcripts. The text data was coded independently into main/sub-themes by two investigators manually, with themes marked beside the coded sentences/paragraphs, which were then organized into a tree structure. Inconsistencies in procedure and grouping were resolved by discussion to reach an agreement.

Phase II: quantitative stage
Questionnaires were conducted between May and June 2020. The questionnaire was designed based on data from the qualitative results and existing literature, in order to test hypotheses generated from qualitative stage and triangulate the whole data set. A hyper-link to a Google form questionnaire was disseminated via email to the entire cohort of MBBS students. The questionnaire collected descriptive demographic information and selfperceived ratings in 4 aspects of the EY experience: perceptions; barriers; enablers and improvements. A 4-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree) was used for a total of 48 questions about views and experiences, while numbers were used for questions related to personal background and academic performance (Additional file 2).
Descriptive statistics were used for student characteristics, barriers, enablers and overall perspective of EY experiences and ANOVA or chi-square tests were used to compare differences. Logistic regressions were conducted to identify the effect of different programme types on barriers, enablers and perspective of EY experience adjusted by student characteristics. Analyses were performed with the latest version of the Stata statistical package. A p-value < 0.05 was considered statistically significant.

Focus groups findings Views and characteristics
Twenty participants (14 female and 6 male) were invited to participate based on the EY programme type, duration of EY programme and application methods used to enroll in EY programme. A series of sub-themes were identified and grouped into: expectations, enablers, barriers, benefits, suggestions regarding EY (Table 1).

Expectations
The most frequently mentioned expectations were personal growth, career planning, and opportunities to explore, travel and network (Quote 1). During their EY, students had academic considerations, so they focused on courses that were related to medicine (Quote 2) or aimed to gain an extra qualification (Quote 3). Participants in overseas programmes chose countries where they could communicate to facilitate a smooth experience (Quote 4).

Enablers
An easy application process was considered helpful to students (Quote 5). They appreciated the variety of programmes provided by HKUMed, and having sufficient time for executing EY backup plans when required (Quote 6). Two enablers were financial support and scholarship subsidies (Quote 7 and 8). The light workload and the high-quality content of EY programme made their experience more enjoyable (Quote 9). Institutional support, in form of foundation/induction courses in

Sub-themes Quotes
Financial barriers 17. Some people want to spend a whole year overseas, so they picked intercalation as they could afford it, if you couldn't afford it, you might take a look at HKU Worldwide, or you would approach the schools yourself, there were many more steps in the process. (2B, Female, IC & SH) 18. For some students this was a huge financial burden so they wouldn't apply to these places [overseas], or they were forced to stay in Hong Kong. [And since they were forced to stay in Hong Kong,] the things they took might not be the things they wanted, they did it just to fulfil the EY requirement, it might not be something that they were interested to do, so for these people they probably thought it wasn't worth it. (2C, Female, SH & IC) Personal trait barriers 19. When we reached there, we were helping out the locals rather than initiating our programmes, because we didn't know the actual situation, for example we were thinking of organising some tutorial classes... however we didn't know the children's educational level and acceptance level, we also didn't know the arrangement of the local NGO, that's why the things that we proposed didn't fit the actual situation, that's why in the end we assisted the local teaching staff rather than initiating our own activities. research skills and in global health, gave knowledge and skills to execute their EY projects (Quote 10 and 11). A few participants believed that being highly self-motivated should be the key to their EY.

Barriers
Significant barriers were insufficient information exchange between the participants, the university or programme providers (Quote 12 and 13), and the competitiveness of admission requirements (Quote 14). Some participants thought that they were not able to gain any practical knowledge from EY (Quote 15). Furthermore, participants faced bridging difficulties in their studies after EY (Quote 16). Participants felt that financial limitation led to more complicated application processes (Quote 17), as well as unfair access to learning experiences, as some students were compelled to take undesired EY activities (Quote 18). Perceived powerlessness was common for SH activities as participants' expectation on serving and making a difference were not met (Quote 19). The most common onsite adaptation barriers were communication difficulties and unfamiliar living conditions (Quote 20).

Benefits
Most participants were unsure of the benefits of EY beforehand, but after participating, many were supportive as it enhanced their personal growth (Quote 21). A few participants had a higher sense of compassion and empathy after their EY (Quote 22). Others felt less pressure to compare themselves with their peers and focused on their own journeys instead (Quote 23). Enhancing interpersonal networks and broadening horizons were some of the social benefits mentioned (Quote 24 and 25). Some participants praised the EY because it allowed them to have greater ownership of their education (Quote 26), and provided an opportunity to de-stress from the preclinical studies completed before EY (Quote 27). EY also helped some participants to decide on what they wanted to pursue in the future (Quote 28 and 29). Some considered it to be an early workplace experience before graduation, especially for SH and RA programmes (Quote 30).

Suggestions
Participants suggested more assistance on planning before the start of EY (Quote 31), as well as timely responses to enquiries would be helpful (Quote 32). A larger exchange quota and more flexible admission requirements were also desirable (Quote 33). Due to the tremendous workload before EY, participants suggested to reduce the workload by shifting the EY activities and/ or induction courses to earlier years (Quote 34). Participants believed a more transparent scholarship application process (Quote 35) and more holistic assessment criteria of the learning experiences, including the nonacademic output, would be appropriate (Quote 36).

Perceptions
EY was well perceived especially on personal growth and interpersonal relationship. Nearly all students (95%) agreed that EY was more worthwhile than they had expected. 83% of the participants agreed that "EY was placed at an appropriate time in the MBBS curriculum". Student generally shared similar perceptions about EY, irrespective of their EY categories or scholarship status. A significantly higher proportion of students with non-local EY agreed that "their EY had broadened their network and improved their interpersonal skills" and "their EY experience was more worthwhile than I had expected". Further, students who had scholarships were highly likely to agree on "EY should be compulsory" (OR: 5.19 (CI: 1.18,22.82, p = 0.029), as well as for students who had self-initiated EY activities (OR: 3.20 (CI: 1.03, 9.89, p = 0.044)) ( Fig. 1a, Supplementary Fig. 1, and Supplementary Table 2a and b).

Barriers
Most students agreed on "the lack of guidance on preparation of EY activities", "information exchange barriers between university and EY providers", and "excessive competition for EY option vacancies". Conversely, less than 25% students agreed that practical adaptation (such as accommodations, cultural adaptation) and onsite communication were barriers. Students who participated in SH were unlikely to agree on "lack of motivation to prepare for EY" (OR: 0.12 (CI: 0.02,0.79, p = 0.027)), and "unable to fulfill the EY option admission requirement" (OR: 0.01 (CI: 0.001, 0.14, p < 0.001)). Students who did not have any EY scholarships had a significantly higher agreement rate on "unable to fulfil admission requirement". Students with only local EY had a higher rate on agreeing that admission requirement was one of their barriers. Students with multi-category EY agreed more with financial difficulties in supporting EY activities, and highly correlated to having financial difficulties in supporting their desired options (OR: 6.60 (CI: 1.24, 35.22, p = .027)) ( Fig. 1a, Supplementary Fig. 2, and Supplementary Table 2a and b).

Enablers
Students had a high agreement rate on "good quality of the programme", "welcoming atmosphere of the EY programme", "personal problem-solving skills" and "individual supports from peers or family". Comparatively, only half of the student agreed that support from senior students or EY supervisors were their enabler. Students who had participated in SH had a higher agreement rate on "light workload" as their enablers, and also were significantly more likely to agree to such statement (OR: 12.56 (CI: 1.06,149.44, p = .045). As expected, scholarship holders were more likely to agree to "having scholarship" as an enabler (OR: 7.86 (CI: 1.27,48.48, p = .026)) ( Fig. 1b,  Supplementary Fig. 3, and Supplementary Table 2a and  b).

Improvements and suggestions
All statements on "improvement and suggestions" had an agreement rate of 50% or above ("Agree" or "Strongly Agree"). "Launching more faculty-based exchange opportunities" and "more EY scholarship and subsidies" were statements that had the highest frequency of agreement. The statement with the lowest agreement was on "assessing personal growth and development as EY outcomes". This indicated that students after EY generally were able to observe their own development and understand the value of EY. Students with different types of EY did not show a significant difference in their responses. The only difference observed was between students with only one and multi-category EY experience, with more students in the latter agreeing that communication between university and students needed to be improved (Fig. 1b

Discussion
From both analyses, non-local EY programmes were better perceived. A university-linked programme list and scholarships were two of the most mentioned enablers  Fig. 1 a Summary of the proportion of students response for perceptions and barriers for EY. b Summary of the proportion of students response for enablers, improvement and suggestions on EY in our mixed-method study. Generally, our results on barriers to EY aligned with existing evidence, with only culture adaptation not seen as significant by our medical students. Better administrative support was one of the major suggestions for improving EY. Differences were observed on academic expectations regarding earning extra qualifications: some aimed to gain additional qualifications through EY for career advancement while others treated the qualifications as a bonus. Some participants admitted they had concerns about the academic value of their EY activities towards their medical study. However, as EY was designed to enhance the total learning experiences of students that deliberately discouraged medical-related activities [28], their experiences actually improved the mental state of some participants allowing them to de-stress from the preclinical studies completed before EY. They reflected on the meaning of studying at a university and could focus on their own journeys rather than comparing themselves with others, suggesting that students became more confident and motivated to confront the new school year and its new challenges. Quantitative results showed that EY was not expected to be a worthwhile component in the MBBS curriculum, but after EY, students found that they perceived EY differently, and it had become something that they would not like to skip in hindsight.
The most significant enabler identified by the qualitative analyses was the university-linked programme list. Participants found the preparation and application procedures to be the most time-consuming part of the EY. Thus, the list provided by the university reduced the work associated with self-initiated EY activities. However, quantitative analyses indicated that the most apparent enabler was scholarships. Students with scholarships might have higher academic achievements originally, which could explain their lower agreement rate on "unable to fulfill admission requirements" to more competitive EY options. This further correlated to students' perception of EY significantly. Our results also suggested that students with SH experience were more likely to have a lighter workload and were unlikely to lack motivation. This suggests that the different types of EY could be an enabler for students depending on the workload.
Our results on the "barriers of EY" were mostly consistent with the studies conducted on the voluntary-based intercalating activities [15][16][17][18][19][20][21][22][23][24][25][26]. Financial constraint was the most significant reason causing differences in satisfaction level as participants tended to believe that they would be able to have an EY with simpler planning and more choices if they were not limited by financial constraints. Thus, financial disparity created a sense of unfairness in accessing desired learning experiences. University students value the importance of a fair opportunity in education believing that both rich and poor students should receive equal opportunities [29]. Students with financial limitations were less motivated to use the opportunities provided by EY to enrich themselves.
Interestingly, cultural adaptation, onsite coordination and the execution of EY activities by the onsite individuals or groups were, in general, not perceived as barriers. The uniqueness of Hong Kong's historic background could potentially explain why problems with cultural adaptation was not observed among our students compared to those in the literature. Hong Kong, which is currently under the sovereignty of China, had been a colony of the United Kingdom. Local Hong Kong students, being at least bilingual (fluent in English and Cantonese), had expressed their sense of "dual identity" and pride at Hong Kong being "a place where East meets West" [30]. Growing up in such environment, it is unsurprising that cultural adaptation was not a notable barrier.
Participants wished to have more overseas opportunities with less financial difficulties, and less hinderances, which included insufficient information exchange and online assignments. Suggestions from both results on EY improvement focused on the administrative support, such as "the university playing a more active role in assisting the preparation procedures", "giving timely announcement of information and response from inquiries", "providing more scholarships with earlier distribution of subsidies" and "timely review of the online tasks".
Our study had three major limitations. Firstly, the focus group interview findings were based on self-reported recollections by the participants but the recall bias should be small as the questions asked about personal attitudes and opinions only. Secondly, participant recruitment was on voluntary basis. Therefore, less-motivated participants who might have more negative comments on EY might not be recruited to participate in the focus group interviews. For the questionnaire, one major limitation was the small sample size. Only 30.6% of the EY cohort participated in the questionnaire, and thus potential selection bias might affect the findings and variances within subgroup might not be detected by the analysis.

Conclusion
From the students' perspective, apart from cultural adaptation, most of our findings on barriers perceived were similar to those that were reported in studies from western countries. Hong Kong students faced similar barriers regardless of the types of EY that they had. Financial limitation was the most concerning barrier, as it could result in unequal access to educational opportunities. The most obvious benefits were perceived personal growth