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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 116-125

The pursuit of healthier communities through a community health medical education program


Center of Studies in Community Health, Faculty of Medicine, University of La Sabana, Cundinamarca, Colombia

Date of Web Publication19-Sep-2017

Correspondence Address:
Francisco Lamus-Lemus
Facultad de Medicina, Campus Universitario, Km. 7, Vía a Chía, Universidad de La Sabana, Cundinamarca
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_283_14

  Abstract 

Background: Distinct periods in the community health undergraduate medical program at the University of La Sabana (Colombia) were identified in its evolution from 1999 to 2013. We describe each period and explain the succesion of changes toward improvement. Methods: An ordered review of the community health program was constructed based on the retrospective recollection, classification, and analysis of information from document archives and interviews with participants. The review of the experience reconstructs periods of the program, organizing the evolution of its learned lessons and identified changes across the development of community health projects (CHPs) and the phases followed in their implementation. Results: Two principal stages were identified, the first when students' CHPs involved only schools, and the second when students worked in a broader array of community settings. Identified phases of the community health cycle leading to identifying changes across the program timeline were focus of the community–campus partnership; development of relationships among participants; health and health determinants' assessment; defining project goals and objectives; devising a project activity plan; implementing and gathering results; disseminating project achievements; and building sustainability of program activities. Periods were bounded by important new characteristics introduced in the pursuit of healthier communities. Discussion: Understanding the evolution of the program revealed the key concepts and practices in setting community health apprenticeship scenarios for the various participants. Overall, trust and commitment from stakeholders requires competent facilitators able to build meaningful and sustainable collaborations that can translate the purpose of community health practice into an effective teaching–learning experience. Institutional capacity building and collaborative practice contribute to improvements in the community health program and its ability to be flexible to adapt to different contexts. Periods reflecting improvement in this school's programs over time can help others identify key elements that need to be integrated into a community health medical education program.

Keywords: Community medicine, health education, medical education, primary health care, qualitative research


How to cite this article:
Lamus-Lemus F, Correal-Muñoz C, Hernandez-Rincon E, Serrano-Espinosa N, Jaimes-deTriviño C, Diaz-Quijano D, García-Manrique JG. The pursuit of healthier communities through a community health medical education program. Educ Health 2017;30:116-25

How to cite this URL:
Lamus-Lemus F, Correal-Muñoz C, Hernandez-Rincon E, Serrano-Espinosa N, Jaimes-deTriviño C, Diaz-Quijano D, García-Manrique JG. The pursuit of healthier communities through a community health medical education program. Educ Health [serial online] 2017 [cited 2020 Oct 24];30:116-25. Available from: https://www.educationforhealth.net/text.asp?2017/30/2/116/215095


  Background Top


There is a growing demand for health professionals who can serve the population by intervening throughout the health–disease continuum. There is also a need for health-care professionals to provide compassionate, integrated, and comprehensive care.[1]

Such competencies should be mapped to learning objectives during students' training and are often gained through community-based educational experiences.[2] Many authorities have spoken of the need to redirect medical education toward primary health care as part of the effort to promote the number, quality, and relevance of the skills of health-care professionals needed to improve population health.[3],[4] This includes providing education in teamwork and in collective action through inter-professional work, inter-institutional collaboration, and community health interventions.[5]

The University of La Sabana introduced a family and community health semester in the medical undergraduate curriculum when the school was founded in 1993. The program assigned medical students to develop their community health projects (CHPs) in various communities within a convenient traveling distance of the school. Community–campus collaboration agreements set the objective for the community and academic participants to work together toward community development through the community service health interventions.[6],[7],[8],[9] Once assigned, students develop their CHPs throughout the academic semester. Ten to 12 groups of up to six students each participated in the projects of 18–20 weeks' duration. Each group worked with community participants and an academic facilitator using a service-learning perspective to identify a community health need, design and implement a work plan, evaluate and share the CHP within the community and with other students at the end of each semester.[10]

The community health education program at the school of medicine has evolved over the years. Its focus on different types of communities has also changed over time. Its initial stage, from 1999 to 2007, concentrated its activites within primary and secondary education institutions. A second stage between 2009 and 2013 opened the program's scope to a varied array of communities including homeless, displaced, and elderly groups, among others. The community health program did not receive students between the second semester of 2007 and the beginning of the second semester of 2009 due to a curricular reform that changed the course of community medicine from the middle to the end of the career.

To understand the evolution of the program, an ordered review of the CHPs was constructed based on the retrospective recollection, classification, and analysis of information from document archives and interviews with participants, supported with the relevant literature. We used a qualitative research approach known as “systematization of experience,” a method of inquiry from popular education in Latin America that provides a structure to explain how the work was done, its effects, and how change occurred.[11]


  Methods Top


The theoretical approach to the systematization of experience methodology is based on the interest to understand the meaning of a program's actions that can be interpreted by exploring available information of the program's trajectory. Verifiable descriptive conclusions can be drawn within the bounds of a context that makes the case for how community health has been taught and learned in the undergraduate medical program. These descriptive conclusions also provide plausible explanations about events that happened within the timeframe from which data were collected and arranged in a progression of characteristics that answers what, how, and why change occurred in the community health program.[12]

The research team consisted of medical school community health professors who participated as facilitators in communities where 25 cohorts of students were assigned in the program's two stages. The unit of analysis was set as the overall “community health program,” and the guiding research question was set as what features in the community health teaching–learning experience define periods of the program that contribute to understanding participants' achievement of competence to create healthier communities?

Information was collected from primary sources through semi-structured interviews and focus groups with key stakeholders from the university and from the participating communities. Secondary sources of information included course syllabi and final academic reports submitted by medical student groups. From an inventory of 210 projects, sixty projects were selected for in-depth content analysis. Program facilitators who reviewed all the 210 projects determined the following selection criteria: Projects whose health achievements had been recognized by the community, presented at local, regional, national, or international meetings, or had been published.

With approval of the research protocol by the institutional review board, summary sheet forms were filled for each of the primary and secondary information sources determining events, people, and situations involved, main themes or issues that could be traced, other topics, ideas, hypotheses, or speculations that could help answer the research question, and finally what other sources of information could be sought.

The first-level process coding organized information on a timeline within the time frame between 1999 and 2013. An adaptation of the model for collaborative partnerships in community health described by Fawcett et al. and the Kansas University Community Toolbox [13] was used to identify a general pattern with recognizable phases that CHPs developed in each academic cycle (semester). Each of these phases allowed the identification of related attributes about how CHPs were developed over time. Each academic cycle followed the following phases: (1) Focus of the community–campus partnership, (2) development of relationships among participants, (3) health and health determinants' assessment, (4) definition of project goals and objectives, (5) project activity plan, (6) project implementation, (7) results' gathering, (8) dissemination of project achievements and sustainability of project actions [Table 1].[14]
Table 1: Analysis of phases of the community health cycle

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A second coding process plotted variations of each of the phases of the community health cycle using MindManager 8.0 from Corel Corporation, software that allows a visual organization and contrast of conceptual frameworks as well as visualization of the progression of periods of the program. Outstanding characteristics determined the integration of new elements related to community involvement, educational strategies, and conceptual contents in the development of the CHPs. These were the features used to group characteristics in a succession of time-bounded periods, each named for its outstanding feature as follows: Blurry mirror, local health needs, community interest, community-based research, CHP cycle, and health-enabling communities [Table 2].
Table 2: Main characteristics of each period

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A final display of the evolution of the program shows the progression of the appearance of characteristics within the different periods across the timeline [Figure 1].
Figure 1: Timeline of the principal characteristics of periods as they evolved to help the program better work toward enabling healthy communities

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  Results Top


Milestones in the program's development were plotted over its 14-year history [Figure 1]. Characteristics emerging from the analysis were plotted based on the organization on the community health cycle phases and the identified periods of the program [Table 2].

Different periods were named according to their outstanding features and traced in their change and evolution toward a combination of characteristics present in the last period described.

Some elements remained constant from one period to another, while others were introduced as innovations and variations.

First period: The Blurry Mirror (1999–2001)

This period was influenced by the legacy of a program in Latin America sponsored by the Kellogg Foundation known as “Proyectos Una Nueva Iniciativa” (UNI),[15] wherein partnerships among communities, local health-care services, and universities with health professional education programs were fostered around community health programs. The UNI approach attempted to integrate and promote collaborative practices among these three health system stakeholders. The blurry mirror label denotes a period that looks back for the footprints of the UNI projects, a comprehensive capacity building program that left a recognizable trace in health profession education and primary health care in Latin America.[16]

Community health programs each began by gathering information to be used in a community assessment to lead to a proposal for an action plan. A comprehensive plan was built to create interventions to strategically target the priorities of guidelines determined by the Colombian national standards for “Healthy School Promoting Initiatives.” Project action plans addressed topics related to nutrition, hygiene, healthy life habits, environmental health and protection, visual health, and oral health.

In this period, results were obtained from student projects despite generally scarce participation by communities. Community members perceived the CHP as a university plan and not as a community initiative. Nevertheless, relationships among program partners were successful in linking the university and the local authorities, following the premise that these could help create the conditions for communitywide change of behaviors to promote health.[17]

Results of programs were disseminated at the end of the semester through a poster presentation and a final report at each community setting. A final symposium also shared poster presentations of all projects to gathered participants of all communities and university personnel in a “Community Health-Final Project Day.” This event persists through the present day.

Second period: Local health needs (2000–2004)

The second period was guided by greater interaction with local health authorities. Some projects over time evidenced wider participation of community members and included disciplines beyond medicine.

This period focused on connecting with municipal stakeholders in joint efforts to support collective health actions as defined by governmental health authorities. The intent was for the university, the community, and local health institutions to collaborate around specific health programs. This period reflects the effort to meet local expectations but lacks leadership intermediating figures and leadership development strategies able to facilitate bottom-up and top-down incentives to maintain communities' and participants' motivation.[18]

Unlike the UNI projects presented above, local health services are absent in this period. Local health institutions do not necessarily provide services to all community members because health services may not be affiliated with the health management organizations that provide their health insurance coverage. Health projects in collaborating communities are directed by the local health authorities' priorities. Collective and individual health actions are disconnected due to fragmentation of health care in the Colombian health-care system.

At this stage, it is clear that building the partnership with the community and local stakeholders must be a process, wherein university members invest enough time and effort to advance toward a collaborative alliance. CHPs are developed through task forces assigned to different lines of action. Task force members include community authorities, leaders, and representatives of diverse local origins, coalescing around shared interests in health promotion and disease prevention.[19],[20]

Prioritized goals and objectives are defined by consensus with institutional members according to local public health guidelines. The concepts of “social capital” and “community empowerment” come into play when both communities and external participants acknowledge the fundamental need to collaborate and interact to pursue community health outcomes, done within a rich community health teaching–learning environment. It is understood that communities that have the ability to create and promote meaningful social interactions can garner appropriate material needs required for better health and also create the conditions for more consistent participation and commitment of participants.[21],[22]

For each local public health priority applicable in the community, an intervention is planned. The goal of these interventions is to support the community in a comprehensive process of achieving a healthier community. This local health needs' period has the challenge of having different interventions dealing with different interorganizational arrangements; nevertheless, strengthening bonds with communities beyond institutional agreements becomes a priority for CHP to advance.[23],[24]

Third period: Community interest (2001–2007)

This period is steered by the World Health Organization guidelines known as “local action creating health promoting schools.”[25] These guidelines are approached through the CHP with the participation of subgroups of medical students and community members. Each subgroup develops a process with the following steps: community contact and relationship building, community assessment, plan development, project management and implementation, and communication of results. Guidelines oriented by a health promotion rationale contribute to community health education and to connect CHP to the determinants of health. Implementing a collaborative and comprehensive community health action requires negotiated planning, intersectorial action, stakeholders' support, and evaluation of results according to objectives.[26]

Active learning strategies strengthen relationships in the whole program, which builds trust and supports CHP development, setting the stage for participants to understand how context in medical education must be responsive to community needs.[27] Participants' collaborative leadership skills can be traced across projects resulting in effective partnerships contributing to the CHP. Formality in community campus committees allows follow-up and continued feedback for program improvement and adaptations.[28],[29] CHP focuses on topics such as screening for nutritional deficiencies, chronic diseases, psyco-social risks, and learning disabilities.

Working plans and their implementation reflect organization and coordination, although the dimension of the commitments is based on the capacity of community members and university students to engage in the process of developing CHP in a service-learning relationship.[30]

Evaluation of processes and results in community–campus collaborations contributes to understand whether service-learning activities make a difference in community conditions, participants' understanding of primary health care, and program accountability.[31] Assessment also contributes to sharing of responsabilities and to designing strategies to strengthen the partnerships that sustain the service-learning experience. Students' CHP finals report their advancements in public health reasoning skills, critical thinking, ability to use a system-based approach, cultural sensitivity, skills in interprofessional collaboration, and skills in information-supported decision-making.[32]

This period identifies materials, tools, and methods that can be used in other communities for future project developments. Lessons from the program reach a wider audience by publishing results locally and presenting the experience in international forums.[23] The program is specifically enriched by its affiliation to The Network – Towards Unity for Health, and other international alliances provide visibility to the CHP and the community–campus partnerships' health program, motivating university authorities to fund more facilitators.

Fourth period: Action research (2004–2007)

In this period, the program assumes an action research approach to develop CHPs. School communities must take greater ownership of the program, and community–campus collaboration can contribute to this goal through focused action research projects built in consensus with community members and local institutions. The university program's ability to develop consistent and committed relationships with communities improves, regardless of threats to program leadership continuity within affiliated institutions due to municipal political changes.

It is important to preserve the trust gained and achieve sustainability by focusing on one community health need that guides the action research project.[33] Facilitators improve their abilities to prioritize community health problems and to support students' learning process through the development of conceptual frameworks that plot the project plans and expected results.[34]

Communities make formal engagements with the University program to work toward healthier conditions. Explicit community–campus partnerships provide motivation for participants to connect with the action research process focusing on one problem at a time. Project reports reflect a synthesis of practice-based evidence captured through participants' experience and evidence-based practice from the literature.[35],[36]

In the participatory action period, better understanding of the reciprocal influence between communities, their environments, and theoretical approaches to work on health problems reflects participants' advances in gaining responsibility to work for a healthier environment beyond the CHP. Community organization improves together with the process of identifying common problems and goals, mobilizing resources, and developing and implementing objectives that have been tailored through collective action.[37]

Fifth period: Community health cycle (2005–2010)

Implementing an ongoing community health cycle to develop CHP requires participants to be committed to a dynamic process where individual and collective competencies are progressively integrated as assets for healthier communities. Facilitators play an important role in sustaining sound community–campus collaborations, mediating University participation, and providing assurance to communites that partnerships will procure continuity over time. Internet-based resources such as the Community Toolbox are an asset to guide and support the development of required skills.[38]

Cultural awareness and interprofessional interaction continue as key assets that participants gain while developing CHP. Scaling up the teaching–learning experience to all participants involves a comprehensive community assessment that considers demographic, epidemiological, socioeconomic, and institutional factors. Participants interact in various adult learning formats and are also exposed to different types and quality of information to be considered in making informed decisions on community health actions. Consistent quality of interpersonal interaction and cultural competencies are understood as key assets to negotiate change in individual and societal behaviors and norms.[39]

The community health cycle considers the rationale behind the social determinants of health, integrating this perspective to an action research approach involving community members. Participants follow project-based learning processes through which they learn while the communities advance in getting empowered to become healthier. Problems that have been prioritized according to community preference and need are well contextualized within a theoretical framework.

Community members help design the action plan. Based on the analysis of the problem and its causes and consequences, a goal for the action plans is established. Knowledge gained from previous projects is integrated into new CHP planning. CHP results show consistent reasoning, creativity, and decision-making by participants.[40]

In this period, there is a deeper understanding of the theoretical basis of the different health problems chosen to work through the action research perspective. Literature is reviewed not only to understand the problem, but also to illustrate future plans. Collaborative working groups decide on how to present and disseminate information, considering how this information may contribute to decisions at different levels within the community. Different narratives reflect the way CHPs are reported and the levels where they may be generating impact at the community level.[41] Results are later presented to other audiences interested in the topics or in meetings where there is shared interest in community health, primary health, public health, education for health, or medical education.

The process of implementation, follow–up, and evaluation is dynamic [Figure 2], with observations and reflections about the process discussed continuously within the working group. Objectives and activities may be reoriented per priorities, barriers, and opportunities for the development of the projects. Results of the action research initiative are evaluated according to the objectives and goals proposed in the planning process. They are later shared with the wider community, the local authorities, and other representatives of university students and school communities. The program at the School of Medicine integrates feedback received through continued monitoring and evaluation.[42]
Figure 2: Community health cycle. Based on Community Tool Box and Community-oriented primary care

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Sixth period: Health-enabling communities (2009–2013)

In this period, the program works together with communities with some type of institutional support such as early childhood care centers, schools, centers to support maternal and child care, homes for the elderly, homeless, and displaced population centers, and organizations serving groups with different disabilities. Communities are invited to participate in a formal process where there are clear assignments of responsibilities to run the community–campus alliance with the purpose of pursuing health-enabling conditions for community members and a learning opportunity for all participants. This new approach to communities aligns with what has been called a “health-enabling community context,” recognizing the leading capacity of different community stakeholders to change the individual patterns of health-related behavior, including the community and social contexts that sustain ill-health.[43]

This pattern also shows an organized effort to train community leaders as facilitators and supporters for CHP development, offering a certified course called “citizenship for healthier environments.”

CHPs where University facilitators and medical students participate are embraced by the wider community health-enabling purpose. These projects follow a planning, doing, checking, and acting rationale, similar to what was previously learned in the community health cycle period, together with the principles of Community Oriented Primary Care regarding active assessment and evaluation of the community health needs and their responses.[44] CHP developments are continuously revisited and adapted as the projects progress. CHP results can be followed in changes and innovations reported at the administrative, individual, institutional, and community levels.[45]

This period shows how robust partnerships between communities and the University Program are the result of higher stake assets of social cohesion, such as active community and institutional trustful participation, which are fundamental elements to effectively address health disparities.[46]

Facilitators involved in the CHP support the importance of acknowledging the diverse experiences and resources that participants can add. They also show the importance of being flexible in understanding different learning styles, varied social stands, various approaches, and levels of commitment with the CHP.[47] Facilitators concentrate in fostering a transformative learning experience that provides opportunities for dialog, critical reflection, orientation, and resources to solve context problems together with the development of meaningful relationships that together construct the CHP.[48]


  Discussion Top


Reconstructing the evolution of the teaching–learning experiences in community health in our University teaches us and hopefully others how medical students, together with communities, can learn ways to approach complex community health issues.[40] This analysis illustrates the importance of flexibility for an educational program in community health, one that adapts to changing circumstances and successively builds upon experience. Following the evolving and fine-tuning processes of the program, it illustrates the complex interplay of diverse concepts, disciplines, organizations, and stakeholders working to provide experiences for students to become competent in primary health care and public health and committed to practice socially accountable medicine in the pursue of healthier communities.[49]

Various models have been developed to improve community health, but they do not always articulate how they can influence medical education or integrate learners. These models include the Precede-Procede model, CDCynergy, SMART, MATCH, a systematic approach to health promotion (a model in itself), MAPP, Healthy Communities, and the Kansas University Community Toolbox, among others.[50],[51]

This paper describes a specific experience that advances the integration of learners and how they can influence medical education through the process of learning community health practice. Systematically analyzing the experience of our school shows the importance of flexibility in planning that can respond to the past trajectory of the health system, the evolution of primary health care, and the current health policies. From the outset, the planning process should involve a robust collaboration between the educational program, universities, participating communities, local agencies, and other community organizations and health facilities. Together, this collaboration is best able to adapt to a rapidly changing community health environment.[52]

The key to long-term sustainability is to nurture the collaboration by openly sharing information, which builds trust and develops bridges and bonds among partners.[53]

Building a collaboration that develops into an alliance focused on building a healthy community requires skilled facilitators who work toward the project's purpose. Individuals participating in the teaching–learning experience can gradually build skills needed for their roles, including leadership, coalition building, and fostering community empowerment, all needed for successful community–academic partnerships.[54] Effective facilitators and community leaders are key elements that help create a significant teaching–learning experience.

Communities that commit to achieving and sustaining healthier standards of living can benefit from the efforts of their academic partners. Community participants can gain transformational skills to care for their own health and that of their families.[55]

A participatory research approach, where facilitators may articulate the voice of community members around their needs and resources, should be considered by others interested in developing a community health initiative for learners, including medical undergraduate students. Facilitating this process for individuals and communities requires the group's capacity to support planning and implementation found on evidence-based practice, while continually documenting, monitoring, and evaluating the community health program.[56] Communicating and disseminating results among participating individuals and communities as well as to broader audiences help build this collaboration and inform other networks that may also benefit from these experiences.[57]

Enhancing medical students' and communities' understanding of the continuum of health and disease through a systemic view of various health problems can advance efforts to build healthier communities. A community health medical education program that understands and learns from its experience can help provide opportunities for diverse types of community members to learn about their rights, responsibilities, and competencies necessary to achieve better health outcomes through collective action.[58]

Acknowledgments

We thank Tony Laduca for his continued orientation during the whole systematization process and, together with Bownie Anderson, for their continued support and assistance in achieving the final version of this manscript, and to Gwen Martin for the final editorial advice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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    Tables

  [Table 1], [Table 2]


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