The values of and definition of Community Based Education

Module 1- Assignment 1

Over the years, Community Based Education (CBE) program has gained popularity in the field of medicine. Its success as well is observable since many Institutions have shifted from the traditional approaches into CBE. The values of CBE in education, therefore, cannot be ignored if the health needs and interests of the community should be met.

The definition of Community Based Education is best defined by first understanding the meaning of a community. A community is a group of people with similar characteristics or people from a specific district or country in the context of social values and responsibilities. It is what makes a group of individuals a society. Based on the very definition of community, Community Based Education (CBE) therefore deals with community and the care of the people. Villani et al. (2000) define community-based education (CBE) as a form of instruction where students learn professional competences in a community setting primarily to build a sense of connection between the students and their communities. CBE is considered very crucial in enhancing independence between education and communities, which in turn helps in improving the quality of life among individuals and groups.

Another definition from John Hopkins University Community Based Learning (CBL) Group states that CBE is a pedagogical model that connects classroom-based work with meaningful community involvement and exchange (John Hopkins Working Group, 2013).Community-Oriented Education, on the other hand, is another medical education approach. Just like CBE, the approach focuses on a comprehensive approach to medicine that emphasizes health promotion, prevention, and rehabilitation at primary, secondary and tertiary levels.

Schmidt et al. (1991) believes that the main objective of COE is to graduate community-oriented

A physician who can serve his surrounding community by dealing with health problems.

Nevertheless, some differences exist between CBE and COE. According to Hays (2007), COE indicates the relevance of the program’s objectives to the health needs and interests of the community. The content, as well, should reflect these objectives. Another difference is that COE is primarily centred within the medical institution while on the other hand, CBE goes beyond the institution walls since its activities are attached to the surrounding community. CBE mainly focuses on learning activities in a particular community setting. CBE is also evidence-based. It utilizes more scientific methods as compared to COE. In this case, students get to learn the basic sciences with relevance to clinical practice which in the long run, equips the learner with efficient competency skills and experience to deal with the community needs.

In other words, CBE is one of the implementation approaches of the Community Oriented Educational Program. Owing to these many definitions, it is clear that there is no standard definition of the two concepts. This is illustrated by the fact that some scholars use the two terms interchangeably to mean the same thing. The two concepts, however, should work towards graduating the social and preventive physician rather than an individual and curative physician (Hays 2007).

From the many definitions of CBE, the community, in this case, is very important. The community provides a place to learn since it exposes learners to a vast array of issues for study and act. Other than simply basing the learning process in the community, CBE puts into consideration the interests and needs of the surrounding community. Due to its involvement in the community, CBE has the capacity of incorporating the emotional and social aspects of learning. (Hays 2007). This is mainly achieved through the interaction of various entities such as parents, schools and the community. Such interaction will foster collaboration which is very necessary for solving the problems faced by the community. Everyone will be involved in the entire educational process. Without community, therefore, the whole learning process would be futile.

CBE emphasizes real-world learning; it links between living and learning. CBE is research-oriented and puts into consideration the fact that young learners are likely to put their energies and attention on content that has personal meaning. More so, the content should build on what they already know and even allow learners to apply what they have learned in the real world. This further enables learners to be responsible for providing solutions to the inherent problems and needs faced in a particular community. The knowledge gain will also help in solving future day problems. Kreitzer et al. (2009) assert that CBE does not restrict itself merely on the intellectual abilities of a student, it involves the ability to gain an understanding of ideas and using the knowledge acquired in solving problems. CBE also facilitates interpersonal relationships and development.

The History and Evolution of CBE

To appreciate the benefits of CBE today in health care, it is extremely important to understand the historical context and evolution of CBE. The term CBE was first coined in Kingston, Jamaica meeting of the network-Towards Unity for Health (TUFH) around years ago. Conversely, the first prospects of CBE were initiated in the 1978 meeting of world health leaders in Alma Atta, Kazakhstan, Primary Health Care in their vision to improve the health care of the population by the year 2000. The main objective of the meeting was to identify the best educational program that would be responsive in meeting the needs and problems of the community they serve. The program needed to be was to be socially relevant and able to ensure health promotion in the community, clean water and proper sanitation for all. CBE, therefore, was established since it had prospects to meet the health conditions primarily within the local context. CBE, however, has developed with a series of models introduced frequently to enhance its sustainability and effectiveness in the community.

Social accountability

Social accountability in medical schools is defined by Boelen et al. (1995) as the ability to work in partnership with key stakeholders to impact greatly on the wellbeing of the people. Key stakeholders, in this case, include healthcare organizations, health insurance providers, policymakers, health professionals and civil society. In CBE, social accountability is important since it helps in identifying current and future health needs as well as challenges facing society. Other than identifying the challenges, social accountability aims to train future health professionals and more so propose working health models that would effectively promote the health status of the immediate community.

The El-Tal-El-Kebir story provides the best example of social accountability at work (Talaat et al. 2012). The story was initiated by the Faculty of Medicine to help the Egyptian people, especially from the district of El-Tal-El-Kebir. The establishment was motivated by residence’ inability to address poor health statistics in the region. The move was a success in proving that social accountability is important in mobilizing other sectors to work for the common good, improve community health. It is also a pointer and a challenge for others that medical schools to at all times develop health projects and research question formulation in association with the community.

In conclusion, a graduate of CBE can be said to have acquired social skills, leadership skills, decision-making skills, problem-solving skills and even the necessary clinical and managerial skills which are pertinent in healthcare provision for all. The need for social accountability is also ingrained in the students’ minds. All-round competencies are fostered through CBE.

Module 1 Assignment 2a

Community-Based Education (CBE) Case Studies

Deep insights about CBE could be fostered by analyzing and synthesizing the experiences obtained through the innumerable global case studies. For instance, the Experiences in developing and implementing a Community-Based Education strategy – a case study from South Africa and Egypt’s case study are perfect examples to use. The case studies provide diverse views and a broad definition of CBE, which is centralized at facilitating sustainability and social accountability. Such diverse views are worth considering since they inform various institutions not only on the prospects of CBE but also on the challenges likely to be experienced by implementing such an educational strategy.

The concept of CBE, according to Suez Canal University’s experience with the local community in Egypt case study is almost similar to that of WHO. In this case study CBE is made of activities that utilize the community extensively as a learning environment in which not only students, but also teachers, members of the community, and representatives of other sectors are actively involved throughout the educational experience (Bester, (2006). In the case study from Egypt, the definition of CBE is further expanded to go beyond community involvement to include empathy and dedication in the whole education process.

The duration of the community-based learning activities varies depending on the method used in each case study. For instance, in the Egypt case study, the all process took SIX years. The flow of events was chronological depending on the training being offered, as the years rolled by the student’s training intensified to managerial competencies, evaluation services, and quality improvement strategies (Talaat, 2012). For instance, in year one, the students attended training at Primary Health Care Centers (PHCC) two days every week in years one and two. The program would then proceed to community survey activities such as the survey on the nutritional habits among the Bedouins. In years two and three children screening for common health care problems were done, year four involved elective studies, and in the final years, the activities were focused on things affecting the community as a whole. At every step, students used problem-solving techniques whereby a problem was first defined, followed by clarification of vague presentations then the analysis of the signs and symptoms and finally setting of objectives and interventions.

The partners involved in the Suez- Egypt case study mostly involve those working under the ministry of health. These include physicians from the ministry and the FOMSCU faculty and students. Other partners included Suez Canal University Schools as Veterinary Medicine, Agriculture, and Education (Talaat, 2012). It is also important to include the major stakeholders such as the people from the TEK community, WHO and the American University in Cairo. These groups were very instrumental in enhancing sustainable development in the underserved areas of the community. The spirit of social accountability for community empowerment was cherished by the partnership from the various sectors (Talaat, 2012).

Formative assessment was the major assessment method used in assessing the students at the PHCC level. The formative assessments at PHCC were done every week. The checklist specifically aimed at assessing the knowledge, skills, and attitude of the patients. The family visits, as well, were evaluated with the help of periodic progress reports. The electives, as well, were assessed through the presentation, defence, and reports. The summative evaluation was used at the end of the program (Maklady et al. 1998).

The case study from South Africa also provides important insights into CBE experiences. South African health programs have evolved. The case study provides the historical changes the government has undertaken in its pursuit to provide comprehensive health coverage to all citizens in the country. The initiative was gradually narrowed down to having a community based primary care. According to Cilliers et al. (2005), the government, through the health care policy initiated CBE mainly to provide appropriate community-based training to medical students to facilitate the provision of appropriate primary health care services. Several studies and research were performed, and they all positively provided support for the implementation of CBE programs to address health issues. The Ukwanda Rural Clinical School provided an ample setting to carry out the activities of the program (Bester, (2006). The community-based learning activities took six years.

According to Hosny (2013), the main participants or partners in this program were sub-specialists from tertiary hospitals, local specialists and family physicians from the local district hospitals. The partnership was solidified by the presence of Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) Mullan et al. (2012). The roles of these partners were to formulate a list of common clinical presentations. They were to attend a series of curriculum planning workshops which pioneered the need for social accountability. Another task for these members was to identify appropriate evaluation methods to be used in the process.

The assessment of students was also done in unique ways. Local family physicians, sub-specialists from the rural district hospital as well other stakeholders served as examiners and provided the assessment at the end-of rotation clinical examination Bester, (2006). The assessment method employed in this case study was a structured interview. The introduction of patient portfolios made it possible to track student progress during the learning process.

In conclusion, these case studies are crucial in understanding CBE as a whole even though they are only but representation from various parts of the globe. The studies provided does not only provide the strategies used in CBE, but it also informs on the creative ways of approaching and interacting with a given community as well as providing the drawbacks associated with the strategy. It is from such experiences also that concerned institutions get to know what should be done in the future to improve healthcare services and the quality of life of all individuals in the community.

Module 2: Assignment 3

We are not using PBL at our school. However, we appreciate that it is one of the proposed ways of improving the learning process for both students and teachers. There are concerns that have been raised by medical teachers on the practice of PBL. One of such concerns is the demands that PBL has on schools. PBL places more strain on faculty time, teaching materials, other resources, and space (Johnson & Finucane, 2000). In one of the institutions that implemented PBL, the teaching load was increased by a third. Some institutions that have implemented PBL have not recorded an increase in the teaching load. The concern of an increase in teaching load raises issues as well on the quality of teaching that is delivered to students (Johnson & Finucane, 2000). Any increase in teaching load will ultimately impact the quality of education that is provided to students. Several types of research have indicated that there is a regressive effect to increase in teaching load to the quality of education administered to students (Johnson & Finucane, 2000). Some of the reasons provided for this effect include the preparation time for lessons, the follow-up processes, and the ability of the teachers to effectively monitor students’ performances.

The other concern that emerges is the initial and on-going implications on resources. In implementing PBL, there is a need to have a substantial ‘lead in’ time to train PBL tutors and case writers (Johnson & Finucane, 2000). The aim of this process is to refine PBL cases. Some institutions, such as the Flinders University medical school, had a five-year planning period for their new PBL curriculum before it was introduced in the institution (Johnson & Finucane, 2000). One of the reasons that Flinders University medical school provided as significant to the successful development of the course was the expert advice that was received and the experience the institution had as it continued to implement the PBL (Johnson & Finucane, 2000). The institution faced a significant challenge, which is faced by all institutions that decide to implement PBL. This revolves around the planning of the institution’s physical resources. Physical resources include providing adequate rooms for tutorials, enabling access to computers, first-class library facilities, and other technologies (Johnson & Finucane, 2000). Our institution is starved of resources and does not have a first-class library facility and enough computers to facilitate the implementation of PBL.

Medical teachers are also concerned by the increasing demand for PBL resources as the student numbers in a learning institution increase. This is not the case with traditional curricula that are lecture-based. The lecture-based curricula have the characteristic of an economy of scale on resource use as class sizes increase. Some experts have argued that PBL would be better suited for smaller schools as opposed to larger schools because of the demand it has on resource increase (Johnson & Finucane, 2000). The concern of implementing such a proposal is the nonuniformity of education across schools. The institutions that decide to implement PBL are further faced with the assessment that PBL is only viable where the number of students in a class is less than 100.

Several institutions have classes with more than 100 students, making PBL on-viable in those schools. This is the same situation that our school faces, where some classes have more than 100 students. Implementing PBL in our school would mean that classes having more than 100 students will have to be split, but there are no additional rooms to accommodate such a change. Institutions that have success in the implementation of PBL but have a higher student intake have done so through the use of technological advances (Johnson & Finucane, 2000). Medical schools at the Universities of Sydney and Queensland are some of the examples that have implemented PBL using advanced technology despite having a higher annual intake of students that exceeds 200.

Other concerns that have been raised are on the inefficiency of the PBL as a way of learning. Estimates indicate that PBL curricula only covers 82 per cent of what is taught through the traditional curricula (Johnson & Finucane, 2000). PBL also has a reduced basic science emphasis as statistics have indicated that students taught through PBL fare worse in science examinations compared to students taught using the traditional curricula. However, some arguments made by critics of traditional curricula are that basic science taught through traditional curricula is quickly forgotten by students as opposed to those taught through PBL curricula (Johnson & Finucane, 2000). This argument is made in favour of the strength of PBL as a better way of learning for science disciplines.

The other reason that has been highlighted as a concern by our institution is the stress that PBL has on both staff and students in the period of familiarity to the teaching process (Johnson & Finucane, 2000). In the traditional curricula, it is teachers that direct the learning process. The basis of PBL curricula is student-directed learning. Students who are used to teacher-directed learning will face an adaptation challenge to a system where the students are expected to direct their learning process (Johnson & Finucane, 2000). Some students might feel that their learning strategies are inefficient or misdirected, and this might negatively impact their success rate in using PBL for learning purposes. This is the situation that our institution faces, where traditional curricula that place teachers as directors of the learning process determine the trajectory of education. When students are exposed to PBL, the process might negatively impact their learning process.

Module 2: Assignment 4

The training of doctors using PBL to serve the health needs of a community requires the understanding of health problems that are faced by a community. In my community, there are several health problems that impact people’s lives in a recurrent nature. For the sake of this paper, only ten of the health problems are highlighted. They are acute urinary tract infection, malaria, typhoid, asthma, burns, sexually transmitted diseases, seizure disorder, anxiety, acne, and pre-natal care. The approach that the Health Professions Educational Institution in my community can do to curb these health problems would depend on their priority levels in my community. This means that the curriculum that will be reached upon by the institutions in educating medical doctors will incorporate the urgency of the health issues that are prevalent in my community. This paper conducts an analysis of the health problems through indices methodology, where ten indicators are used to ascertain the veracity of each health problem. The indices range from 0 to 5.

The ten indicators that form the indices are Magnitude (M), Case-fatality (C), Quality (Q), Time (T), Urgency (U), Prevention (P), Diagnosis (D), Therapy (R), Severity score, and Effectiveness score. The first eight indicators are considered as the priority health problem indices, and their sum provides the priority health problem weighting. It is from this weighting that the learning institutions will develop their curriculum on, prioritizing on the health problem that is of most concern to locals. Through the PBL form of learning, the medical students can understand more about the diseases and the best way to handle them by engaging the affected locals in the mentioned ten health problems in the community.

In the ten indicators, Magnitude is measured using the prevalence or incidence of the disorder in the community. Case-fatality is measured through the rate of fatality recorded from the health problem, while Quality is measured by the quality of life that individuals experience after the illness begins. The level of quality life remaining in an individual after being attacked by the health problem is one of the most difficult indices to measure with accuracy. This is because different people would react differently or have their quality of life change in disproportionate ways. Some of the reasons for the varying measures or lack of a standard mode of evaluation is because of differences in immunity in people living in a community. On-Time as an indicator, the measure is achieved through identifying the duration of the deviation from health that is recorded in an individual.

Urgency, on the other hand, is measured through the deterioration of an individual’s health once a disease is discovered, and this could be between periods of six hours, twelve hours, or a day. In the case of Prevention, the measure is achieved through examining the availability of a preventive measure for the identified health problem, while the measure of Diagnostics is achieved through identifying whether patients are complying with the directions provided by the doctors, and the availability of equipment that enables the identification of the health problem. The case of Therapy is measured by examining the efficacy component of the procedures implemented to assist the patient in regaining the initial health levels.

The other two indicators, which are scores, are an accumulation of scores of some of the eight independent indicators. For instance, in the case of severity scores, the indicator is achieved by accumulating the scores of Case-fatality, Quality, and Time. The Effectiveness score, on the other hand, is an accumulation of Urgency, Prevention, Diagnosis, and Therapy. Through the scores that are provided from the evaluation of each health problem, it would be possible for the learning institutions to formulate a learning curriculum for teaching medical students using PBL. Below is a table of the scores for each health problem.

Priority Illness conditions for medical education

Health Problems	Priority health problem indices								Severity score	Effectiveness score	Priority health problem weighting
Health Problems	M	C	Q	T	U	P	D	R	Severity score	Effectiveness score	Priority health problem weighting
Acute urinary tract infection	2	0	2	1	1	2	2	1	3	6	11
Malaria	1	1	2	2	1	0	2	1	5	4	10
Typhoid	2	2	1	1	2	2	1	2	4	7	13
Asthma	2	2	2	1	1	1	0	1	5	3	10
Burns	1	2	1	2	1	1	1	2	5	5	11
Seizure disorder	2	1	1	2	2	2	1	1	4	6	12
Anxiety	1	2	1	1	2	0	1	2	4	5	10
Acne	2	2	1	1	2	1	2	2	4	7	13
Sexually transmitted diseases	2	1	1	2	1	2	2	1	4	6	12
Pre-natal care	0	1	2	1	1	2	0	1	4	4	8

Given the above table, the weighted scores for the health problems provide a priority for the medical institutions in my community a highlight of the health needs of the community in formulating their PBL curricula. Below is the table with the highest to lowest weighted scores of the most pertinent health problems in my community.

Weighted scores of the health problems in the community

Health problems	Weighted scores
Typhoid	13
Acne	13
Seizure disorder	12
Sexually transmitted diseases	12
Burns	11
Acute urinary tract infection	11
Malaria	10
Asthma	10
Anxiety	10
Pre-natal care	8

From the above table, the Health Professions Education Institutions can institute a curriculum with a structured framework on how students can practically associate with each health problem. The frequency of each health problem allows education policymakers to assign students areas of exploration, analysis, and research, to improve their understanding of each health problem highlighted in the above-weighted scores

References

Bester, J. (2006). The development of a theory to inform an interdisciplinary teaching and learning framework for the Stellenbosch University Faculty of Health Sciences. 2006. Unpublished document. Bester (2006)

Boelen C. & Heck JE (1995). Defining and measuring the social accountability of medical schools. Geneva: World Health Organization, 1995:3.

Cilliers F., Mji G. (2005). Community-Based Education at the Faculty of Health Sciences at Stellenbosch University. 2005. Unpublished document

Education. Journal of Education in Clinical Practice 6(3):281-291

Ezzat, E.S. (1995). Role of community in contemporary health professions education. Medical education, 29(supplement 1), 44-52.

Hamad B (1991). Community Oriented Medical Education, What it is? Medical Education, 1991, 25: 16-22.

Hays, R. (2007). Community-Oriented Medical Education. Teaching and Teacher Education, 2007, 23, 286–293.

Hosny S., Kamel M.H., El-Wazir Y. & Gilbert J. (2013). Integrating Interprofessional Education in Community-Based Learning Activities: a Case study. Med Teach. 2013;35Suppl 1:S68-73.

Johnson, S., & Finucane, P. (2000). The Emergence of Problem-based Learning in Medical

Kreitzer M.J. Kligler B. Meeker W.C. (2009). Health professions’ education and Integrative health are commissioned for the IOM Summit on Integrative Medicine and the Health of the Public. February 2009.

Magzoub M.E. Schmidt H.G (2000). A taxonomy of community-based medical education. Academic Medicine, 2000, 75 (7), 699-707.

Maklady F. & Talaat W. (1998). Research document on the graduate’s competencies in the Faculty of Medicine, Suez Canal University in collaboration with the Eastern Mediterranean Regional Office of theWorld Health Organization. Geneva: WHO. Pp. 82–85.

Medicine, 1991, 66(5): 259-263.

Mullan F., Frehywot S., Omaswa F. et al. (2012). The Medical Education Partnership Initiative: PEPFAR’s effort to boost health worker education to strengthen health systems. Health Affairs. 2012; 31(7); 1-12.

Schmidt H.G. Neufeld V. R. Nooman Z. M. Ogunbode T. (1991). The network of Community-Oriented Education institutions for health sciences. Academic

Talaat W. & El Wazir Y. (2012). The El-Tal El Kebir Story: an example of social accountability from Egypt. Medical Teacher, 2012, 34, 354-360.

Talaat W., El-Wazir Y. (2012). The El-Tal El-Kebir Story: An example of social accountability from Egypt. Medical Teacher 2012; 34:354-360.

Villani C J. & Atkins D (2000). Community-Based Education, School Community Journal, Vol. 10, No. 1, Spring/Summer 2000.

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