Medical students’ perceptions of a community-engaged learning approach to community health in Ghana: the Students’ Community Engagement Programme (SCEP) | BMC Medical Education

Community-engaged learning (CEL) has been acclaimed as an effective teaching strategy in public health. It helps to acquire the knowledge, attitude and skill that medical students need to understand the balance between biologic and non-biologic determinants of health and to appreciate patients’ community contexts [1, 2]. This is best done in a framework of community engagement which entails developing relationships and working with groups of people with common interests in tackling health-related issues and promoting well-being to achieve desirable health outcomes [3].

This approach to learning offers useful opportunities for experiential learning which reinforces theoretical course content through community engagement and reflection on relevant activities [4, 5]. Ultimately, community-engaged learning contributes to shaping medical students for future roles as socially-responsive clinicians who can identify, assess and address broader sociocultural, economic and environmental determinants of health [1, 6, 7]. In seeking to strengthen primary health care and reform, the World Health Organization (WHO) contends that the health workforce, particularly medical doctors, should be aware of the significance of public health in the well-being of people and to use public health measures more in their interventions [8]. This point is further elaborated by calls for greater community engagement in any new orientation for training health professionals [9].

Though often linked with training in public health, CEL is used in many other disciplines including pharmacy practice, sociology education and engineering [10,11,12] and provides a platform for nurturing mutually beneficial relationships between academic institutions and community structures [5].

The goals of CEL are largely long term and this makes its evaluation challenging. This underpins the limited publications on the subject, especially in Africa [13]. Studies reporting evaluations of CEL programmes have broadly considered program design assessment [1, 5, 14], short-term learning outcomes based on student perceptions [12, 14, 15] as well as motivating factors and barriers to participation in such programmes [10]. Some evaluations of student health professionalcommunity engagement programmes looked at short-term objectives with a clinical bias and reported improvements in health knowledge, attitudes and practices among community members as well as varied student reflections on their experiences in the programme [10, 14, 16]. In a recent article exploring pharmacy students’ participation in CEL, some of their reflections hinted at contentment for the opportunity to develop their professions and careers and to positively impact the community while others lamented time constraints, the lack of confidence and preparatory information on the roles they were supposed to play in the context of activities constituting the community engagement programme [10]. Evaluation of clinically-oriented medical student clerkship programmes, solely involving interactions with health staff and patients in hospital settings in rural Australia and Canada, reported useful values in terms of team work and participatory learning among the students [17].

The Students’ Community Engagement Programme (SCEP)

The University of Health and Allied Sciences (UHAS), Ho in the Volta Region of Ghana, West Africa, is a young public university established in 2012 with a vision to become a pre-eminent health research and practical-oriented health educational institution dedicated to community service. In line with this, innovative approaches to research, teaching and community engagement are encouraged. The Department of Community Health in the School of Medicine in UHAS, in its bid to innovate and make learning of Community Health beneficial to both medical students and surrounding communities, has proactively adopted a collaborative approach in engaging with these communities for teaching parts of the subject while contributing to improving their health status.

In UHAS, the fourth-year Junior Clerkship in Community Health is a 4-week programme designed for medical students to study the interactions and interrelations of health-related activities in the context of Primary Health Care at the community level. Students are to be exposed to health promotion and disease prevention activities and the health care delivery system in the community. They are expected to study in a practical way and apply theoretical knowledge acquired in specific Community Health concepts to analyse, understand and help solve health problems at the community level. The clerkship is intended to encourage students to function in teams and to develop their ability to collect relevant health-related information through observation and practical participation in health activities in the community. Students are also expected to develop the ability to critically assess and analyse this information and present it in the form of written reports and oral presentations at seminars for group discussion.

The fourth-year medical students’ Junior Clerkship in Community Health curriculum was adapted to implement a CEL programme dubbed the “Students’ Community Engagement Programme (SCEP)”. This derives from John Dewey’s learning-by-doing theory of education and emphasizes some principles including experiential learning, social learning and interaction, collaborative learning and critical reflection [18]. A cardinal principle in Dewey’s experiential learning theory is that human experience occurs through engaging a social environment with contact and communication [19]. Living and interacting in social environments such as the programme communities create a learning experience. Students reflect on these learning experiences to help construct knowledge which can then be transferred or applied to new situations [19]. These considerations underscore Dewey’s learning-by-doing theory as a theoretical lens to the current work. In agreement, other authorities have emphasized the multidisciplinary nature of education and that academic content needs to be complemented with learning activities in a variety of settings beyond the school [20, 21].

The SCEP concept seeks to build students’ capacity to undertake the following relevant public health-related activities; (i) community entry including using appropriate channels to reach community/traditional leadership and interacting with community members, (ii) community profiling and diagnosis including conducting a transect walk through the community, extracting information about the health of a community from health centre records, identifying and prioritizing health problems with community members, (iii) community mobilization and stimulated action including organizing durbars for sharing health information and liaising with existing organizations to undertake health promotion activities in the community, (iv) conducting epidemiological research including research problem identification and analysis, questionnaire development, data collection and basic data analysis and (v) reporting on activities and findings from the SCEP through writing, presentations and discussions. Overall, SCEP not only reinforces the curriculum but also contributes to students’ appreciation of community and socio-cultural contexts of illnesses.

To help achieve the objectives, the students spend up to two weeks living in designated, mostly rural and peri-urban, communities in near-by districts to build skills in community entry, profiling, diagnoses and community mobilisation/ engagement through interaction with community structures. In addition, based on their observations from the community diagnoses, they carry out health promotion and preventive activities by giving health talks in community durbars, schools and local radio stations Working together with community health nurses and volunteers, they also conduct health screening activities. Where possible, they initiate a sustainable health project having built consensus with the community.

Furthermore, the students conduct research into identified prevailing health issues in the community and use the opportunity to hone their questionnaire design / administration, data collection, organization, analysis and report writing skills. One such study assessed the water, sanitation and hygiene situation in ten communities across two districts [22]. About 5–15 students are sent to a community depending on the size of the community. Accommodation and, sometimes, feeding of these students are catered for mainly by the traditional leadership of the communities. Sometimes, health facilities in these communities may offer accommodation too.

Prior to leaving for their designated communities, the students have lectures on topics relevant to their stay in the community. These include the healthcare system in Ghana, health and the environment, community entry, engagement, mobilisation and diagnoses and health promotion. Building on the previous year’s introduction to research methodology course, the students are guided by their lecturers in identifying problems, setting objectives and in developing appropriate questionnaires from literature review on a common health-related issue. These questionnaires are administered to relevant participants in the communities to build the students’ competencies in data collection. On the field, they are aided and supervised by designated community preceptors who may be healthcare workers in the local health facilities or members of the community health committees. These preceptors are considered partners in the SCEP and they receive training from the Department of Community Health on their roles in the SCEP. While the students are in the communities, the faculty also visit them and provide some supervision of their activities as well. Indeed, an initial community entry is done by the faculty before the students get to their designated communities as a preliminary measure to ensure that accommodation and other support are available for the students, among other reasons.

Existing literature is lacking in research on CEL for medical students that is purely public health-oriented and engages with community members, their non-biologic health determinants and their belief systems. Many studies on the subject report on CEL with a bias for clinical orientation in local hospitals in much larger urban settings rather than emphasizing engagement with the community membership on health promotion and disease prevention activities [6, 14,15,16, 23,24,25].

Since its inception, six batches of students have passed through SCEP with the first four graduating from medical school already and working in various hospitals across the country. However, SCEP is yet to be evaluated with respect to the following research questions; (i) what are students reactions to or perceptions of the usefulness and processes of the programme?, (ii) what broad scope of knowledge and skillsets do students perceive they learnt or strengthened from SCEP, and (iii) whether students perceive that the knowledge and/or skills learnt have translated to behaviour change in attitude and practice towards patients? There is currently no data describing its successes or deficiencies and its perceived effects on learning have been anecdotal so far. This gap in knowledge is problematic as faculty have no insights at all into what participants in the programme (students and community members) perceive of the programme. There is no evidential basis to identify programme gaps or to inform appropriate interventions to address them. A need to conduct some assessment of the programme to help fill knowledge gaps was pertinent. Thus, an assessment of students’ perceptions of learning and training outcomes in Community Health through SCEP and community members’ perceptions of SCEP was conducted.

This report focuses on students’ perceptions and will contribute knowledge on the direct student-oriented short-term effects of the programme, inform on community-engaged learning, especially for medical students, in Ghana. It will also highlight weaknesses in the programme, draw suggestions on addressing them and guide didactic teaching of relevant topics including health promotion, community entry and participation and health priority setting.