The social contract challenge in medical education

Medical education has been criticized for loss of touch with the health needs of society. A social contract implies that medical schools, their students and teaching staff have certain rights and privileges in return for serving society. Commitment to this important reciprocal relationship makes it necessary to ensure that medical students gain understanding of the basic health needs of the communities they will serve. Health, Illness and the Community (HIC) is a mandatory course in the first and second years of the curriculum at the University of Toronto. Its goal is to provide students with community learning experiences by involving over 300 community agencies as learning sites. The course takes place one half-day per week throughout first and second year. All 177 students initially work with patients in their homes and in public health units and related agencies. Students are then assigned to agencies using health determinants and health promotion strategies. In the second year, each student selects an agency in the community, and carries out for the entire year a major project focused on the interaction of a health problem with a social issue. This educational initiative has been received well by community agencies and patients. Teaching staff have been enthusiastic and students have performed very well. A major obstacle has been the negative attitudes of some students to community-based learning, but these appear to be improving with time. Involving multiple agencies as learning sites is a feasible method for enabling students to learn about community health needs.     

Community Organizing Network for Environmental Health: Using a Community Health Development Approach to Increase Community Capacity around Reduction of Environmental Triggers

The Community Organizing Network for Environmental Health (CONEH), a project of Community Action Against Asthma, used a community health development approach to improve children’s asthma-related health through increasing the community’s capacity to reduce physical and social environmental triggers for asthma. Three community organizers were hired to work with community groups and residents in neighborhoods in Detroit on the priority areas of air quality, housing, and citizen involvement in the environmental project and policy decision-making. As part of the evaluation of the CONEH project, 20 one-on-one semi-structured, in-depth interviews were conducted between August and November 2005 involving steering committee members, staff members, and key community organization staff and/or community members. Using data from the evaluation of the CONEH project, this article identifies the dimensions of community capacity that were enhanced as part of a CBPR community health development approach to reducing physical and social environmental triggers associated with childhood asthma and the factors that facilitated or inhibited the enhancement of community capacity.     

COMMUNITY PARTNERSHIPS: THE UNI PROGRAM

In September 1992, the W. K. Kellogg Foundation undertook its UNI Program initiative, as part of its Latin American programmes, with the funding of 15 projects, in eight countries, and supporting strategies. The aim of the UNI Program in health professions education is to achieve synchronous development of educational models that are based on local health care systems where there is an important community participation in their management. An overriding problem inhibiting reform in health professions education towards a community orientation is the absence of academic community-based, problem-focused health care systems integrating the functions of health care, research, and teaching which would balance the tertiary-oriented models. The process of community participation is also unclear. All institutions propose major changes in the areas of curriculum, use of new learning opportunities at the community level, and interdisciplinary work. All will involve, as a minimum requirement, medical and nursing education, although 12 projects will also involve dentistry education, and 10 will involve other health professions — pharmacists, social workers, nutritionists, etc. This paper provides an overview of the programme, information on the progress of the 15 projects, and the perspectives to extend the programme to other countries in the Latin America region.     

Development of a culturally appropriate, home-based nutrition and physical activity curriculum for Wisconsin American Indian families

We designed an obesity prevention intervention for American Indian families called Healthy Children, Strong Families using a participatory approach involving three Wisconsin tribes. Healthy Children, Strong Families promotes healthy eating and physical activity for preschool children and their caregivers while respecting each community's cultural and structural framework. Academic researchers, tribal wellness staff, and American Indian community mentors participated in development of the Healthy Children, Strong Families educational curriculum. The curriculum is based on social cognitive and family systems theories as well as on community eating and activity patterns with adaptation to American Indian cultural values. The curricular materials, which were delivered through a home-based mentoring model, have been successfully received and are being modified so that they can be tailored to individual family needs. The curriculum can serve as a nutrition and physical activity model for health educators that can be adapted for other American Indian preschool children and their families or as a model for development of a culturally specific curriculum.     

Peer Reviewed: Development of a Culturally Appropriate, Home-Based Nutrition and Physical Activity Curriculum for Wisconsin American Indian Families

We designed an obesity prevention intervention for American Indian families called Healthy Children, Strong Families using a participatory approach involving three Wisconsin tribes. Healthy Children, Strong Families promotes healthy eating and physical activity for preschool children and their caregivers while respecting each community's cultural and structural framework. Academic researchers, tribal wellness staff, and American Indian community mentors participated in development of the Healthy Children, Strong Families educational curriculum. The curriculum is based on social cognitive and family systems theories as well as on community eating and activity patterns with adaptation to American Indian cultural values. The curricular materials, which were delivered through a home-based mentoring model, have been successfully received and are being modified so that they can be tailored to individual family needs. The curriculum can serve as a nutrition and physical activity model for health educators that can be adapted for other American Indian preschool children and their families or as a model for development of a culturally specific curriculum.     

Beijing health promoting universities: practice and evaluation

The aims of this study were to create a health promoting university within the framework of the Ottawa Charter for Health Promotion. Strategies included reforming and issuing healthy policies, creating a healthy physical and social environment, developing personal health skills, reorienting the health services, and implementing intervention activities. To evaluate the study, 180 students and 120 teaching/administrative staff were sampled for an in-depth interview with open-ended questions administered 1 year after the launch of the project. To assess health knowledge and behavior, 2500 students were sampled to answer a questionnaire, both prior to and following project implementation. With respect to policies, environment and health services, 166 students and 117 teaching and administrative staff participated in the in-depth interview. Approximately three-quarters (75.90%) of university students considered that the physical environment of the campus had improved significantly and 83.73% reported they had a good social environment. All university administration departments made commitments to health promotion. Consultations on mental health, smoking cessation and STD/AIDS prevention were provided all year round. Health education was included in a curriculum as a selective course with 1-2 credits. Almost two-thirds (60.66%) of teaching/administrative staff reported that they had had a yearly physical examination. In the final stages of the research, significantly more college students reported improved mental health (38.25% compared with 17.93% at baseline) (p < 0.01) and more were knowledgeable about transmission of STDs/AIDS (57.00/35.50% compared with 51.66/28.20% at baseline, respectively) (p < 0.01). Significantly less regular smokers were found (45% compared with 15.81% at baseline) (p < 0.01). However, there was a significant increase in high-fat food intake (44.81% compared with 49.50%) (p < 0.01) and pre-marital sex (5.11% compared with 14.00%), and a significant decrease in physical exercise participation (29.41% compared with 23.50%) (p < 0.01). As a health promotion setting, the university community can benefit greatly from implementing health promotion campaigns based on the principles of the Ottawa Charter.     

Dental Health Knowledge Tests: Their Development, Implementation And Evaluation

The present study discusses the development of dental health knowledge tests as part of an integrated dental health curriculum in the public school system of a rural community. It is part of a large project designed to test the effectiveness of a school-based dental health delivery system. Cognitive measures of dental health were designed to study the relationship of dental health knowledge to oral health behaviors. A review of the literature revealed no suitable dental health knowledge tests for grades K-6; new assessment measures were then developed by project staff. The tests consisted of 14 objectively scored tests--two parallel forms at each of the seven grade levels, K-6, and were administered four times to 1,942 students. Consistently, the tests have demonstrated high reliability estimates and low standard errors of measurement and indicate that the instruments are functioning as parallel forms and measuring the same dental concepts with equal precision.     

The health promoting school: progress and future challenges in Welsh secondary schools

Data were obtained from a random sample of 87 secondary schoolsin Wales (UK) about the organization and provision of healtheducation teaching, the implementation of health related policies,and the involvement of outside agencies and professionals inthe planning and delivery of health education programmes. Theresults suggest that schools have made progress in curriculumdevelopment. However, if the concept of the health promotingschool is to be translated into practice, greater attentionwill need to be given us the development of broadly based policiesfor health covering both pupils and staff and the better integrationof school programmes with community resources. Greater understandingof the health promoting school concept by teaching staff andthe development of examples of good practice in embedding healtheducation into national curriculum subjects, are also advocated.     

A nutrition/health training program for Peace Corps volunteers

Nutrition and health education is a crucial component of the overall mission of the Peace Corps program. Individuals selected to work as Peace Corps volunteers need to be well prepared to perform this complex and challenging job in recipient countries. This article presents a model for a training program for Peace Corps trainees that was conducted over a 5-week period. The program was planned in accordance with some specific training guidelines that were provided by the Peace Corps. The trainees included nine women ranging in age from 22 to 61 years with diverse backgrounds; however, all had a BA/BS in a health-related discipline. Training curriculum included fundamental nutrition and health-related areas: basic nutrition, foods, clinical nutrition, maternal and child health, communicable diseases and sanitation, health strategies, and community development. Fifty percent of the curriculum was devoted to "hands-on" practical and clinical activities. Maternal and child health was emphasized in the training curriculum as this is an area of concern in all developing countries. The trainees were evaluated by weekly quizzes as well as completion of a special project involving applications of all their newly acquired skills. Implications of the training program are discussed.     

Listening to the community: a first step in adapting Diabetes Today to the Pacific

Diabetes is a growing problem among Pacific Islanders, but few community-based groups in the Pacific are actively working on diabetes prevention and control. The Pacific Diabetes Today Resource Center (PDTRC) was established in 1998 to adapt the Diabetes Today (DT) curriculum for Pacific Island communities in Hawai'i, American Samoa, and Micronesia. To gather data to guide the development of the Pacific Diabetes Today (PDT) curriculum, a year was spent listening to Pacific communities. First, data were gathered from health professionals on how the DT curriculum should be modified. Second, health and community leaders in 11 sites were trained and supported to conduct discussion groups with people affected by diabetes. Third, site coordinators evaluated the discussion group process. A Pacific-wide Advisory Council (AC) was established to guide the project, and the AC used findings from the first year to generate guidelines for staff to follow in adapting the DT curriculum to the Pacific. These guidelines directed staff to: a) realize that Pacific communities need to build awareness about diabetes; b) train and support local community leaders as co-facilitators in the PDT curriculum, using a learn-by-doing approach, with the goal of developing them as independent trainers; c) encourage the involvement of a broad range of community members in PDT training, including the involvement of local physicians to counter medical misconceptions about diabetes; d) give the PDT curriculum a Pacific "look" and "feel;" and e) keep the training logistically flexible to accommodate differences in communities across the region. Other programs and agencies that want to develop training programs in the Pacific may find these listening strategies and guidelines helpful.     

First Steps in Initiating an Effective Maternal,Neonatal, and Child Health Program in Urban Slums: the BRAC Manoshi Project’s Experience with Community Engagement,Social Mapping,and Census Taking in Bangladesh

The processes for implementing effective programs at scale in low-income countries have not been well-documented in the peer-reviewed literature. This article describes the initial steps taken by one such program—the BRAC Manoshi Project, which now reaches a population of 6.9 million. The project has achieved notable increases in facility births and reductions in maternal and neonatal mortality. The focus of the paper is on the initial steps—community engagement, social mapping, and census taking. Community engagement began with (1) engaging local leaders, (2) creating Maternal, Neonatal, and Child Health Committees for populations of approximately 10,000 people, (3) responding to advice from the community, (4) social mapping of the community, and (5) census taking. Social mapping involved community members working with BRAC staff to map all important physical features that affect how the community carries out its daily functions—such as alleys, lanes and roads, schools, mosques, markets, pharmacies, health facilities, latrine sites, and ponds. As the social mapping progressed, it became possible to conduct household censuses with maps identifying every household and listing family members by household. Again, this was a process of collaboration between BRAC staff and community members. Thus, social mapping and census taking were also instrumental for advancing community engagement. These three processes—community engagement, social mapping, and census taking—can be valuable strategies for strengthening health programs in urban slum settings of low-income countries.     

Promoting Health in Early Childhood Environments: A Health-promotion Approach

This paper investigates the mechanisms by which a health-promotion intervention might influence the health-promoting behaviours of staff members working in early childhood centres. The intervention was an ecological health-promotion initiative that was implemented within four early childhood centres in South-East Queensland, Australia. In-depth, semi-structured interviews were conducted with 10 early childhood centre directors, early childhood centre staff, and health-promotion professionals involved in the same initiative. The case studies were based on informal observations and a documentary analysis of health-promotion practices and activities. A thematic analysis was conducted on the data to reveal the key characteristics of the approach. This study found that the health-promotion intervention in early childhood centres was reliant on the development of collaborative, “relationship-focused” partnerships between health and community agencies and early childhood centres. These relationships supported early childhood centre staff to promote healthy and developmental appropriate behaviours such as communication and social connectedness between children, parents and the broader community. Collaboration between health and community agencies and early childhood centres led to the shared planning of curriculum activities designed to create supportive structures within the early childhood centre and home environments to promote the development of health-related behaviours. These findings demonstrate the potential value of an ecological health-promotion approach to support the development of health-promoting behaviours in early childhood centres. Although the direct impact of health promotion is difficult to assess, this paper addresses an important gap in the literature about how health promotion might indirectly contribute to the health in children by supporting childcare staff in their endeavours to promote health.     

School children as health change agents in Magu, Tanzania: a feasibility study

The feasibility of an action-oriented and participatory educational approach, where school children function as health change agents, in a rural community of (Magu district) Tanzania was explored. Observations, in-depth interviews and focus group discussions with pupils, teachers and parents were undertaken. Findings showed that study participants favoured an approach where school children played an active role as health change agents in a combined school and community health education project. This conclusion contradicts traditional views in many African cultures where power, status and wisdom are usually closely associated with old age. However, a number of barriers were found, including the curriculum, time constraints, class size, teaching materials and teachers' skills and working conditions. The idea that pupils act as health change agents in the community as part of an action-oriented and participatory health education approach in schools was supported. A list of factors to consider when planning an action-oriented health education project is provided and discussed.     

Implementation of Comprehensive School Health Education in Elementary Schools: Focus on Teacher Concerns

ABSTRACT: This paper reports on the effectiveness of a teacher development project in promoting implementation of a comprehensive school health education curriculum among inner city elementary school teachers. The longitudinal evaluation design provides empirical data on the efficacy of a strategy to reduce teachers' concerns and promote use of the curriculum at the classroom level. Data were collected at various points throughout the project period from 156 school staff from five schools. Results from analyses of repeated measures of teachers' feelings of preparedness to teach specific health topics, and the observed relationship between both high and improved feelings of preparation and reported health teaching suggest that teacher development efforts including training and ongoing reinforcement to increase teachers' feelings of preparedness can have significant classroom effects.     

The UCLan community engagement and service user support (Comensus) project: valuing authenticity, making space for emergence

OBJECTIVE: To develop and evaluate service user, carer and community involvement in health and social care education. BACKGROUND: Despite the high policy profile of involvement issues, there appear to be no published accounts of schemes that have used a systematic whole-faculty approach to community engagement in health and social care higher education. FOCUS OF THIS PAPER: The set up and early development of a faculty-wide community engagement project. SETTING AND PARTICIPANTS: Staff from the faculty of health in one University, local service users and carers and community group project workers and local National Health Service (NHS) and public sector staff. DESIGN: Participatory action research including document review, field notes, questionnaires and interviews. ANALYSIS: Thematic analysis. The emerging themes were tested by seeking disconfirming data, and through verification with stake-holders. RESULTS: Prior to the study, there were examples of community engagement in the participating faculty, but they occurred in specific departments, and scored low on the 'ladder of involvement'. Some previous attempts at engagement were perceived to have failed, resulting in resistance from staff and the community. Despite this, an advisory group was successfully formed, and project framing and development evolved with all stake-holders over the subsequent year. The four themes identified in this phase were: building accessibility; being 'proper' service users/carers;moving from suspicion to trust: mutually respectful partnerships as a basis for sustainable change; and responses to challenge and emergence. CONCLUSIONS: Successful and sustainable engagement requires authenticity. Many problems and solutions arising from authentic engagement are emergent, and potentially challenging to organizations.     

Project community diagnosis: participatory research as a first step toward community involvement in primary health care

'Community participation' and 'bottom up planning' have become fashionable themes in international health circles. However, in the absence of sociocultural perspective these themes remain largely rhetoric. In this paper, a deprofessionalization of social science is advocated in the service of participatory research as a first step towards community involvement in primary health care. Deprofessionalization is suggested as an adjunct to, not a replacement for in-depth professional social science research. An exploratory community diagnosis of health project conducted in rural south India is described. During the project, lay researchers received rudimentary social science field training and collected data on health behaviour deemed important to health planners as well as the health concerns of the community. Illustrative data, generated by the project is presented on the rural poors' utilization of government health facilities, their attitudes towards Primary Health Centre staff, and their ideas about how a proposed community health worker scheme could best serve them.     

The effect of an interdisciplinary community health project on student attitudes toward community health,people who are indigent and homeless,and team leadership skill development

This study examined whether students' attitudes about community health practice, attitudes toward people who are indigent and homeless, and perceived leadership skills changed after participation in a planned interdisciplinary community health experience with an urban homeless or formerly homeless population. Data were collected from medicine, nursing, occupational therapy, physical therapy, and social work students who participated in the community health experiences and from students in these disciplines who did not participate in this curriculum. The interdisciplinary community health curriculum and practicum experiences, based on the Community Health Empowerment Model (CHEM), were designed and implemented by a coalition of community and academic partners. Students in the CHEM project self-selected into the curriculum and initially showed more positive attitudes about community health and indigent and homeless people than their peers not participating. Despite the CHEM students' positive initial attitudes, data from pretests and posttests revealed a significant positive change in their attitudes toward community health practice at the completion of the curriculum.     

Alcoholism curriculum development: an examination of the process

Alcoholism is one of several topics that may be integrated into family medicine clerkship teaching. This article focuses on the process of curriculum development in alcoholism. The process is traced from its beginnings in a third-year clerkship to its integration into the medical school curriculum and other areas of medical education. Strengths and pitfalls in this project are discussed. Enlisting community support and field testing newly developed strategies are emphasized as successful methods. Less successful in this project, though equally important, are faculty development and long-term evaluation. Recommendations for curriculum development in similar projects are made.     

A WIC-Based Curriculum to Enhance Parent Communication with Healthcare Providers

The objectives describe a curriculum to support parent-provider communication about child development, and to demonstrate its impact and effectiveness when delivered by staff from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). A curriculum was developed by a university-WIC partnership for a WIC center-based health education class to teach parents about child development and how to talk to their child’s doctor about development. During a 90-min training session, university pediatricians used this curriculum and trained WIC paraprofessionals to conduct a 20–30 min center-based education session. WIC paraprofessionals completed an on-line survey to obtain their demographic characteristics, and their attitudes and perceptions about the training sessions and their experiences teaching the center-based health education session to parents. Approximately 500 WIC paraprofessionals received the 90-min training session across 60 centers in the Public Health Foundation Enterprises WIC Program in Southern California. About 250 WIC paraprofessionals completed the on-line survey and over 80 % of WIC staff reported that they had learned new information about child development as a result of the training, and 87 % of the WIC staff reported that the training was sufficient to feel comfortable teaching the class content to parents. We demonstrated the ability to build WIC paraprofessional capacity to promote parental participation in child developmental surveillance and communication with their child’s doctor. With appropriate training, WIC staff are interested in supporting population-based efforts to improve parent-physician communication about child development that can complement WIC’s existing maternal and child health topics.     

Planning the teaching of community health (COPC) in an MPH program

The Community Medicine approach, focussed on an active assessment of health status with a subsequent provision of health care directed to the community as a whole, is recommended today as a means for addressing the fragmentation of health services. In parallel, in recent years the Community Medicine approach has been incorporated in a growing number of health academic institutions. In this paper it is suggested that the teaching of Community Medicine should be an active process in a practical environmental in which students could be involved with real life situations. Our teaching methods are illustrated by the experience of the Community Oriented Primary Care (COPC) Workshop of the School of Public Health and Community Medicine in Jerusalem. This Workshop is included in the curriculum after the core courses in the Israeli and in the International MPH Program at the Braun SPH. The central component of the workshop are the workgroups of 6-8 students with the assistance of a tutor member of the School's staff. The group, resembling a health team, focussed its work in the assignment of planning a proposal for the development of a community health program in the students' communities. The workshop is an illustration of the problem-based learning method carried out by public health workers of different professions background and with diverse practical experience reproducing a real life situation in a classroom environment. Repeated evaluations done by students has shown a positive assessment as measured by a reported adequate acquisition of knowledge, having an useful experience and practicing skills.