Defining Community-Engaged Health Professional Education: A Step Toward Building the Evidence
The Global Strategy for Health Workforce 2030 (WHO, 2016) outlines a set of milestones and strategies to expand and strengthen the health workforce that could better position countries to achieve universal health coverage and relevant sustainable development goals (SDGs). The Strategy underscores a need to counter the global shortage of health workers (expected to be 17 million by 2030) and ensure the workforce is appropriately trained to address the evolving health needs of the population. This training would ideally produce health professionals who are responsive to the population, socially accountable, both person- and population-centered, and supportive of empowered and engaged communities. Community-engaged health professional education is a mechanism for learning how to work in and with communities while obtaining the attributes just listed. Developing socially accountable individuals and institutions within a health system is key to improving the health and well-being of present and future societies.
Health professional schools with a commitment to social accountability are distinguished by their “obligation to direct their education, research, and service activities toward addressing the priority health concerns of communities, region, and /or nation they have a mandate to serve” (Boelen and Heck, 1995, p. 3). What has become evident is the lack of published literature analyzing learning taking place in and with communities that has a demonstrated value to that community.
The Innovation Collaborative on Learning through Community Engagement (the Collaborative) is a participant-driven group formed by members of the National Academies of Sciences, Engineering, and Medicine’s Global Forum on Innovation in Health Professional Education. The Collaborative was catalyzed by a desire to generate and highlight the evidence behind community-engaged health professional education with the aim of sharing and disseminating best practice models. The authors, along with individual members of the Collaborative, recognize that the current lack of evidence is attributable to a number of factors, including disparate nomenclature for work related to community engagement and limited resources assigned to the evaluation of community-engaged activities, particularly in low-resource settings. In response to these challenges, the Collaborative members determined that an important first step in building the evidence would be to establish a common definition for community-engaged health professional education. A critical element of this definition would be its relevance to all health professionals in all disciplines in all settings (or contexts).
In developing the definition, an initial search was conducted to compile existing explanations. Through a consultative and iterative process, Collaborative members ultimately chose to base the definition on one described by Strasser in 2010. By modifying the language to be relevant across professions, and highlighting the importance of community-engagement at the individual and institutional level, the members of the Collaborative and authors of this paper put forth the following definition of community-engaged health professional education:
Health professional education is community engaged when community-academic partnerships are sustained, and they focus on the collaborative design, delivery, and evaluation of programs in order to improve the health of the people and communities the programs serve. Programs and partnerships in community-engaged education are characterized by mutual benefit and reciprocal learning, and they result in graduates who are passionate about and uniquely qualified to improve health equity.
Elements of the Definition
The term community is an intangible entity that is not homogenous and is hard to define or measure (Rifkin, 1986). A community can include various geographic areas, clinical needs, socioeconomic statuses, cultural backgrounds, religious identities, ages, and more. Health professional schools with a social mission tend to focus on both medically underserved and/or disadvantaged communities. However, the Collaborative recognizes the importance of defining community based on the context, and therefore the proposed definition of community engagement can be applied to communities however they are defined.
Community-engaged health professional education involves learning activities that take place within and with the community. They require engagement of individuals (students, teachers, community members), institutions (from academia and from the community), and their leadership—all of whom come together to collaborate on the design, delivery, and evaluation of their learning activities. Such activities should serve two purposes: (1) to educate the learner, and (2) to serve the community. While it may be difficult for one program to successfully implement every aspect of community engagement, the authors encourage the reader to view this definition as a vision from which institutions can embark on a journey toward community engagement, and therefore take a stepwise approach to gradually introduce and strengthen different elements of a program.
Sustainable Community-Academic Partnerships
An ideal and authentic community-academic partnership is interdependent, socially accountable, and sustainable. Community engagement in health professional education requires partnerships to be genuine and based on reciprocal learning and mutual benefit, recognizing the community as a teacher and students as part of a team of service providers. Community participation should ideally be nurtured both formally and informally. Formal policies within academia can facilitate leadership engagement and community representation at various levels of program management. Informal linkages between students and community members should also be encouraged to facilitate a shared understanding of the value each brings to the other. Personal relationships with community members would enable students to understand the effect of health on quality of life and the link between health and social determinants of health. In turn, student and academic activities that specifically address community-identified health needs within the community would lead the community to value the contribution of students and engender a relationship of trust and confidence. Successful community-academic partnerships are adequately resourced, have achievable goals, and are regularly evaluated and reported back to the community so program changes can be implemented that strengthen the learning and the value of the work by the community.
Collaborative Design, Delivery, and Evaluation
Collaborative Design and Establishing Priorities for Community-Engaged Activities
Community engagement means that the communities are active partners and that community and academic voices are valued equally. In a community-academic partnership, participants actively seek and listen to all voices and acknowledge their necessary interdependence in achieving the goals set out in the partnership. Community representatives are involved at every stage of the process—during the design, implementation, and evaluation of educational activities. Another term for this is co-creation, and it occurs when communities have an active and equal role in decision making.
For students or academia to effectively engage in processes of co-creation, they must first have a deep understanding of the communities they serve. This can be achieved through community health assessments or asset mapping exercises, which identify community deficits, strengths, and resources. Understanding community health requires an appreciation of the effects of social determinants on individual and population health. The National Academies of Sciences, Engineering, and Medicine recently published a comprehensive framework for educating health professionals on the social determinants of health, which can serve as a resource for academic institutions in this process (NASEM, 2016). An important outcome of asset mapping and conducting a community health assessment is identifying mutually beneficial and desired priorities for learning and service activities.
Collaborative Delivery and Evaluation
Community-engaged health professional education requires more than just a community-oriented curriculum. It requires learning and service to be located in the community. With thoughtful pedagogy, the immersion of learning in and with communities, focused on areas of common interest and importance, is intended to be synergistic where students learn from community members while providing them a valued service in the community’s environment.
Monitoring and evaluation of community-engaged education should incorporate three important elements. First, evaluation should assess the learning environment and the engagement of individuals within the program. For example, are the students, their teachers, and community members all contributing to and learning from the program? Second, evaluation should be conducted at the institutional level. Are community members adequately represented within academic leadership and/or are they active in managing education programs? Do the needs and resources from both the community and the academic institution inform the strategic plans? Are findings shared and discussed between academia and community groups? Third, is there truly a shift in the broader systems? Are graduates being produced who are socially accountable and who choose to work in underserved
communities? Are academic institutions improving community health and contributing to responsive health systems?
Building Evidence and Next Steps
Capturing and sharing the experiences of learners, teachers, community members, and educational institutions is important for program improvement and for identifying and replicating best practices. However, many academic institutions struggle with inadequate funds, limited expertise, overstretched staff, and lack of time to be able to evaluate their programs and publish their findings. As a result, the published literature is limited. If adequate resources are allocated and programs collect data systematically, program outcomes could be pooled and/or compared to facilitate the spread of effective models of community-engaged health professional education.
An important starting point in evaluation is defining a vision and objectives against which activities can be measured. The Collaborative hopes the definition and elements of community-engaged health professional education described in this paper will catalyze the generation or analysis of evidence. Building the evidence for community-engaged health professional education is an important step in meeting health workforce goals for 2030.
References
- Boelen, C., and J. Heck. 1995. Defining and measuring the social accountability of medical schools. Geneva, Switzerland: World Health Organization. Available at: https://apps.who.int/iris/handle/10665/59441 (accessed August 5, 2020).
- NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press. https://doi.org/10.17226/21923
- Rifkin, S. B. 1986. Lessons from community participation in health programs. Health Policy and Planning 1(3):240-249. Available at: https://www.researchgate.net/publication/260336920_Lessons_from_community_participation_in_health_programmes (accessed August 5, 2020).
- Strasser, R. P. 2010. Community engagement: A key to successful rural clinical education. Rural Remote Health 10(3):1543. Available at: https://pubmed.ncbi.nlm.nih.gov/20815653/ (accessed August 5, 2020).
- WHO (World Health Organization). 2016. Global strategy on human resources for health: Workforce 2030. Geneva, Switzerland: WHO. Available at: https://www.who.int/hrh/resources/globstrathrh-2030/en/ (accessed August 5, 2020).
