|
|||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||
CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE Community Health Diagnosis as a Curriculum Component: ABSTRACT: Community diagnosis is used to determine and describe the health status of the population (HSP), reflected in health indicators in a community over a specific time period. In public health practice, community diagnosis is a tool for evaluating HSP. The purpose of the community diagnosis (health diagnosis) in the Community-Based Education and Service (COBES) curriculum for third-year medical students is to provide a training component that exposes students to intervention methods that depend on working directly with populations and on understanding patients in the context of their communities. Introduction The Faculty of Health Sciences of the Walter Sisulu University (formerly University of the Transkei, UNITRA) is located in Umtata, in South Africa’s Eastern Cape Province. This essentially rural region, known under apartheid as the Transkei bantustan, is historically one of the poorest provinces in the country (see Table 1). Table 1: Demographics of Eastern Cape Province, South Africa
*Eastern Cape is 14% of total population Today, in an effort to offer high quality and relevant education to medical students, the Faculty has developed a Problem-Based Learning (PBL) and Community-Based Education (CBE) curriculum. Its main aim is to train and equip doctors with technical skills for patient care, as well as with the necessary social skills for assuming broader responsibilities in health care delivery and health promotion. The community-based branch of this curriculum (CBE) has two essential components: 1. Community-Based Experience and Service (COBES) during the first three years of study; 2. Community Clinical Clerkship (COMCC) for later years of study. The main learning objectives of COBES are to: · Sensitize medical students to clinical situations that reflect the social, cultural and economic factors that are important causal factors for disease;
This COBES Program for third-year medical students is developed through three main activities: 1. Clinical Skills; 2. Know Your Clinics and Evaluation of Health Centers; 3. Community Diagnosis. The community diagnosis is made in order to define and describe the health status of the population (HSP) in a specific community. Students learn that the HSP is a complex phenomenon including morbidity, mortality, disability, composition and reproduction, and influenced by other related indicators, such as food supply and nutrition, educational level and opportunities, employment, etc. Similarities and differences exist between the approaches of clinical medicine and community health: “The clinician examines the individual patient and has to recognize and identify the pathological significance of the clinical symptoms and signs in order to make a specific diagnosis and to prescribe the appropriate treatment. In community health, epidemiological skills are needed to examine the whole population and to select the most suitable diagnostic indicators that describe and explain the health problems in the community. It is then necessary to make the community diagnosis and decide which (interventions) would be most effective in raising the health status of the population. A clinician may order a variety of laboratory or other special tests after making a preliminary assessment of a patient, based on the case history and physical examination. In the same way, the doctor in the community may need to organize special surveys in order to obtain more epidemiological information…however, there is a fundamental difference in the approach: the clinician usually sees the patient after the disease has started…by contrast, the epidemiologist attempts to understand why the disease exists… and how it can be prevented.”[1] “Decisions on the management of a patient require a clinical diagnosis, based on the history, examination and special investigations. Management of ill-health in the community as a whole requires a community diagnosis which rests on epidemiological information.”[2] One main question is the starting point and guide for working with students throughout the community diagnosis: How healthy is this community? The objective of this article is to present the main activities of community diagnosis as a core component of Community-Based Education for third-year medical students. Methodology Students visited community health centers every Wednesday, where morning sessions were devoted to clinical skills and afternoons to community activities. Students were divided into groups, each one assigned to a different health center as follows: 4 centers/groups (1998-2000); 6 (2001-2003); and 7 (2004-forward). Each group was assigned a tutor, and students were also assisted by the matrons (supervising nurses) in charge of the health centers, community liaison officers, community health workers and other health personnel. The COBES Program is carried out over the entire third year as follows:
Selected topics covered in the household survey questionnaire:
For the purpose of monitoring the program, weekly meetings were held between students and tutors to discuss results, difficulties, what students had learned that week, aspects that needed greater attention, etc. Each October, students presented their Community Health Diagnoses in oral presentations in the University Auditorium, accompanied by a written report, including essential recommendations and proposals for improving the health status of these communities. These presentations were made before an audience consisting of fellow students, University and Faculty managers and senior staff, faculty, Department of Health representatives, distinguished guests, health center workers, community members and other guests. Figures 1 and 2 are excerpted from student final reports, presented in Power Point. Students are assessed as individuals and as a group, according to their participation in clinical and community activities, group reports on specific activities, and their final project. The resulting grade contributes to their year’s mark in Community Medicine. The following are examples of PowerPoint pages from a 2003 third-year medical student presentation: sample conclusions from their household survey and epidemiological research. Figure 1
Figure 2
Results “Community-Based Education is a means of … implementing a community-oriented educational program. It consists of learning activities that take place within the community where not only students, but also teachers, members of the community and representatives of other sectors, are actively engaged through the educational experience…Community-Based Education can be conducted wherever people live, be it in a rural, suburban or urban area, and wherever it can be organized.” (WHO, 1987) Students – with their tutors - worked according to COBES’ main objectives for third-year medicine, learning to:
At the community level, the immediate impact has been to:
The medium-term community-level impact should be to:
At the Faculty of Health Sciences level, the immediate impact has been to:
Discussion Third-year medical students at the Walter Sisulu University of Health Sciences have benefited from the necessary process of integrating clinical skills and a public health approach, so as to enhance their epidemiological thinking and be of greater use to the communities where they will practice. As a result, they have learned and acquired knowledge and skills from real-life situations, and have had an opportunity to work in problem-solving and decision-making processes. They have applied critical thinking, and become - with other actors - agents of change towards better health. These community health diagnosis activities are an integral part of the whole educational process, as demonstrated by the total weight given to this program in the form of time spent working in the community and as an important component in determining their final grades for graduation. With COBES in their third year specifically oriented to work on community health diagnosis, students have transformed their learning experience, exchanging the classroom for the community. In the process, classroom lectures have been enriched by interacting with the life and professional experiences of health centers, their staff and community members. Therefore, the community has become their chief learning environment. Conclusions The Alma-Ata Conference (“Health for All”) confirmed the need for a new paradigm for educating tomorrow’s physicians and health workers. In the Walter Sisulu University Faculty of Health Sciences, the author and other tutors have attempted to develop such an approach, aimed at making graduates relevant to the health of communities beginning in their student years. From our experience, we are convinced that the community diagnosis has and will continue to produce positive results for the community, students, staff and Faculty as a whole. In particular, this curriculum component has helped students gain a greater sense of social responsibility and a deeper understanding of the problems facing communities. At the same time, community leaders have supported this program by introducing students into the communities, and have expressed satisfaction with the results. Finally, this modality of teaching is a way to practically demonstrate that the link between the University and society is possible. That is, the University can serve the community and thus society, with specific activities to improve health and the skills of students who will serve as future health professionals. At the same time, community-based teaching of medicine does not constitute a “lower level” of professional training, but rather a comprehensive approach for equipping physicians with adequate skills, appropriate approaches and a knowledge base that will serve them well in all settings, particularly in the most disadvantaged communities. REFERENCES
|
|||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||
