Benefits of a community based interdisciplinary learning exposure: A qualitative study of the One Health approach in teaching at Makerere University, Uganda

Makerere University implemented a One Health Institute (OHI) in 2016 involving undergraduate students selected from different disciplines. The students were first taken through theoretical principles in One Health followed by a field attachment in communities. The field attachment aimed to expose students to experiential educational opportunities in the communities in a One Health approach. In this paper, we present students’ experiences and their contributions to the communities of attachment. This was a cross-sectional study, utilizing qualitative data collection methods. The study involved students who participated in the OHI field attachment and community members in Western Uganda. Four focus group discussions (FGDs) and four in-depths (IDIs) were conducted among the students, while four FGDs and eight IDIs were conducted among community members. All interviews were audio-recorded, transcribed and analysed manually.


Introduction
The beginning of the 21st century has been marked by many global public health challenges. Inequities in health persist both within and between countries, emphasizing the failure to share health advances fairly. (1). At the same time, new health challenges have emerged such as new infectious, environmental and behavioural risks, rapid demographic and epidemiological transitions threatening health security of all (1). Solving these complex global health problems requires innovation and a paradigm shift in the traditional systems for response. Globally, the multi-sectoral and inter-disciplinary mode health for people, animals and the environment (4)(5)(6). Several factors have changed interactions between people, animals, and environment leading to the emergence and reemergence of many diseases. For example, over 60% of emerging or re-emerging diseases have animal origins especially wildlife. In addition, at least 70% of the known human and animal pathogens affecting public health, global trade, and security are resident in Sub-Saharan Africa and in particular, Eastern and Central Africa (7,8). Uganda in particular is a 'hot spot' for emerging and re-emerging infectious diseases. Thus successful public health interventions in Uganda and the surrounding region requires the cooperation and collaboration of human, animal, and environmental health sectors in order to attain optimal health outcomes for the environment, people and animals.
However, health professional education has not kept pace with the current health challenges, largely due to fragmented, outdated, and static curricula that produce illequipped graduates (1). Global movements and the Commission on the education for health professionals for the 21st century have argued for a redesign of health professional education systems to better match current health challenges (1). In order to make the future workforce be able to collaborate across sectors, appreciate each discipline's contribution to health, and work in effective teams, they need to be trained in a multidisciplinary and professional interdependence manner (1). In addition, community based education integrates education and practice in the learning process (9) to foster competency acquisition. It creates appropriate knowledge and attitudes; to promote social skills and multidisciplinary teamwork; and deepens trainees' understanding of the contribution of social and environmental factors to causation and prevention of ill-health (10).
The training of future workforce in One Health is critical in order to improve the health and well-being of humans, animals, and ecosystems, thus promoting sustainable health for prosperous communities, productive animals, and balanced ecosystems. Since 2016, the USAID One Health workforce project (OHWF) has focused on developing a workforce with skills and mindset to tackle One Health challenges, including emerging infectious disease and antimicrobial resistance (11). The One Health Central and Eastern Africa (OHCEA), which is a network of 23 schools of veterinary and public health are championing the One Health in academia in Africa, by piloting an interdisciplinary training, with an aim to produce a One Health workforce. Through OHCEA, the Makerere University School of Public Health and College of Veterinary Medicine, Animal Resources and Bio-security jointly with other colleges at Makerere University designed and implemented an innovative One Health Institute (OHI) in 2016. The OHI is intended to train and transform the knowledge of young interdisciplinary and cross-sectoral teams of professionals at the start of their careers and give them ability to detect, prevent and respond to infectious diseases. At the time of this study, the OHI had run three cohorts of undergraduates and graduates students (89 students in 2016, 38 in 2017 and 55 in 2018) since 2016. However, there is a dearth of information regarding how students specifically gain from the training and how they contribute to communities (where they do their practical attachment) during their fieldbased training. This study was conducted to explore the students' gains, experiences of the OHI including their contributions to solving communities' challenges at the end of cohort of 2018.

Setting
The study was conducted in selected communities in western Uganda (where the community/field based training was conducted as described below). Uganda is situated in the Congo Basin a 'hot spot' of zoonotic disease out breaks. This region has recently faced many outbreaks of zoonotic diseases including, rift valley and anthrax, Marburg, avian influenza and ebola (with current outbreak in the Democratic Republic of Congo) (12).
There is therefore urgent need both within Uganda and the neighboring region (Eastern and Central Africa) to develop or improve capacity to prevent, detect and respond to these infectious disease outbreaks. The OHI is intended to train and transform the knowledge of young interdisciplinary and cross-sectoral teams of professionals at the start of their careers and give them ability to detect, prevent and respond to infectious diseases. The specific aims of the OHI are to equip students (future workforce) with competences; i) to respond to the community threats that are infectious or have the potential to be infectious using the One Health, ii) to effectively exchange information, and offer advice to the experts and community who face the threats that are infectious or have the potential to be infectious and iii) be able to work in a multi-disciplinary team.
Selected from the different disciplines at Makerere University through a competitive process, students are trained in a certificate course in principles of infectious disease management using One Health approach in order to prepare them to more effectively combat the spread of diseases. Students are first taken through a 16-days didactic One Health courses including leadership, policy analysis, gender risk analysis, outbreak investigation, antimicrobial resistance, biosafety and bio-risk management and community entry and engagement. Following the theory component is a 28-days field attachment, designed to expose students to experiential education opportunities in which the students get a chance to apply skills and knowledge gained. This mode of learning is aimed to enhance long term learning outcomes through students working closely with communities to identify their health threats by creating appropriate knowledge and attitudes; as well as promoting social skills and multidisciplinary teamwork (10). Briefly, the field experiential learning involves the following; 3-days of interacting with community leaders to explain the mission at hand and gain acceptance and confidence to work in a selected community. This is followed by rapid assessment of the community for health challenges (7 days).
Attempts are made to implement some simple and sustainable solutions to some challenges identified in consultation with the community (14 days). During the final days of the field engagement, students make presentations of what they have done in an audience of the district officials and community members. While in the field, students in study groups of approximately 14-15 students each are mentored by a multi-disciplinary team of faculty and field-based supervisors (including the district health officers, the district veterinary officers, the district environmental officers), with the help of the local councillors or village/ community leaders. Through community based training, students are expected to gain One Health competencies including team work, negotiation, collaboration and cooperation.

Study design, population and sites
This was an explorative cross-sectional study, utilizing qualitative data collection methods involving focus group discussions (FGDs) and in-depth interviews (IDIs). The study participants included OHI students of the cohort 2018), members and leaders in communities of Kasese town and Bwera municipality in Kasese district, Western Uganda (where students had their community placement).

Data collection
Using English and local languages, a total of eight IDIs were conducted with district officials/field mentors such as district health officers (DHOs), districts veterinary officers (DVO), veterinary officers, animal husbandry officers, field supervisors, members of Village Health Teams and local councilors (LCs). Four IDIs were conducted with student leaders in English. Four FGDs were conducted among community members in local languages, while four FGDs (two with science, and two with Arts students) were conducted in English. The key questions and discussion topics focused on the students' understanding of One Health concept, their experiences and contribution towards solving community health challenges in the perspective of community members. Some of the specific questions included; What do you understand by the term 'One Health.' What were the strengths and key achievements of multi-disciplinary/One Health field attachments in the communities? In your view, what contribution did the students make towards solving some of the challenges the communities are facing during the time they were here for their field attachment? How best can this field attachment be organized and run so that it profits both the students and the community? Data was collected by two research assistants with experience in qualitative research and the local language, who were re-trained on FGDs and IDIs, ethical conduct and study objectives. All the interviews were audio recorded.

Data management and analysis
All interviews were transcribed verbatim (and translation to English for the FGDs that were conducted in the local language). The transcripts were manually analyzed. After reading transcripts several times by different research team members (mainly by EB, ET and CN), codes were agreed upon, and were used to code all the transcripts. Through consensus, related codes were merged into categories, which later were emerged into themes.
Consistently appearing themes were identified, tabulated as to frequency, and illustrated with representative quotations. Discrepancies were resolved through discussion.

Results
Four themes emerged including: students' understanding and appreciation of One Health concept, students' experiences and gains from the field attachment, students' contributions to the communities and challenges faced.

Students understanding and appreciation of One Health concept
When asked about their understanding of One Health approach, all the students had good knowledge about the concept. They explained that it is how different disciplines work in a collaborative manner to address complex challenges. They recognized and emphasized that health cannot be achieved by one discipline or sector , due to the interdependence between human, animal and the environment. Thus the need for collaboration and combined efforts as the corner stone to address the current health challenges. Students' experiences and gains were described in a number of ways as shown in the following categories; a) appreciation of the concept of team work, b) appreciation of the role of community involvement and c) innovative use of available resources.

a) Students' appreciation of the concept of team work
Students appreciated the different disciplines working together to develop solutions to the challenges they identified in the communities. This was reported to be critical due to the complex nature of the interconnectedness of human, animal and the environment, and through team work they recognized that each discipline contributes importantly in achieving community health

c) Innovative use of available resources
In their attachment, students did not have funds for the interventions to address identified challenges, but were expected to use the available local resources in the community.
Students were able to come up with useful innovations.

Students' contributions to communities
In all the community interviews, students were appreciated for being very instrumental in addressing community challenges. Community members' views on the students' contributions have been categorized into; a) participation in health promotion activities such as health education, sanitation and hygiene, b) enhanced interaction between the communities and their leaders, c) stimulated One Health practice in the communities, d)

Committed, caring and compassion a) Participation in health promotion activities
The students were widely recognized and appreciated by the communities for their engagement in health promotion activities in homes, schools, markets and other communal places, creating awareness among the communities on how to prevent various diseases. They conducted health education sessions which covered various topics including the interconnectedness of animal, human and environmental health.

c) Stimulated appreciation of One Health practice in the community
The students' work ethic challenged community members including the district officials by demonstrating potential efficiency and effectiveness in collaborative efforts. Communities appreciated the One Health approach based on what the students' way of work, where they exhibited collaboration, team work and respect for each discipline, unlike where they work in siloes. They said that lessons from experiences with students in the communities guided a multi-sectoral response against a cholera outbreak in the district.

Challenges faced by students
One of the major challenges reported was related to inadequate funding. While students were encouraged to be innovative and use available resources, they noted that lack of funding limited the extent of the appropriate and sustainable interventions they could implement in the communities. The students felt that if some funds were available, they would have come up with strong and more meaningful solutions more so than using inferior materials. Lack of community ownership of interventions was also a concern. It was reported that some community members refused to participate because they wanted to be paid. Such lack of community participation indicates less or no ownership of interventions. The need for payment by some community members before they could to engage in their own community solutions threatens sustainability mechanisms of any interventions the students implemented. Relatedly, community respondents were concerned about the sustainability of the interventions given the short period of attachment because students would leave the communities immediately after implementing the interventions. This raised concerns regarding limited lessons and follow up with some interventions which communities wouldn't maintain on their own in the long run. There was also a challenge of language barrier, with some students and community members failing to communicate which compromised the community engagement process to some extent.
The issue of culture was also raised as a factor affecting assimilation of what the students sensitized the communities about in terms of preventing diseases. Some cultural practices promote transmission of diseases. For example it was reported that the Balalo (cattle keepers) love their animals so much that they don't believe they can be of risk to their health. They find it normal to share a house with their animals or drink uncooked milk from them.
"Ok for the Balalo they got annoyed because for them you cannot separate them with their animals, they wouldn't mind seeing an animal sharing with them a saucepan. Some of them were not happy with the changes as a result of the interventions of these students" (FGD Hima Town Council)

Discussion
This study explored the students' gains, experiences and their contribution to solving communities' challenges during a community based interdisciplinary training. The students' appreciated the training citing skills gained in communication, team work and collaboration. They appreciated that each discipline contributes uniquely and meaningfully towards achieving health in the community. Students also reported a feeling of gratitude and accomplishment. They felt that they had made a positive impact to the community by coming up with interventions to some of the challenges that the communities were facing.
The communities learnt and appreciated the concept of One Health from the students.
They appreciated the students' contribution such as improving sanitation and hygiene in schools, slaughter areas and markets. In addition, students raised awareness about general disease prevention and health promotion. They were also reported to exhibit a spirit of team work and collaboration in addition to showing love and commitment to their work in the communities. Students also enhanced interaction between communities and their leaders. However, students encountered some challenges such as language barrier, less community involvement and ownership of the interventions which affects sustainability.
Students embraced the spirit of team work, collaboration and appreciated the relevancy of each discipline's contribution towards achieving health in the community. This is in line with Frenk's (1) recommendation of multidisciplinary and professional interdependence training for the future workforce to be able to form effective teams across disciplines/sectors and cause a transformative change (1). Interdependence is a prerequisite for One Health, an approach that recognizes multi-sectoral collaboration locally, regionally and internationally to address health challenges. This multidisciplinary training in the OHI has proved that these One Health competencies can be fostered among a future workforce. Indeed, in addition to their good technical discipline or sector-specific skills, workers also need to be prepared with a collaborative mindset that allows them to organize and maximize their technical skills with other professionals (13). Thus a One Health workforce is the sum of its parts, and that collaborative work requires each individual worker to have (1) technical skills and competencies to work well within their own discipline and sector, (2) cross-sectoral skills and competencies to work collaboratively across sectors, and (3) a supportive institution to enable their collaborative work (13). Bringing together these multidisciplinary student teams to learn, plan and innovate together, fosters the cross-sectoral skills and competencies of collaboration across disciplines/sectors in addition to technical skills and competencies in their own discipline. This provides an environment for partnership which allows multisectoral/multidisciplinary collaboration i.e. One Health approach with ability to mobilize and respond to public health challenges (13).
In the same way, the multi-disciplinary community based attachment provided an opportunity to students to innovate. For example a group came up with a bat repellent using the concoctions from the local herbs-which is environmental friendly than fumigating with chemicals. Exposing students to the realities of health challenges that communities face, makes them more likely to become advocates for change (14,15) and thus acts as a stimulus for innovations. Thus the multi-disciplinary training exposure has great potential to expand scientific knowledge and innovation to address public health challenges and thus improve the longevity and quality of life for millions of people. This is because of marked synergy between the different disciplines in achieving human, animal and environment health (16). As observed in OHI, the foundational technical skills allow students/workers to contribute to niche aspects of the challenges (13). For example, multi-disciplinary/scientific collaboration between the veterinary and the medical community resulted into the development of the First Balloon Expandable Coronary Stent (16).
The students were taught One Health theoretical courses, which include leadership and management, and equipped with communication, teamwork and collaboration skills.
These courses are in line with what Frankson and inter-professional expert panel referred to as the One Health core competencies (17,18) which are critical needs for successful collaborative efforts. These competencies suggest similar needs for collaborative efforts.
By applying One Health core competencies during classroom and field-based training, as was done in the OHI, we can change the way graduates/future workforce see the world, allowing veterinarians, medical professionals, nurses, pharmacists and environmental health practitioners to see their part in the greater system of disease prevention (13).
Community based training was a major component in the OHI as it provides an opportunity for experiential learning by integrating education and practice in the learning process (9) fostering competency acquisition. In addition to benefiting students, community based education is meant to benefit communities in terms of providing a service to underserved communities and, hopefully, to affect student career choices (19)(20)(21). In the OHI field attachment, communities appreciated students' contribution ranging from interventions such as improving sanitation and hygiene in schools, abattoirs and markets as well as creating awareness about diseases prevention and health promotion. In addition, students were also reported to pass on cross-sectoral skills to the community members, having a multiplier effect on student training in a community based approach.
The benefits of the OHI student attachment to the community makes community based education a 'win win' program for both students and communities (22)).
However, there were challenges that students faced such as lack of community engagement linked to high community expectations that were not fulfilled which can threaten community ownership and sustainability of the interventions. This calls for what Williams and colleagues suggested (23)-the need for a more balanced partnership where the community is consulted in planning a health programme that is relevant to that community's particular needs . The need to work in a partnership while planning for a community based training is very critical so that the roles and expectations of each party are clarified. As was raised by Mbalinda and colleagues (24), the long-term success or failure of a community based training programme rests on the nature of the agreement between the stakeholders . Indeed from the interviews, students reported that community involvement was critical in solving their health challenges and attracted their participation and ownership which is important for sustainability. This community involvement to be successful, benefiting both parties and fostering ownership and sustainability, it should start with the planning process of the activities and a dialogic relationship between the two partners (19,25). Overall, community based education has been found to increase service delivery to remote and rural areas through improved retention of workers (21,26), by improving awareness of community values as well as increases trainees' interest in uptake of careers in rural practice (27, 28).

Strengths and limitations of the study
The OHI uses a unique approach to field-based training, in that it is multidisciplinary in nature, while most community based education programs have been conducted mainly by health science students or one discipline (19)(20)(21). In addition, this study captured both the students and communities' views and gains from the OHI attachments. This is in line with the ideal community-based training program being a 'win-win' programme as it provides both the training institution and the service site with additional resources (22).
However, the study had limitations; being qualitative in nature, the findings cannot be generalizable. In addition, having limited number of interviews and lack of pre-experience interview to draw a contrast with the cited post-experience interviews.

Conclusion And Recommendation
The OHI was an attempt to put in practice the recommendations of global movements and the Commission on the Education for health professionals for the 21st century, by redesigning teaching for the future workforce from silo based to multidisciplinary and professional interdependence manner.

Ethics approval and consent to participate
Ethical approval was sought from the Makerere University School of Public Health Higher Degrees Research and Ethics committee to conduct the study. All participants provided informed consent before their participating in the study.

Consent for publication
Not applicable