Developing a community-oriented curriculum in medical education is a complex endeavour that requires careful consideration of various determinants to ensure its effectiveness and relevance. This study delved into eight critical determinants that play a pivotal role in shaping a curriculum that is rooted in the needs and priorities of the community it serves. These determinants encompass a wide range of factors, including relevance to community needs, priority health problems, integration of the curriculum to reflect community orientation, community involvement and empowerment, cultural sensitivity, social accountability, incorporation of health systems science, and collaboration with community organizations and local government health authorities.
Each of these determinants interacts with one another, creating a dynamic framework that shapes the overall design of a community-oriented curriculum. The curriculum must not only be responsive to the health needs of the community but also empower students with the necessary skills and knowledge to address those needs effectively. It requires a delicate balance between clinical expertise and a deep understanding of the socio-cultural context in which healthcare is provided.
While the concept of a community-oriented curriculum holds immense promise, its implementation is not without challenges. The transition from traditional medical education to a curriculum that emphasizes community needs and engagement demands a fundamental shift in pedagogical approaches, faculty training, and institutional priorities. Obstacles such as resistance to change, resource limitations, and the need for continuous evaluation and adaptation can pose significant hurdles.
This discussion seeks to explore these eight determinants in detail and shed light on how they interact to shape a community-oriented curriculum. Moreover, it will address the challenges and obstacles that educators, institutions, and students may encounter during the process of curriculum development and implementation. By understanding the intricacies of these determinants and acknowledging the potential challenges, we can pave the way for a more effective and impactful community-oriented medical education that ultimately benefits both aspiring healthcare professionals and the communities they serve.
Suggested Determinants of Community-oriented Education:
Determinant. 1: Relevance to Community Needs
Relevance to community needs is a cornerstone of community-oriented education, fostering active citizenship and a positive community impact [16–46]. To ensure this relevance, conducting a needs assessment involving diverse stakeholders is essential [10–11–15–46]. Methods include community surveys, focus groups, leader interviews, and data analysis [17]. This information informs a curriculum tailored to community health concerns and objective-oriented modular systems. For instance, if a community shows high rates of obesity, the curriculum may include modules on healthy habits and physical activity [18]. Creating an education strategy that is rooted in the needs of the community is crucial not only for empowering individuals to make positive changes within their own communities, but also for building stronger and more resilient communities [22].
Despite its potential, obstacles exist. Comprehensive assessment and incorporation of community priorities can be challenging [27]. Faculty may lack skills in community-based pedagogies [28], and building enduring community relationships demands time and resources [21]. Students may resist community mandates affecting core content mastery. Tailored curricula may appear academically less rigorous than standardized ones. Translating community needs into defined competencies and assessments poses methodological challenges. Communities may feel burdened by continual student placements and projects, and balancing local relevance with global health perspectives presents tensions. Proactive measures, like faculty development, student orientation, and community capacity building, can help navigate these challenges [34].
Determinant. 2: Priority Health Problems: Selection, Prioritization, and Incorporation in the Curriculum
Identifying priority health concerns for effective healthcare planning and resource allocation is essential. To integrate these into the curriculum, data must be gathered and analyzed, ranking issues by factors such as prevalence, preventability, treatability, burden of illness, and economic impact [11–47]. The curriculum should then address these ranked problems, equipping graduates to address major health challenges in their communities. Regular reviews and updates of priority issues are crucial for maintaining curriculum relevance [1].
While aligning curricula with health concerns offers benefits, barriers exist. Determining priorities necessitates community engagement and consensus-building, which can be resource-intensive [21]. Limited access to updated community health databases hampers data collection [27]. Prioritizing certain topics risks marginalizing others in packed curricula. As health needs evolve, curricula require continual updating which demands flexibility [22]. Balancing community relevance and academic rigor remains a challenge that necessitates ongoing negotiation.
Determinant. 3: Level of Integration of the Curriculum to reflect Community Orientation
Efficiently integrating community orientation in medical education requires precise alignment of all curriculum components with community health priorities and necessary competencies [19]. At the course level, explicit objectives, content, and assessments can promote the application of knowledge and skills to local issues [21]. Innovative teaching methods, like community visits and projects, offer experiential learning, exposing students to community needs [27]. Clinical placements in community settings provide early exposure to diverse populations [48]. Capstone projects addressing real community problems in collaboration with local partners can enrich applied learning experiences [22]. Students may face challenges such as resource limitations, unforeseen circumstances, communication barriers, and stakeholder conflicts, necessitating guidance from faculty and community partners [42].
Moving beyond individual courses to a program-wide commitment to community focus requires embedding community orientation from curriculum inception [20]. Institutional values, faculty development, student assessment, and graduate competency frameworks should reflect this commitment [23]. Ongoing community engagement ensures curriculum evolution in response to local needs [15]. Comprehensive integration of community-oriented principles across the curriculum and learning environment equips graduates to collaborate effectively with communities for improved local health and equity.
However, full integration faces challenges. Balancing competing priorities, logistical complexities of community placements, relationship-building, student workload concerns, faculty resistance, fragmented curricula, and community fatigue are potential barriers [21, 27, 28, 22, 49]. Proactive measures like coordination, faculty development, student orientation, and community capacity building are essential for successful community orientation integration in medical education.
Determinant. 4: Community Involvement and Empowerment
Community involvement and empowerment are essential for socially accountable curricula [25]. To create culturally appropriate and relevant curricula, community members must be genuine partners in design, implementation, evaluation, and improvement. Overcoming participation barriers like language, culture, time constraints, access limitations, and power imbalances is crucial [27–50]. True community involvement empowers them to set the agenda, respecting their values and engaging them in the process [51–52].
In a community-oriented medical curriculum, the empowerment approach relies on starting from life experiences, recognizing human values, and connecting with historical memory and community identity [25]. This foundation ensures respect for community values, active community involvement, and acceptable resource utilization. The goal is to empower the community to address their health needs. Such curricula foster students' recognition of community members as experts and co-educators, enabling them to understand social determinants of health and promote community well-being [1–53].
However, barriers like time constraints, power differentials, resistance from students and faculty, and community dynamics can impede full community involvement. Students may lack understanding and receptiveness towards community co-education [21]. Curricula co-created with communities may appear less rigorous and standardized [25]. Faculty may, on the other side, resist perceived encroachment on their curricular authority and expertise [15]. Developing reciprocal relationships demands time, trust-building, and addressing access barriers. Proactive measures, such as bidirectional communication, transparency, capacity-building, and power-sharing, are essential for maximizing the benefits of community empowerment in medical education [22, 40].
Determinant. 5: Cultural Sensitivity
Cultural competence education in community-oriented curricula must be complemented by cultural safety principles to address power imbalances and systemic discrimination in healthcare [29–54–55–56]. Developing competence involves shifting from culture-blind to culture-centred approaches [30]. Strategies include immersive community fieldwork [1–22], teaching cultural health beliefs and historical context [31–57], diverse faculty recruitment [58], collaboration with cultural organizations [59], and community involvement [60]. Competence is assessed through knowledge, skills, attitudes, and practice integration [1–61], with continuous evaluations for inclusiveness [29].
However, competence alone risks reductionism without the lens of safety. Cultural safety aims to create respectful, empowering care environments [62]. This requires self-reflection, power redistribution, and lifelong learning from communities [33–63]. Integrating cultural safety and competence helps students understand how culture affects health beliefs, addresses systemic care barriers, and aligns care with community priorities [32–64–65–66]. Challenges include terminology, pedagogies, resources, and partnerships, but sustained culture-centred education fosters graduates who deliver equitable, socially accountable care [67].
Barriers may hinder realizing the potential of cultural education. Faculty may lack expertise in cultural pedagogies and partnerships, requiring training [68]. Developing reciprocal community relationships takes time and trust-building. Students may react defensively to confronting privilege and racism [30]. Curricula may prioritize knowledge over lifelong learning skills, with assessment tools lacking sophistication to evaluate competences as cultural competency [56]. Cultural immersion may risk voyeurism without critical reflection [33]. Translating learning into clinical settings marked by systemic inequities is challenging [31]. Also, conceptual ambiguity surrounds terminology for culture-centred education [29]. Recognizing these challenges can help navigate them through dialogue, humility, and community engagement. Leadership's sustained commitment is vital for culturally safe, socially accountable care.
Determinant. 6: Social Accountability and integrating Community Research and Health Economics into the Medical Curriculum
Social accountability aligns education, research, and services with community health needs, emphasizing social responsibility, responsiveness, and accountability to improve community outcomes [19–24–69]. Accountability assessment involves evaluating relevance, quality, cost-effectiveness, and equity [23], aided by tools like the social accountability grid, THEnet framework, and Boelen's CPU model help evaluate schools’ societal alignment [70–71–72] underpinned by the excellence benchmarks set by the Association of Medical Education in Europe (AMEE) [73]. Strategies to foster accountability include incorporating it into institutional missions and values [21–74], community-engaged education, [50] interprofessional training [75–76], community governance involvement [35–77], and advocacy for addressing social barriers [36–78].
Integrating community-based participatory research and health economics principles enhances social accountability [36–79–80–81]. Participatory research, engaging community members in addressing priority health issues, can drive positive change [82]. Analysing healthcare access, costs, and delivery through a health equity lens aligns with community needs [83].
Despite its potential, social accountability faces barriers, including power imbalances, logistical challenges, sustainability, and dissemination in participatory research [36]. Conceptual ambiguity and tool limitations exist, but sustained partnerships and community-engaged education enhance schools' understanding and address local priorities while upholding social justice values [84]. Health economics principles like cost-effectiveness analysis may conflict with community priorities and social justice aims [85]. Lastly, frameworks to evaluate accountability are subjective and underdeveloped [72]. Curricular integration, faculty development, student orientation, and refined evaluation metrics help maximize social accountability despite obstacles. Ongoing critical reflection and dialogue with partners maintain ethical engagement and mutually beneficial outcomes [78]. Assessing progress in socially accountable practice requires understanding students' evolving views on accountability, fostering their comprehension of societal responsibility [20].
Determinant. 7: Incorporation of Health Systems Science in Community-oriented Curriculum
Medical education historically prioritized basic and clinical sciences, but health systems science (HSS) is transforming curricula by formalizing systems-level competencies [85]. Accreditors now require systems-based practice training [38]. HSS expanded as a “third pillar” alongside basic and clinical sciences, encompassing competencies like healthcare policy, public health, teamwork, health IT, value-based care, quality improvement, and systems thinking. HSS facilitates authentic learning experiences producing “systems citizens” able to collaborate across health teams and organizations, aligning with community-oriented medical education (COME) aims of broader community and system perspectives [37][48]. COME’s experiential community learning aligns with HSS and systems citizenship [38]. Shared competency frameworks demonstrate the synergies between HSS and COME [85]. Incorporating HSS helps achieve COME’s systems-level, community, and accountability goals [86]. Challenges include limited faculty expertise, complex competencies, insufficient partnerships, superficial coverage, difficulty translating classroom HSS principles to under-sourced community settings, complex assessments of HSS competencies, and rigid cultures. Strategies like faculty development, community engagement, curriculum mapping, authentic projects, and competency evaluation can maximize HSS-COME synergies despite barriers.
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Determinant. 8: Collaboration with Community Organizations and Local Government Health Authorities
Partnering with community organizations enhances relevance and impact of medical education [42]. Local collaborations provide insights into health issues, priorities, challenges, and solutions [88]. Community partners contribute authentic perspectives shaping culturally sensitive curricula [40]. This approach improves outcomes through education tailored to local needs [43]. Curricula developed with communities equip students to address diverse patient needs, social determinants, inequities, and drive positive change [88]. Ongoing partnerships have substantial benefits including advancing equity and inspiring transformative change [45]. Aligning with the public mission to serve embedded communities [22], engagement signifies social responsibility and justice-oriented education [88]. Examples like Detroit Urban Research Centre demonstrate impactful collaborations addressing health inequalities [88]. Global initiatives in South Africa, Tanzania, India, Philippines highlight successes [87–88]. However, challenges exist including differing priorities, lack of trust, limited funding and resources, staff turnover, bureaucracy, logistics, transportation barriers, and inadequate training [22–40–42–43–87–88]. Proactive communication, administrative support, funding, participant orientation, and relationship building can overcome barriers to realize collaboration benefits [45]. To incentivize medical schools to prioritize community engagement, accreditation agencies could require evidence of impactful relationships for maintaining accreditation [45]. This could be coupled with policy changes mandating partnerships with underserved communities, recognizing partnerships for career progression metrics, and offering technical support for high-quality engagement. A combination of top-down mandates and bottom-up capacity building can drive progress in establishing impactful community engagement as a core mission of medical education [22].