More than half a century ago, Benjamin Paul set forth a new concept for improving the health of communities by understanding local cultural beliefs that can perpetuate disease and illness (Paul, 1955). His tenet was that if health professionals and others want to change behavior, they must first understand the existing ethnomedical beliefs and values of the community. This is known in anthropology as the “insider” versus “outsider” perspective, and it is largely accepted in public health for the prevention, control, and management of infectious disease (Sommerfeld, 1998; Morris et al., 1999).
Terminology is critical to the insider/outsider discussion. For example, according to Hyder and Morrow (2012), disease in many cultures is seen as a western biomedical, outsider term, while illness is an insider’s subjective expression of not feeling well. The problem Hyder notes arises when the two perspectives come into conflict. In this instance, a person may be diagnosed with a disease such as HIV or hypertension without feeling sick. It is then up to the health care provider to explain why medication or behavior change is necessary when the person does not view him- or herself as sick. This is the sort of insider training that community-based health
1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteur (with acknowledgment of the assistance of staff as appropriate) as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine. They should not be construed as reflecting any group consensus.
professional education is meant to provide. By exposing students to people in their home or community settings, learners gain a greater understanding of the challenges faced by those they serve.
On May 1–2, 2014, members of the Institute of Medicine’s (IOM’s) Global Forum on Innovation in Health Professional Education came together to substantively delve into issues affecting the scale-up and spread of health professional education in communities. This workshop builds upon previous workshops of the Global Forum that specifically addressed the value of interprofessional education for breaking down the siloed nature of health care and health professional education (IOM, 2013, 2014a). The financial and other cost implications of not conforming to more collaborative work that also embraces the person/patient as the key member of the team was also previously addressed (IOM, 2013, 2014b). These workshops not only were instrumental in providing context on which to build, but also set in motion dialogue around the importance of addressing communities and community health, the topic of the workshop described here.
A purpose of the workshop was to challenge the participants to think about community in new ways that could provide fertile ground for educating health professional students. Participants thus heard a wide variety of individual accounts from innovators about work they are undertaking. Some of the examples were from educational institutions working with communities; others represented potential opportunities for education in and with communities. The thinking behind presenting the variety of examples that range from student community service to computer modeling was to stimulate discussions about how educators might better integrate education with practice in communities. This report is not intended to be a comprehensive guide to implementing a community-based educational program. In fact, the report often raises more questions than it answers, as intended by the Global Forum, which was set up to provide a platform for open and creative dialogue and discussion.
The Forum is an ongoing, multinational, multidisciplinary approach to proposing and exploring promising innovations for achieving recommended reforms in the instructional and institutional spheres. Members of the Forum represent varied interests oriented toward a variety of countries, professions, and organizations. They joined forces at the IOM’s Keck Center in Washington, DC, to share personal experiences, explore new ideas, and hear about best practices in community-based health professional education from those who are currently working in this space.
The statement of task in Box S-1 provided the basis on which the workshop planning committee developed the agenda. Both community-based education (CBE) and interprofessional education (IPE) are featured prominently in the task and on the agenda; however, members of the planning committee listed chose to make CBE the main thrust of
Statement of Task for Community-Based
Health Professional Education: A Workshop
There is growing evidence from developed and developing countries that community-based approaches are effective in improving the health of individuals and populations. This is especially true when the social determinants of health are considered in the design of the community-based approach. With an aging population and an emphasis on health promotion, the United States is increasingly focusing on community-based health and health care.
Preventing disease and promoting health calls for a holistic approach to health interventions that rely more heavily upon interprofessional collaborations. However, the financial and structural design of health professional education remains siloed and largely focused on academic health centers for training. Despite these challenges, there are good examples of interprofessional, community-based programs and curricula for educating health professionals. Some of these examples make use of new technologies for reaching rural communities while others use technology for faculty development and still others use it for curriculum delivery to train health professions students. This training can extend to the health professionals and nonprofessionals that are based in communities of need in order to create the necessary workforce that can respond to the community’s identified needs. In this way, the needs of diverse communities are met by those who live in the community thereby improving health equity and decreasing disparities among typically underserved populations.
These issues will be examined in a 2-day public workshop that will be planned and organized by an ad hoc committee of the Institute of Medicine. The committee will develop a workshop agenda, select and invite speakers and discussants, and moderate the discussions. Following the workshop, an individually authored summary of the event will be prepared by a designated rapporteur.
the workshop while IPE was emphasized in many of the discussions. The two should not be conflated. Whereas IPE is often a part of CBE, it is not always part of CBE. Similarly, IPE can be experienced in academic centers and is not exclusively taught through CBE. A possible gap in the statement of task was the lack of a clear connection between service delivery models and education models (e.g., if clinicians are to work together in interprofessional teams, the inherent logic is to have at least some training in how to collaborate and in team-building skills). Similarly, if there is a need for more care to be delivered in the community, there is a logic for more education to be occurring in communities in order to prepare graduates for this work. With that understanding about the elements contained in the statement of task, the planning committee used it as a guide for developing the workshop objectives.
Warren Newton, who is the American Board of Family Medicine representative on the Forum, and Susan Scrimshaw, president of The Sage Colleges, co-chaired the workshop. In his welcoming remarks, Newton described the agenda as having four parts, reflected in each of the four sessions. The first establishes a framework so all the workshop participants have a shared understanding of what makes up a community and what are best practices for engaging community members. The second looks at the core competencies for working with communities and includes the demonstration of a pedagogical tool. The third explores tools and examples for spreading and scaling up community-based education. Lastly, the fourth involves sharing individual lessons learned through participation in this Forum activity.
In looking at the plan for the workshop, Newton emphasized the value of interacting on this topic with such a diverse group. To him, the real power of the Global Forum is in its diversity, which was a main consideration around the structure of this workshop.
ORGANIZATION OF THE REPORT
The four chapters contained in this workshop summary report comprise accounts of the presentations that took place at the workshop. Speakers (whose remarks are noted in the report) were identified by the workshop planning committee members, who were instrumental in determining the focus of the workshop. Appendix B is composed of abstracts that are written versions of the 8-minute webcast presentations provided by some of the members of the Forum or their organizational affiliates. Each abstract is an example of community-based education as defined by the authors, who were given flexibility in defining community-based health professional education (HPE) and in determining the material to be presented. In a similar fashion, Appendix C contains abstracts of posters that were submitted by informed members of the public and were presented during a designated evening session of the workshop. All of the abstracts focused on some aspect of health professional education in communities. A number of them directly addressed spread and scale-up of their program, and although evaluation data and evidence on effectiveness of the community-based interventions were included in some abstracts, the level of detail varied among the abstracts.
Chapter 1 sets the stage for the workshop. In discussions led by co-chair Susan Scrimshaw, there was a constant reminder of the importance of taking health care providers out of the clinic and into the community to get to the source of a community’s health issues. This was emphasized in her examples of inside versus outside perspectives, and underscored by the professionals and community workers who described their experiences
in working in and with communities. Forum members’ reactions to the presenters are captured in the final section of this chapter.
In agreement with Scrimshaw’s remarks that alerted the audience to the risks of a cross-cultural divide, Jusie Lydia Siega-Sur provided her evidence from the University of the Philippines for what is possible when the health providers and the health service share the same context, history, and culture as the community in Chapter 2. This chapter is an overview of competencies needed by health professional students for working with communities as explained by the moderator and reinforced by the two speakers. Each presenter described a community-based educational program. The first drew from experiences in the Philippines, where educators created a stepladder curriculum that is community and competency based. Students who enter the program are recruited and supported by the communities themselves. The second speaker leads an educational program in Maine that uses community health outreach workers who supply a bridge between health providers and their large refugee and immigrant populations. This chapter closes by looking at the structure of education within which community-based programs might exist. Forum member and workshop co-chair Warren Newton begins with a description of the value of debates as a pedagogical tool and then leads a demonstration of debates as an innovative pedagogy for educating health professionals. A global view of the issues raised during the debates is included in this chapter.
Chapter 3 contains a variety of examples that initiate a dialogue around factors that might facilitate the spread or scale-up of innovations in community-based health professional learning on the continuum of education to practice. For the purposes of this workshop, it was explained that spread would mean increasing the number of types of health professionals trained in community settings, and scale-up would mean increasing the number of sites offering opportunities for community-based learning. The moderator laid the foundation for the two presenters who each described their program in terms of spread and scale-up. One involved a global “train the trainer” model for mental health facilitation, and the other was an example of how to build and sustain leadership teams for improving communities’ health systems. Also in this chapter are two examples of how groups have leveraged technology for improving care, population health outcomes, and the value of health care. The first describes the work of organizations in Camden, New Jersey, to help patients recover from harmful medical events, rehabilitate, and then reintegrate back into society. The second is a telehealth solution meeting the health care needs of rural communities in Alaska. Both presentations included the educational component to their work.
Chapter 4 looks at potential impacts and outcomes of work and education in and with communities. It begins with remarks from the Global
Forum on Innovation in Health Professional Education Co-Chair, Afaf Meleis, before going to the small group leaders’ view about discussions that took place during their breakout sessions. The topics and particular models described in these groups were selected to stimulate thoughtful conversations among the meeting participants and not necessarily meant to be used as in-depth case studies. Group 1 looked at community colleges as a model for spreading and scaling up community-based interprofessional education. The example they used to base their discussions was the Lewis and Clark Family Health Clinic in the state of Illinois. Challenges to getting IPE started at community colleges was a key discussion point for this group. Group 2 considered issues around scaling up and spreading community-based, interprofessional, faculty-run and faculty-assisted student-run clinics. This group drew upon work from student-involved dental clinics, Georgetown Hoya’s safety net clinic, and experience from the Nutritional Sciences/Rutgers University student-engaged community clinics. Issues around sustainability featured prominently in this group’s discussions. Group 3 addressed the possibilities of establishing a new type of interprofessional education bringing law enforcement and the health professions together for experiential learning opportunities. To frame their thinking, a representative of the DC Metropolitan Police Department Gay and Lesbian Liaison Unit described the training he received to sensitize police officers to the needs of special populations. The group explored the potential of improving communication between law enforcement and the health professions through a joint interprofessional curriculum. In their report back to the large group, each of the small group leaders described their interpretation of an innovation that was discussed in their small group, along with the challenges and opportunities for spreading and scaling up the innovation.
This chapter closes with a discussion led by the co-chair that reflected upon the lessons learned throughout the course of the workshop. The lessons proposed by individual participants of the workshop included
- Broadening the definition of health,
- Looking carefully at the roles of community health workers,
- Retaining education as a key element for health impacts,
- Evaluating education’s role in impacting health,
- Leveraging global accreditation and licensure, and
- Envisioning the future (the intent of this comment is to start training people for a world that currently exists and anticipate changes for the future).
Hyder, A. A., and R. H. Morrow. 2012. Culture, behavior, and health. In Global health: Diseases, programs, systems, and policies, edited by M. H. Merson, R. E. Black, and A. J. Mills. Burlington, MA: Jones & Bartlett Learning.
IOM (Institute of Medicine). 2013. Interprofessional education for collaboration: Learning how to improve health from interprofessional models across the continuum of education to practice: Workshop summary. Washington, DC: The National Academies Press.
IOM. 2014a. Establishing transdisciplinary professionalism for improving health outcomes: Workshop summary. Washington, DC: The National Academies Press.
IOM. 2014b. Assessing health professional education: Workshop summary. Washington, DC: The National Academies Press.
Morris, M. W., K. Leung, D. Ames, and B. Lickel. 1999. Views from inside and outside: Integrating emic and etic insights about culture and justice judgment. Academy of Management Review 24(4):781-796.
Paul, B. D., ed. 1955. Health, culture, and community: Case studies of public reactions to health programs. New York: Russell Sage Foundation.
Sommerfeld, J. 1998. Medical anthropology and infectious disease control. Tropical Medicine and International Health 3(12):993-995.
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