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Community-engaged medical education: helping to address child health and social inequality
  1. Ravi Parekh,
  2. Arti Maini,
  3. Bethany Golding,
  4. Sonia Kumar
  1. Medical Education Innovation and Research Centre, School of Public Health, Imperial College London, London, UK
  1. Correspondence to Dr Ravi Parekh, Medical Education Innovation & Research Centre, School of Public Health, Imperial College London, London W6 8RP, UK; r.parekh{at}imperial.ac.uk

Abstract

Medical education has a key role in helping to address child health and social inequality. In this paper we describe the rationale for developing a community-engaged approach to education, whereby medical schools partner with local communities. This symbiotic relationship enables medical students to experience authentic learning through working with communities to address local health and social priorities. Case studies of how such approaches have been implemented are described, with key takeaway points for paediatric healthcare professionals wanting to develop community-engaged educational initiatives.

  • primary health care
  • paediatrics
  • child health
  • child health services

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Children’s health and social inequality in the UK

The COVID-19 pandemic has highlighted increasing inequalities in the UK, particularly affecting children’s health and education. Research has demonstrated the negative impact for children from disadvantaged backgrounds on educational access, educational progression, mental and physical health, and food insecurity.1 The impact on physical health spans problems accessing care, chronic disease management and immunisation delays.2 Studies show a particular concern with delayed paediatric presentations related to diabetes, mental health, safeguarding and sepsis.3

These negative impacts of the pandemic are on a background of worsening inequality in paediatric health outcomes and increasing levels of poverty.4 Asthmatic control, infant mortality rates and levels of severe obesity have all been shown to be worse in children from poorer families.5–7

The role of medical education

There is a building momentum calling for medical education to consider what role it can play to address health and social inequalities. Leaders in medical education have called for a significant and fundamental shift in medical education to develop more socially accountable medical schools.8 This has been defined by the WHO as:

the obligation of medical schools to direct education, research and service activities towards addressing the priority health concerns of the community, region or nation that they have a mandate to serve.9

This definition highlights how medical education may itself be an important approach to help address some of the health and social inequalities faced by children in the UK. Social accountability in medical education describes the need to develop a symbiotic relationship between medical schools and communities, whereby both sides gain; medical students experience authentic opportunities that enhance their learning and professional development, while students add value for the communities with whom they partner.10 This mindset considers medical students not only as future healthcare professionals (HCPs), but as current active participants and change agents within their local communities.11

This shift in education requires institutions to ensure that the students entering medical school are diverse and representative of the wider population, while also providing an inclusive and nurturing higher education experience for all students to progress and thrive during their medical student journey. In higher education more broadly, children from the most affluent fifth of families in the UK are 10 times more likely to attend ‘high status’ institutions than those from the poorest fifth.12 Within the medical profession, there are significantly higher proportions of applications to UK medical schools from independent (fee-paying) schools than state schools.13 The aspiration for the medical workforce to be representative of the general population in the UK has yet to be achieved, with 51% of the most influential doctors in the profession being educated at fee-paying schools.14

What is community-engaged medical education?

To put into practice some of the core principles of social accountability, several medical schools globally have embarked on community-orientated, community-based and community-engaged medical education (defined in box 1).15 These approaches in medical education have increasing levels of engagement with local communities to inform curriculum design, delivery, assessment and evaluation.

Box 1

Glossary

  • Social accountability: the obligation of medical schools to direct education, research and service activities towards addressing the priority health concerns of the community, region or nation that they have a mandate to serve.9

  • Community-orientated medical education: medical education activities that address topics in community health but still take place in traditional academic settings.15

  • Community-based medical education: medical education activities that take place in community settings but do not directly engage the community in the design, conduct and/or evaluation of these activities.15

  • Community-engaged medical education: medical education activities that directly engage members of a community in their design, conduct and/or evaluation so as to meet the needs of the community in some way and to enhance the experience or outcomes of the learners involved.15

At the community-orientated end of the spectrum, there may be faculty-led campus-based teaching on health inequalities and the social determinants of health impacting communities. At the community-engaged end of the spectrum, curriculum innovations are codesigned with local community members in a way which addresses community concerns and priorities and builds on local assets.

Taking an example of child food insecurity, a community-orientated approach may include lectures or workshops designed by university faculty discussing the evidence and impact of child food insecurity in the UK. A community-based approach may involve discussion with a supervisor around the impact of child food insecurity, having seen a family affected in a clinical setting. A community-engaged approach may involve students partnering with relevant stakeholders such as local food banks and community organisations to codevelop and evaluate a community-led project addressing a community-identified priority. All three types of approach add value to a medical curriculum. However, community-engaged medical education additionally recognises that communities themselves should be involved from the outset, as they are best placed to understand the assets and priorities within the local area.

Community-engaged medical education involves acknowledging the value of community-engaged approaches as part of a strategic vision, committing sufficient resource to adopt coordinated, sustainable approaches and developing trusted relationships with local communities.

Implementation in practice

Based within Imperial College London’s School of Public Health, the Undergraduate Primary Care Education team and the Medical Education Innovation and Research Centre are designing and implementing a community-engaged primary care curriculum. This curriculum enables students to collaborate with local communities on a range of priority child health and social inequalities, such as educational access and attainment, food insecurity, childhood mental health, health literacy, sexual health, menstrual health and vaccine hesitancy. There is a dedicated community collaboration lead, enabling us to build trusted relationships with local groups working with children and young people. The community collaboration lead has engaged with youth councils and centres to work collaboratively on course materials for students, teaching plans and project ideas.

Listed below are some case examples which demonstrate how we have implemented a community-engaged approach in our educational innovations:

Working with local schools

Medical students are often involved in extracurricular outreach; however, there are often limited opportunities for students to engage with and learn from outreach activity during curriculum time itself. We have developed a programme where medical students partner with local schools to design, develop and deliver health-based teaching sessions for local primary school pupils. These sessions are designed and delivered in collaboration with school and community partners, informed by the priorities of the local school and the students’ medical curriculum (see box 2 for details).

Box 2

Working with local schools: case study

The project

  • Several schools in our local area in North-West London have described wanting to work more closely with our university to help expose their pupils to relatable, diverse and inspiring role models drawing from students in higher education. We designed an optional module where medical students work in partnership with schoolteachers at a local primary school, based in an area of deprivation, to design and deliver STEM (science, technology, engineering & mathematics) -based teaching sessions.19

Evaluation

  • Medical students produced written reflective entries detailing their experiences and interviews were conducted with the schoolteachers to explore the impact of the project on the school and pupils.19 Results showed medical students benefited from developing key transferrable skills including leadership, teamworking, science communication, deeper knowledge of their curriculum and creative thinking, while providing school pupils with science-based teaching and aspirational, relatable and diverse role models.19 20

Next steps

  • Building on the success of this programme, we are now launching a larger scale project working with the local council where medical students partner with a number of local secondary schools to design and deliver teaching on topics directly related to students’ MBBS curriculum, such as children’s mental health, sexual health and physical well-being. The students will be supported by university faculty, local school leaders and community partners to design inclusive and interactive teaching sessions.

Community-engaged quality improvement projects

Clinical placements provide an ideal opportunity for students to get involved in impactful quality improvement activity, engaging with the local community to address health and social priorities. Students learn about health inequalities through real-world projects that make a difference, and the local community and health system benefit by students adding local capacity in addressing health priorities and disparities.16

During a longitudinal primary care placement, we have developed the Community Action Project, connecting medical students with local communities to help address a tangible community health priority (see box 3 for details).

Box 3

Community-engaged quality improvement: case study

The project

  • During their GP (general practice) placement, a pair of students identified challenges with engagement and satisfaction of young people in the practice population, particularly those with long-term health conditions. The students discussed these concerns with young patients in the practice. Working in collaboration with these young people, the students suggested the development of ‘Youth Champions’ in the practice to provide young people a platform to have a voice to discuss their concerns and consider how these can be addressed.

Evaluation

  • A ‘Youth Champion’ system was set up in the local practice, and engagement with the process evaluated by the medical students and practice. Iterative improvement has enabled the practice to increase engagement with their younger population.

Next steps

  • Several community-engaged projects have been presented and published across a number of conferences and journals. During the pandemic, students have focused on issues such as mental health, social isolation and vaccine hesitancy. We are continuing to expand community-engaged quality improvement projects across the medical curriculum in all our undergraduate primary care courses.

Panel patients

Longitudinal integrated clerkships rest on the principles of continuity with patients, supervisors and across specialties.17 Students on such educational programmes learn through working with and being involved in the care of a panel of patients who they follow over a year across healthcare settings, including hospital appointments, investigations, home visits and GP (general practice) appointments. The students build relationships with their patients, supporting the patient journey and taking on advocacy roles where required, providing a much-needed bridge link between primary and secondary care to the benefit of the student, patient and health system. Working with patients in this way reinforces students’ medical knowledge, development of person-centred skills and experience of managing uncertainty and complexity.18 Often these ‘panel patients’ will be children and their families, ranging from newborn babies to adolescents, including those with long-term conditions, disabilities or complex social backgrounds. Such educational initiatives require careful supervision and logistical planning; however, such experiences can be transformational for students (further details and examples are provided in box 4).

Box 4

Longitudinal community-engaged programmes

UK example

  • Many paediatric patients with long-term conditions or complex social backgrounds are at risk of ‘falling through the net’ as they navigate through complex patient journeys across multiple healthcare settings.

  • We developed a course placing a pair of medical students in local GP (general practice) surgeries where students were able to support a panel of patients over a year through home visits, secondary care appointments, emergency admissions, investigations and primary care reviews.

  • Results from student focus groups showed how working with longitudinal panel patients provided students with authentic learning experiences, enhanced their understanding of patient journeys and increased their knowledge of healthcare systems.18

International example

  • The Northern Ontario School of Medicine based in Canada has been founded with a socially accountable mandate to provide ‘undergraduate and post graduate medical education programs that are innovative and responsive to the individual needs of students and to the healthcare needs of the people in Northern Ontario’.

  • One of the examples of how this is achieved is in the development of their longitudinal programme, the ‘Comprehensive Community Clerkship’, whereby students are placed in pairs in rural communities to live and learn in small groups within the local community. Students cover a range of specialties including child health.21 Research has shown how such a model can help students in their transition to clinical learning and in developing their professional identity as a physician.22

Relevance to paediatric HCPs

All HCPs play a role in addressing child health and social inequalities. The Royal College of Paediatrics and Child Health’s ‘State of Child Health’ report highlights the need for paediatricians to continue to advocate and take an active role in supporting research and innovation to tackle child health inequalities as a key priority.4

Paediatric HCPs are integrated into local child health community networks and are often involved at local, regional and national levels in both undergraduate and postgraduate education. Therefore, in addition to their clinical commitment in addressing child health inequality, paediatric HCPs could also consider ways of applying some of the community-engaged principles outlined in this article within their educational roles across undergraduate and postgraduate healthcare education (boxes 5 and 6). Community-engaged medical education has the potential to provide rich and meaningful experiences for learners and local communities, equipping our future healthcare workforce with the knowledge, skills and values to sustainably address child health and social inequalities, in partnership with local communities.

Box 5

How to put community-engaged approaches into action

Below are some ideas for how paediatric healthcare professionals may take community-engaged approaches forward:

Initial engagement and planning

  • Engage with diverse local community organisations working with young people and with young people themselves, for example, local schools, youth clubs and societies, and young people from protected groups (BAME, LGBTQ+, with a disability, etc), to better understand their local priorities and assets.

  • Codesign new educational innovations in partnership with local community organisations to address community priorities and maximise assets while meeting curricular aims for students.

Implementation

  • Codeliver educational innovations with local community organisations working with children and young people tailored to community priorities.

  • Provide opportunities for learners to follow up ‘panel patients’ over time so they can understand how social determinants impact on child health and the role of doctors in advocacy, while providing service to local children and families.

  • Develop quality improvement projects which focus on addressing health disparities in a community-engaged way.

Evaluation

  • Ensure you have robust evaluation strategies to demonstrate effectiveness of new educational innovations for both educational merit as well as community impact.

  • Ensure that evaluations consider community perspectives and that what is being measured is what matters to them.

  • Publish, present and disseminate your work to as many different audiences as possible to help drive further change.

Strategic level

  • Find like-minded individuals to work with, particularly those involved in health policy and educational leadership roles.

  • Engage with your local, regional or national education leads in the undergraduate and postgraduate settings to consider strategic approaches to embedding community engagement activity.

  • BAME, black, Asian and minority ethnic.

  • LGBTQ+, lesbian, gay, bisexual, transgender and queer (or questioning) and others

Box 6

Further resources

  • Students’ Toolkit on Social Accountability in Medical Schools 23: a toolkit for students on social accountability created by the International Federation of Medical Students Associations.

  • TheNET: The Training for Health Equity Network 25: a global collaborative of committed partners sharing a vision of targeting education, research and service programmes designed to meet the health and social needs of underserved communities; contains several resources, with article, guides and frameworks to instigate change (https://thenetcommunity.org/).

Ethics statements

Patient consent for publication

References

Footnotes

  • Funding This report is supported by the National Institute for Health Research Applied Research Collaboration Northwest London.

  • Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

  • Competing interests SK and RP work as consultants for the FCDO on the Better Health Programme, Mexico, focusing on curriculum development and community-engaged medical education (2020–2021).

  • Provenance and peer review Commissioned; externally peer reviewed.