Community‐engaged primary care medical education

Community‐engaged medical education (CEME) requires medical schools to partner with local communities to help address community priorities, whilst enhancing the learning experiences of students. Current literature on CEME has focused on evaluating its effects on students; however, there remains a gap in exploring whether CEME initiatives can have a sustainable impact for communities.


| BACKGROUND
Medical schools can play a vital role in addressing societal inequalities. 1 This has been reinforced by the World Health Organization, who have defined the need for medical schools to be socially accountable as 2 'the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve'.
Such a shift requires an institution-wide approach to transform its management, admissions, curriculum, learning experiences, community engagement and research priorities. 3,4 The development of socially accountable curricular innovations requires authentic partnership with community stakeholders. Such a community-engaged medical education (CEME) approach has been defined as 5 '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'.
The development of socially accountable curricular innovations requires authentic partnership with community stakeholders. CEME has been extensively integrated in several notable medical schools founded with strong social missions to serve their region's communities, such as in Canada, 6 the Philippines, 7 South Africa 8 and Sudan. 9 The benefits to learners of CEME have been shown to include development of critical-thinking, problem-solving, leadership skills, applied health promotion learning and increased awareness of social determinants of health. 10 However, critique of current CEME projects has highlighted a lack of research on the extent of community impact and sustainability. 11 In 2016, the Undergraduate Primary Care Education team at Imperial College London developed the Community Action Project (CAP). CAP is a community-engaged, quality improvement project completed by all third-year undergraduate medical students, during their eight-week general practice placement, alongside clinical experiences. In this article, we present a review of all projects completed between 2019 and 2021, to evaluate their community impact and understand the breadth of local health priorities being addressed by the projects. The CAP has evolved based on student, community and tutor feedback. Community input into CAP development has been facilitated through the appointment of a community collaboration lead within the team. Students work in partnership with their local general F I G U R E 1 Flowchart demonstrating the three stages of a typical Community Action Project. practitioner tutors, patients and community stakeholders to design and develop their projects, and are supported by guidance from faculty tutors. Upon completion, students present their projects for faculty and peer marking. As the CAP has evolved, we have increasingly emphasised community engagement and sustainability to our students, including through written guidance and inclusion in the marking scheme ( Figure S1). We also broadened the needs analysis to include an asset-based approach, to evaluate strengths and resources available in the community. The development of the CAP is part of a wider initiative of developing an increasingly community-engaged primary care curriculum. Most projects involved creating patient information leaflets or posters, with other common formats including patient education courses, direct patient contacts/discussions, and patient information videos or websites.

| Specific examples of projects
Several projects excelled and sparked conversations in local communities and beyond. One such project, featured two students working with local care homes and the local Clinical Commissioning Group to address low COVID-19 vaccine uptake in health and social care staff.
F I G U R E 2 Percentage of Community Action Projects from 2019 to 2021 demonstrating primary evaluative outcomes.
A qualitative assessment was conducted to understand reasons for poor uptake during meetings with community stakeholders.
An animated video, offered in multiple languages, was then created to specifically address these barriers. 12 Video interviews with community leaders and health and social care staff about their experiences with vaccination, were also created and distributed to care homes. 13 Students organised multiple educational webinars that staff could attend. Local charities and the local authority shared the videos widely on social media, and they were also used by other primary care organisations. Of 50 staff survey respondents, 84% said they would be more likely to accept the COVID-19 vaccine after watching the videos. This award-winning project has since been presented at a national conference 14 and promoted by the UK Department of Health via their social media platforms.
Another project identified using needs analysis and patient interviews, that there was a gap in T2DM health education within the local Arabic-speaking population, which was further linked to belowaverage medication adherence. An information leaflet was created in English and Arabic, explaining T2DM medication, and was distributed to all patients with T2DM in the practice. Following this, the students developed and delivered in-person seminars with local translators, educating patients on lifestyle and medication management of T2DM.
A diabetes charity was also engaged to help develop this project. Preand post-project patient surveys revealed significant improvements in patient understanding and decreased concern around medication side-effects. 15

| Implications
We believe the CAP model of CEME is of key relevance to health educators and students. It offers a practical, simple model of service-learning, where students can contribute to the health of local communities, whilst undergoing professional and personal development. Despite the risk of disengagement during the early stages of the COVID-19 pandemic, through remote-working with clinicians, community stakeholders, and patients, students were able to develop projects responding to key community priorities at the time, including vaccination uptake and mental health concerns.
Students can contribute to the health of local communities, whilst undergoing professional and personal development.
A key strength of the CAP is that it can provide CEME whilst integrating seamlessly into an existing clinical primary care placement. The main challenge facing both educators and students in delivering the CAP is the limited time students have to complete projects, alongside other competing clinical commitments. This also meant that impact could only be assessed within the 8 weeks, and sustainability could only be assessed on the students' plans to continue their projects beyond the placement. An additional challenge has been in establishing stronger relationships and collaborations between students and community members, partly due to the project's limited time. Some students did not involve any community members in their CAP, and most limited this involvement to patients and not wider community groups.
Possible evolutions of the CAP to address these challenges include placing students directly in contact with relevant community members at the start of the CAP, as has been shown in other CEME innovations 6,7 ; however, this could diminish an authentic aspect of students identifying their own priority groups based on their needs analysis. Other possible enhancements to our community engagement include involving community members in the presentation and marking of projects and in establishing an advisory committee to steer the CAP development.

| Limitations
We acknowledge that there are important limitations to this study.
Firstly, there was a lack of community stakeholder representation in the analysis of CAPs. Using a more community-engaged approach would be valuable in assessing for meaningful community involvement and impact. Secondly, whilst the CAP provides an example of a community-engaged curricular innovation, a whole institutional approach is required for true social accountability, addressing all aspects of higher education. 6-9

| Future Steps
This study lays the groundwork for further studies to explore the impact, and facilitators and barriers of CEME approaches in undergraduate primary care education. We suggest that qualitative research is required, assessing the impact of the CAP from community and student perspectives. Additionally, a longitudinal study assessing community impact would help us understand whether projects lead to lasting impacts beyond the placement.