Method: A qualitative descriptive study was conducted at CBE placement sites of students from the Faculties of Health Sciences of the University of Limpopo (UL), University of KwaZulu-Natal (UKZN) and University of the Western Cape (UWC) during 2010 and 2011. Focus group discussions were held with site facilitators, community leaders and patients, and interviews were audio recorded, transcribed and translated into English where necessary. Data were analysed using NVivo (version 9).

Findings: CBE was seen to benefit communities, students and host institutions as there was perceived improvement of service delivery, better referral to hospitals and reduction of workloads on site staff. CBE was also seen as having potential for recruiting professionals who have better orientation to the area, and for motivating school pupils for a career in health sciences. Students acquired practical skills and gained confidence and experience. Challenges included poor communication between universities and host sites, burden of student teaching on site facilitators, cultural and religious sensitivity of students and language barriers.

Conclusion: The study revealed that communities have an important role to play in the CBE of future health care professionals. CBE activities could be better organised and managed through formalised partnerships.

Contexte: En Afrique du Sud, des étudiants en médecine et en sciences de la santé suivent un enseignement communautaire. Des professionnels de la santé basés sur des sites d’accueil partagent la responsabilité de former ces étudiants conjointement avec un personnel universitaire. Cette étude a analysé les points de vue, les attitudes et les recommandations des communautés sur l’enseignement communautaire suivi par ces étudiants, en vue d’améliorer la qualité du soutien communautaire en faveur de ces programmes.

Méthode: Une étude qualitative descriptive a été réalisée en 2010 et 2011 sur les sites d’enseignement communautaire auprès d’étudiants venant des facultés des sciences de la santé de l’université du Limpopo, de l’université du KwaZulu-Natal et de l’université du Cap occidental. Les discussions des groupes de discussion ont été organisées avec des facilitateurs sur le site, des responsables communautaires et des patients, et les entretiens ont été enregistrés, retranscrits et traduits en anglais si nécessaire. Les données ont été analysées en utilisant NVivo (version 9).

Résultats: L’enseignement communautaire est considéré comme bénéficiant aux communautés, aux étudiants et aux institutions d’accueil en raison d’une amélioration perçue des prestations de service, d’une meilleure orientation vers les hôpitaux et d’une réduction de la charge de travail du personnel sur place. On considère également que l’enseignement communautaire a des effets positifs sur le recrutement des professionnels qui seront mieux orientés vers la région, et sur la motivation des élèves à s’engager vers une carrière dans les sciences de la santé. Les étudiants ont acquis des compétences pratiques, une confiance en eux et de l’expérience. Les défis rencontrés sont une faible communication entre les universités et les sites d’accueil, le fardeau de l’enseignement pour les facilitateurs sur place, les sensibilités culturelles et religieuses des étudiants et les barrières de la langue.

Conclusion: L’étude a montré que les communautés ont un rôle important à jouer dans l’enseignement communautaire des futurs professionnels de la santé. Les activités de l’enseignement communautaire pourraient être mieux organisées et gérées par le biais de partenariats officiels.

A community can be defined geographically or as a social or political construct that can be influenced by its members.² For the purposes of our study the communities were the placement sites where Health Sciences students undertook learning outside the university classroom. Sites included district hospitals, primary health care clinics, non-governmental or non-profit organisations and home-based care. Literature reveals the benefits of this experiential learning to students.³ However, some studies have shown that the relationship between communities and centres of higher learning is commonly one-sided, in that communities tend to be passive recipients of services provided by the students.^4,5In this study the authors intended to create awareness of what is happening in CBE by exploring views and opinions of both recipients and providers of the service.

CBE has been recognised as potentially influencing students’ career choices as well as addressing community health needs: ‘community based training was identified as the main factor shaping values and attitudes of those who were in favour of rural practice, and were confident and willing to work in rural areas.’³In sub-Saharan Africa there is a human resources crisis of skilled health professionals, with poor retention of new graduates in the health professions, particularly in rural areas.^6,7Hence the imperative to better understand CBE, with a view to improving existing programmes and developing new ones.

This is being addressed by researchers globally and in Africa,^6,7,8,9in particular by the likes of Kaye and colleagues⁷ in Uganda, who have looked at both community perspectives and student learning. However, much of the research is discipline-specific and typically refers to CBE in medical or dental education, or focuses on a particular project or context. To our knowledge there has there been no study conducted in South Africa to explore CBE from the community perspective. Studies conducted on CBE focused mainly on services delivery by personnel from institutions of higher learning and student teaching and learning.^8,9 The voice of the community where CBE takes place is yet to be heard.

Facilities were selected as research sites based on the CBE programmes in the Health Sciences faculties/schools at the respective universities; sites were selected through purposive sampling to include both urban and rural sites (UWC’s were mainly rural), as seen in Table 1.

The sites selected across the six provinces were those where CBE programmes for nursing, occupational therapy, speech and language therapy, audiology, pharmacy and physiotherapy as well as for medical students took place for the three universities. Sites not involved in CBE and those where permission to conduct the study was not obtained were excluded.

Content analysis of the data was conducted. The CHEER representative and research intern from each university (six members) plus the national CHEER coordinator conducted more than one reading of the transcripts to identify themes as per the interview guide. A final round of data analysis took place in a peer-debriefing meeting of all collaborating universities, where consensus was reached on major themes and subthemes. To ensure neutrality one collaborating member who did not take part in coding of transcripts led the peer-debriefing meeting. Data analysis was aided by use of NVivo (version 9).

Various strategies were employed to ensure trustworthiness: the researchers interviewed participants in their local languages, audio recorded the interviews and made verbatim transcriptions. Use of data from the transcriptions and field notes ensured triangulation.^11,12

‘Now patients who are seen by the [student] doctors here do not [need] to go to the hospital ... we are happy that our pensioners … will not be going to the hospital but will be seen here’ (SF, UL)

Another perhaps indirect benefit to communities is the potential for recruiting students who are already familiar with the context once they are qualified:

‘I think by exposing them to a rural area they get interested in that field of work and as they have been here it might help us get the very same students to come here’ (SF, UKZN)

Through the exposure students were perceived to acquire clinical skills and gain confidence, making them better prepared for future clinical training and practice:

‘… and you could see the difference when she first came in and when she left, she was much [more] confident and improved clinically as well …’ (SF, UKZN)

Exposing medical students to rural contexts was seen to benefit them by providing an alternative view for future career pathing, in that in such settings competency in general medicine was viewed as important, as opposed to specialisation which was often emphasised in tertiary training centres:

‘I think one of the things [that] are important is that we are also building our doctors for the future, we want to show people that there is another career alternative except for specialising because at medical school they get taught basically idealism: you have to be a gynaecologist or surgeon, that is the main thing they see the whole time. Only when you come here you cannot say this is not my problem, because everything is your problem’ (SF, UKZN)

The site facilitators felt that the programme offered the students good practical experience. There was reciprocity of learning and exchange of knowledge between students and themselves:

‘What they really did there inspired me as well, I also learnt a bit’ (SF, UWC)

‘I think their coming here is very important because whatever there is that is difficult for the [nursing] sisters gets referred to them’ (SF, UL)

‘…on the other hand, they teach us something.’ (SF, UL)

In addition to the students’ own experiences, site facilitators enlisted the students’ services to motivate school pupils for a career in the health care sector:

‘…because like the group that worked with [me], we had to go out to school and talk to children about it. I think it should have a positive impact on the society.’ (SF, UKZN)

‘These [student] doctors are so helpful because there is a shortage of doctors’ (CL, UKZN site)

Community leaders perceived the students as playing a role above that of nursing sisters, and rendering services that could be equated to those of qualified doctors:

‘… people need a doctor urgently because the doctor and sister do different things. That is the importance of doctors, and that is why they need to be in the clinic.’ (CL, UL site)

‘… in my view [student] doctors have more knowledge than what we have in the clinic. There are some problems that the sisters cannot solve’ (CL, UL site)

The community leaders perceived the students as adding service value:

‘So, I think the presence of the students in the community gives more value to the community project [in Genadendal]’ (CL, UWC site)

‘I know they [students] are very involved with the nurses, and the nurses see the benefit of interacting with them in the clinic’ (CL, UWC site)

‘The students have taught the community to do sewing and knitting. Furthermore, they have taught the mothers to generate own income through gardening in their own backyard’ (CL, UWC site)

‘… but with them, they gave me medication and I saw a big difference.’ (CM, UL site)

‘... immediately as you arrive at the OPD, the [student] doctors attend to you.’ (CM, UKZN site)

‘… they [should] let them come more often like perhaps three times a quarter …, that would be helpful’ (CM, UWC site)

They were also seen as helping to reduce the clinic queues, thereby improving quality of service.Unlike the already qualified professionals, community members viewed the students as being patient with clients:

‘I was satisfied the way they checked me, I was satisfied because they did not rush any one, they took a long time checking me…’ (CM, UL site)

‘The way they check, they check in the mouth, the ears, the eyes, my back I have never met a sister who checked me that way’ (CM, UL site)

Communication between the universities and site facilitators as well as between sites and community members appeared to have been a significant challenge.

Some site facilitators reported that universities, for the most part, did not formally inform them of the student programme, and that they were not given guidance as to course structure and content. They were unaware of the duration of stay of each group of students, and were not fully briefed on their responsibility to teach the students:

‘… so I think there should be more information, clearer information because the people may not understand it properly so we [need] to share more information with each other [university and student placement site] so that everyone is on the same page…’ (SF, UWC)

‘… I want more information from the university, students or someone who must explain it to me what the project is all about…’ (SF, UWC)

‘… we are not formally told that [these are] your students, you are supposed to teach them 1, 2, 3. They [students] just introduce them[-selves] to us – that’s all’ (SF, UL)

‘I think it [teaching of students] happens a bit by default because I have been involved and interested in the long time – I am a family physician and probably by default it has been pushed into me because I like doing it.’ (SF, UKZN)

Communication seemed to follow the tradition that students were sent to placement sites year after year, often as a result of individual relationships:

‘I think it is almost unspoken because it develops over a longtime, I think the students have been coming here as long as the rotations have been going on, probably for more than ten years … so I think [that] is what is expected of everybody …’ (SF, UKZN)

Although most community members (leaders and patients) felt the presence of students resulted in much better service delivery, some site facilitators mentioned that students were a burden in the clinics, especially when it was busy and patients needed to be seen fast enough to be able to access transport back home:

‘It is a great learning opportunity for the students but it can be quite a burden on the hosting institution, in a sense that we are busy and our efficiency is impeded by the fact that we have a teaching responsibility as well…’ (SF, UKZN)

Site facilitators also expressed their concerns regarding lack of material and human resources, which affected student training. They indicated that they could not cope with student supervision alone and would have liked to have university lecturers assisting with facilitation:

‘…they should send more facilitators [from the university] or maybe a mentor, they should maybe make more mentors for the student because sometimes it becomes a problem for the sister’ (SF, UL)

‘I see the university as an academic institution with lots of resources … it should not be so difficult for the university to link up with our [hospital] internet system …’ (SF, UKZN)

Various community members appreciated the presence and role of the students in the community health care facilities. However, in some contexts the services offered by students provoked an inflow of patients from other communities not usually covered by that clinic, hence paradoxically increasing the workload:

‘… Although their work is good, their coming caused us a problem because the surrounding areas like Hebron and Mabopane now come here …’ (SF, UL)

Whilst CBE activities were highly valued by the communities, there were challenges in the way they were structured. The site facilitators were of the view that student exposure to practical experience started too late into their course:

‘At least we must have those who are in the second year, third year just like that, just to be exposed earlier because they are doing theory most of the time. If they can mix theory with practical at least to get an idea of what is happening, because you find out that they don’t even know how to take Hb [haemoglobin] or blood glucose and they are doing their sixth year …’ (SF, UL)

Members of communities explained various forms of cultural and religious challenges that they and the students faced in their interaction. Specific cultural practices and religious doctrine may, for example, impact on the manner in which a physical examination of a patient is conducted, or behaviour towards an elderly person:

‘... what he said is right because that is what we deal with Muslim females, they will sit there and when the nurse comes she will say she wants to see a Muslim doctor and they must be aware of that too …’ (SF, UWC)

‘… say like if it is a gogo [granny] who has a gynaecological problem and is looking at this one is too young, “No sister I want to be seen by you, I’m too old to be seen by a young one”… they take it like cultural things you know, a young one must not see the private parts of an elder …’ (SF, UKZN)

The lack of communication made community leaders feel undermined, as they were not in a position to inform the communities they were representing:

‘Yes, S said it well, but you see if things are happening in the clinic and you are not informed as the link between the community and the clinic, one of the thing is that we feel undermined because we can’t even respond to the communities … [to] tell them not to be surprised’ (CL, UL site)

‘They [students] should be introduced especially in the clinics … I need to be honest that they are not introduced in the communities’ (CL, UKZN site)

‘Yes, in the beginning the students held meetings with me and my colleague, they had beautiful ideas to help the community. But afterwards, they organised meetings alone and that did not seem to work’ (CL, UWC site)

Communication with the community members as patients was only hampered by the language barrier:

‘I was praying to get someone who speaks IsiZulu and was lucky so that we could understand each other’ (CM, UKZN site)

‘The biggest barrier is the language’ (CM, UKZN site)

Some site facilitators also remarked on the lack of a sense of responsibility amongst some students:

‘… They will just sit and talk, sometimes they just wait for transport laughing and talking at the same time and then they want your signature …’ (SF, UL)

Furthermore, only very few students were deemed exceptional, ‘who will be confident and competent to go ahead and run the clinic by themselves with minimal supervision’ (SF, UKZN).

Community leaders were well disposed towards the students, viewing them as potential substitutes for retiring doctors:

‘The programme should continue because even the qualified ones, the time will come for them to retire so it is good when the youth study’ (CL, UKZN site)

In some instances community members expressed concerns regarding students’ ability to treat patients:

‘What I heard is that some patients were saying they are sending us students who are going to give us wrong treatment …’ (CM, UL site)

Most recommendations came from site facilitators. They recommended that the university provide them with a curriculum guide, including what was expected in terms of student facilitation; also that there be joint planning between the community and universities on curriculum development and student placement, perhaps through formalisation of the partnership to enable resource sharing:

‘Like I said, we need to be involved and know about each other. If I knew what they really wanted to do and if they could tell me what they expect of me and we network, I think it would be wonderful’ (SF, UWC)

‘We don’t know if what we are doing is good for them’ (SF, UL)

‘I think maybe when the students come here, if they can bring maybe a programme, something in written form to say they are lacking in this section …’ (SF, UL)

There was also a recommendation that students be supported through mentors from universities to capacitate service delivery at the training sites, and for students to work in pairs to support one another:

‘… they should send more facilitators [from the university]; they should maybe make more mentors for the student because sometimes it becomes a problem for the sister because immediately the queue is slow then the patients start fighting and it ends up not being nice …’ (SF, UKZN)

‘When they are paired, I should think it is easy for them to ask each other, support system …’ (SF, UL)

Over and above mentorship, the site facilitators recommended support in the form of resources, new guidelines and new thinking. This would be an encouragement for the site facilitators to assist the students:

‘I see the university as an academic institution with lots of resources … it should not be so difficult for the university to link up with our [hospital] Internet system …’ (SF, UKZN)

Recommendations about programme structure included that CBE should be introduced early in the students’ training, preferably at first-year level, as this would encourage a linkage of theory and practice. That would also increase the students’ self-confidence and enable them to learn to work independently.

The community also recommended an increase in the duration of students’ stay at placement sites to maximise mutual benefit, and that student learning activities be scheduled during ‘off-peak’ hours of a facility:

‘Maybe if they can lengthen the time and if they can spend a little more time, they will get more out of it … because two weeks is short’ (SF, UKZN)

‘… during the night we’ve got plenty of time to teach them …’ (SF, UL)

‘I think during the week, the students aren’t full but I think on weekends they must be more involved in different activities in the community and not just keep office hours 8 am to 4 pm’ (SF, UWC)

The need for continuity of service rendered by the students was expressed in various ways by site facilitators, community leaders and patients:

‘… for the nursing students they are here for seven weeks but they only have one day out of the week that they are working on the project, so at the end of it you are looking at only seven days on which they have to do a project’ (SF, UWC)

The community remarked that students started projects, for example on quality improvement, but could not stay long enough to complete them:

‘… but after they have gone, it is no longer there … there is nothing happening regarding the improvement they have made.’ (SF, UKZN)

Community leaders remarked on the language barrier between students and patients. They recommended basic knowledge of the local languages, such as IsiZulu, Afrikaans, SePedi, isiXhosa and others by students:

‘They should include IsiZulu during their training because they get paid to work in the communities, I cannot be the interpreter’ (CL, UKZN site)

‘… we need these doctors indeed but they should have basics of IsiZulu, it is hurting to see that a child cannot speak IsiZulu’ (CL, UKZN site)

Community members appreciated the continuity of care by a particular student (‘doctor’), which they hoped for when coming for a consultation:

‘… when you come to hospital you know you will get Dr so-and-so but on arrival that doctor is not there, maybe the doctor had helped [you] before, but when the doctor is no longer there you just do not know whom to ask’ (CM, UKZN site)

Community leaders felt that teaching professional behaviour to students was one of the most important tasks of student site facilitators. Hood¹⁵ is of the view that teaching professional behaviour is one of the objectives of CBE. Most responses on students’ behaviour were positive, which enabled patients to feel they could be open and honest and, with few exceptions, patients were satisfied with the services students rendered.

The negative effect of lack of communication with community leaders and therefore with the community at large was the missed opportunity for shared ownership of the programme. Joint ownership with communities has been found to play a significant role in student learning in ‘the community as a classroom’.¹⁷ In this study the concern of community leaders indicated the need for a dialogic relationship between the two partners.

Site facilitators were not formally informed on the student programme, and were not given guidance as to course content. They indicated that they were not aware of the duration of stay of each group of students coming to their sites, they were also not aware of the academic levels of the students they had to facilitate. Neither were they aware of their responsibility to teach the students. This could negatively affect student learning, since it has been shown that staff enthusiasm for student presence enhances student learning experience.¹⁸ It has also been shown that site facilitators prefer coordinated communication between the universities and placement sites both prior to and during clinical placement.¹⁹

Regarding the students’ placement, there was a disproportionate allocation of students to site facilitators, which created a teaching burden. There was also poor communication between the university and placement sites which impacted on proper planning, e.g. provision of teaching space and allocation of manageable student numbers to site facilitators. This was also found by Kristina, Majoor and Van der Vleuten,²⁰ who found ‘few medical schools involved the community in the process of programme planning and evaluation’, resulting in imbalance in student allocation to teaching sites.

Communities expressed concern about the lack of resources, indicating that staff members, equipment to suit different disciplines and budgets were insufficient. They also expressed a desire to be equipped with more formal instruction from the university on how to teach and interact with the students.^6,21

Whilst this was regarded as a challenge, it was simultaneously providing future health care professionals with experience of the context of service delivery within marginalised rural areas, and cultivating understanding of the barriers to and social determinants of health in the rural context.²² Bruning and colleagues²³ state that in poorly resourced settings students experience ‘real world’ lessons and acquire skills that complement classroom teaching, introduce civic responsibility and provide leadership experiences.

Language and cultural competence were seen as a challenge as they play a vital role in professional interaction between students and patients.⁶Some students were working in cross-cultural settings where they had difficulties because of their lack of understanding of local languages. Where nurses assisted with interpretation during the consultation, this increased their workload and became potentially counterproductive.

Improving communication is regarded as the foundation to establishing partnerships. The manner in which this could be addressed includes making students’ curricula available to site facilitators to enable guided student learning, and for the community and academic institution to engage in joint planning in all matters relating to student placement. It is strongly recommended that the partnership be formalised to encourage sharing of resources. The community recognised that their contribution was not merely an input to the project but formed the basis upon which the project would operate. Meyer and colleagues²⁵assert that community- academic partnerships in training of medical professionals can induce a paradigm shift such that physicians view the community as a teaching resource and partner rather than a passive recipient of services or just a placement site.

The Health Sciences faculties have to take the recommendations made by the community seriously. The communities felt that CBE activities should be introduced early in the students’ undergraduate training, preferably at first-year level, as this would link theory and practice. The communities were also of the view that early exposure to practice would increase students’ self-confidence and enable them to work independently. Dornan and co-workers²⁶ found that broadening student experiences within community settings was more beneficial if introduced earlier, and the importance of practical experience in the community is confirmed by Mudarikwa et al.²²

Although we did not find religion and culture to be obstacles to students’ community participation, there is a need for students to have the basics of the community languages. Mbalinda et al.²⁷advise that language and cultural understanding are crucial in the development and maintenance of strong relationships between students and the communities they are training in.

The study recommendations are based on those made by the community members. By improving communication with the host institutions and involving communities in planning of the CBE curriculum, CBE activities could be better tailored to suit the needs of the host health care institutions and academic training institutions. Introducing CBE early in the curriculum is strongly recommended, with a continued and sustained programme throughout the undergraduate curriculum in order to obtain maximum benefit for students and communities alike.

It is also recommended that an in-depth exploration of each institutional approach and CBE programme offered could highlight and give insight into some similarities and differences of implementation amongst the three institutions.

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