Abstract

Background: Community-based medical education (CBME) integrates medical students into real-world community settings to enhance clinical skills, empathy, and understanding of healthcare delivery. This approach helps bridge the gap between theoretical knowledge and practical experience.

Objective: This study aimed to evaluate the quality of the CBME program in the undergraduate medical curriculum at the Faculty of Medicine, Hasanuddin University by exploring students' perceptions and lived experiences.

Methods: A qualitative study with a phenomenological approach was conducted from March to April 2023 at the Faculty of Medicine, Universitas Hasanuddin, Indonesia. The participants were seventh-semester medical students pursuing their Bachelor's degree. They completed open-ended questionnaires, and focus group discussions (FGDs) were conducted to explore their responses in greater depth. All data were transcribed and analyzed thematically.

Results: A total of 12 students participated in focused group discussions. Thematic analysis generated 20 sub-themes categorized into positive and negative perceptions, and 8 themes reflecting students' experiences. Positive perceptions included "improved communication and social skills" and "better understanding of public health issues," while negative perceptions involved "inconsistent supervision" and "logistical challenges." A representative student quote stated, "We learned to truly listen to the community, not just diagnose." Experiences also varied, from "inspiring encounters with marginalized families" to "confusion due to unclear task guidelines."

Conclusion: The study highlights both strengths and areas for improvement in the CBME program. Insights gained may inform curriculum development, particularly in enhancing supervision quality, clarifying learning objectives, and strengthening community partnerships to ensure CBME remains impactful and contextually relevant.

Keywords: Community-based medical education, program evaluation, undergraduate medical education, qualitative research.

INTRODUCTION

Health professionals must provide appropriate community-based patient management, considering the individual's background and community context. Community-based Medical Education (CBME) is a teaching and learning approach conducted directly within community settings. The term implies that students are placed in a community where they engage in the learning process by actively participating in and interacting with the local population [1]. CBME uses the community as a learning environment, actively engaging students, teachers, community members, and other stakeholders to address community needs [2, 3]. Previous research has shown that CBME is more suitable for learning about public health than hospital-based education, as it provides early exposure to community situations and enhances meaningful learning [3].

CBME is an integral part of the undergraduate medical curriculum, complementing classroom and clinical teaching by immersing learners in social and medical communities [2, 4]. Students' experiences in community placements shape their perceptions of the work environment and motivation to achieve learning goals [5]. Following the Indonesian Medical Council and Faculty of Medicine regulations, Hasanuddin University divides the curriculum into academic and clinical phases. The CBME programs are included in the undergraduate phase to facilitate direct community learning [6]. However, the implementation of CBME and students' achievement of learning objectives can be influenced by various factors in the community setting. Since students are the primary consumers of medical education, their evaluation and feedback on learning methods are valuable [7]. Therefore, this study aims to explore medical students' perceptions and experiences regarding the implementation of the CBME program in order to identify strengths, weaknesses, and potential areas of improvement.

METHODS

This qualitative study was conducted at the Faculty of Medicine, Universitas Hasanuddin (UNHAS), a national university located in South Sulawesi, Indonesia, from March to April 2023. This study was approved by the Research Ethics Committee of the Faculty of Medicine, Hasanuddin University, Makassar, Indonesia (Approval Number: 17/UN4.6.4.5.31/PP36/2023, dated April 10, 2023). The Faculty of Medicine at UNHAS offers an integrated medical program (Bachelor-MD). As of the 2022-2023 academic year, the undergraduate program enrolled approximately 1,700 students across seven academic levels (semesters 1 to 7), with around 250-300 students per level. The curriculum is conducted a spiral curriculum, includes basic medical sciences in the first year (1st and 2nd semesters), a transition from basic to clinical theory in the second year (3rd and 4th semesters), and an integrated system of basic and clinical theory in the third and fourth years (5th to 7th semesters). The Competency-Based Medical Education (CBME) program is embedded in the Community Medicine course during the 7th semester, where students are expected to apply their knowledge in real-life community settings. This study uses a qualitative design with a phenomenological approach to explore the lived experiences of medical students participating in the CBME program. Informed consent was obtained from all participants in both written and verbal forms before their participation in the study. Seventh-semester medical students pursuing their Bachelor's degrees at Hasanuddin University were selected as participants. A total of 243 students were enrolled in the Community Medicine course during the study period. These students actively participated in CBME activities, including field investigations, home visits, and health promotion activities. Initially, students conducted field investigations by collecting data at the community health center (Puskesmas) and identifying health issues within the community. As part of their family medicine learning outcomes, students visited patients' homes within the Puskesmas's working area on the second occasion to identify health problems in individuals and their families. In addition to personal and familial health issues, students also observed broader environmental and social determinants of health, including housing conditions, access to clean water, waste disposal methods, and infrastructure such as roads and schools, which significantly affect community health. Subsequently, students analyzed the gathered data, focusing on both internal and external factors related to the identified health issues, as well as environmental and social determinants of health. On the third visit, students engaged in health promotion activities, addressing specific topics at the community health center and other public venues, such as the university's sports arena. They utilized educational media, such as banners or previously created videos, to deliver their health education. The detailed explanation of the research flow is shown in Fig. (1).

This study employed a qualitative methodology involving seventh-semester students as key informants. Purposive sampling was used to select participants in accordance with the research objectives, with sample size determined by the principle of data saturation rather than statistical calculation [8]. Data collection from students was initially conducted through a structured open-ended questionnaire consisting of seven open- ended questions, distributed manually to capture detailed narrative responses. Based on the diversity of responses, 12 students were purposively selected to participate in a focus group discussion (FGD) to further explore and deepen understanding of their experiences [9]. It was specified that pseudonyms were used, data were stored securely, and participants were informed of their right to withdraw at any time. The FGDs were conducted in a classroom within the university's medical education department and were audio recorded for analysis. The primary discussion prompt was: "How did you experience the community-based activities in the undergraduate study program?" Students were asked to provide descriptive answers in an extended textual format, which were then further explored and clarified through FGD. The open-ended questionnaire was developed primarily based on the research objectives and relevant literature. To ensure content validity, the questions were reviewed and validated by faculty experts in community-based learning.

Thematic analysis was performed on both the questionnaire [10, 11] and, FGD data. Open-ended questionnaire responses were transcribed and analyzed using QDA Miner 5.0 software. FGD audio recordings were transcribed verbatim, and MAXQDA Analytics Pro 2020 software was used for thematic analysis [12].

Trustworthiness

Data triangulation was employed using the questionnaire and FGD methods to ensure trustworthiness. Credibility was enhanced by recording participants' voices and transcribing them verbatim. Dependability was achieved by seeking confirmation from participants regarding their perceptions. Transferability was facilitated through a detailed description of the study setting and participants. Conformability was ensured by maintaining an audit trail, researcher triangulation, and supporting themes with participants' quotes [13, 14].

RESULTS

Characteristics of Participants

The subjects in this study consisted of 52 individuals who completed the open-ended questionnaire and 12 individuals who participated in the FGD. The participants included male and female students aged 19 to 23 years old. The details of the subject data, categorized by gender and age, are presented in Table 1.

Open-Ended Questionnaire Results

The open-ended questionnaire responses were analyzed using inductive thematic analysis, resulting in the identification of twenty-nine sub-themes, which were grouped into six overarching themes, and further into two interpretive categories: positive and negative perceptions of the CBME program. These classifications were qualitatively derived based on the content and tone of participants' narratives, without the use of numerical scoring or percentage-based conversion. Positive perceptions encompassed four major themes: interaction opportunities, skill acquisition, learning opportunities, and effective facilitators. Negative perceptions centered around two major themes: system issues and inadequate facilitator roles. Table S1 presents the sub-themes and supporting statements for each theme.

The questionnaire responses also shed light on students' experiences in community-based activities at Hasanuddin University's Faculty of Medicine. Data analysis identified seven themes for positive experiences and six for negative experiences. Table S2 provides the division of themes and excerpts from supporting statements.

Focus Group Discussion Themes

Based on the in-depth exploration of students' perceptions through the FGD and the subsequent thematic analysis, a total of twenty-one sub-themes and six themes were identified within the categories of positive and negative perceptions. The division of themes and several quotes from the FGD recordings are presented in Table S3.

The thematic analysis results and several quote statements from the FGD process regarding students' positive and negative experiences during their participation in community-based activities at Hasanuddin University, categorized into nine main themes, will also be provided in the Table S4.

Final Integrated Themes

After integrating the findings from the open questionnaire and FGD, the final theme was identified twenty sub- themes within the categories of positive and negative perceptions and eight themes were identified within the categories of positive and negative students' experiences as presented in Table 2.

*Categories were classified based on semantic orientation identified through qualitative thematic analysis of narrative responses. The classification does not involve numerical scoring or percentage-based grading.

DISCUSSION

This study explored medical students' experiences and perception of their CBME activities in an undergraduate program study. Through the data collection methods of open-ended questionnaires and FGDs, several themes regarding students' experiences and perceptions were identified.

"What I like is that I can interact with the community, speaking and sharing what we know with the people is something enjoyable." (P36)

Students highly value opportunity for interaction with healthcare professionals and community members in the community health center. This enables collaboration, knowledge sharing, and real-life observation, enhancing their learning experience. Naali found similar perceptions among medical students, where they could establish connections and friendships with healthcare workers and stakeholders during their community placements [15]. CBME offers valuable learning experiences by engaging students with diverse individuals from various social, cultural, and ethnic backgrounds in the community [2].

"This program provides us, as medical students, with the experience to learn how to communicate effectively and appropriately." (P20)

Students also reported acquiring various skills through CBME, including communication, ethics, professionalism, interview/history-taking skills, and health promotion techniques, which are crucial for future healthcare careers. Similar findings were found in a study conducted by Narapureddy et al. [4], where CBME in an undergraduate program was shown to enhance students' socio-humanistic skills such as communication, collaboration, listening, and observation. Another study by Atuyambe et al. [14] found that students were praised by the community and staff for their professionalism displayed through their communication skills and respectful behavior.

"I learned to develop a mindset, innovation, and creativity in solving health problems in the community." (P40)

Community-based activities in undergraduate programs provide valuable early learning opportunities for students, enabling them to identify prevalent health issues and gain a deeper understanding of the social determinants of health (SDH) and contextual factors associated with health conditions [4]. In support, another study shows that community-based pedagogy enhances students' understanding of the influence of SDH on individuals, families, and communities. Students also have the opportunity to observe the healthcare service system and apply theoretical knowledge in practical settings. This approach allows students to bridge the gap between classroom learning and real-world societal needs [15, 16]. However, Yusof et al. found that some students struggled to apply theoretical knowledge in real-life situations, possibly due to insufficient skills or a lack of strategies for application during community- based learning [16, 17].

"The facilitator in my group was very dedicated in imparting knowledge, sharing experiences from community health centers, and providing us with tips and tricks on how to be a doctor working in a health center or rural area in the future." (P45)

Claramita et al. state the importance of teachers in CBME as role models who actively participate and provide constructive feedback [3]. Positive facilitator behaviors, such as sharing knowledge, engaging in discussions and offering guidance, were highly valued by students. However, negative perceptions arose when facilitators were too busy or passive, and when there was a lack of facilitators. The varying student perceptions of CBME activities may be influenced by the different community sites and facilitators encountered by each student group [18]. Insufficiently qualified facilitators in the community may limit the impact of the CBME program, as they need to balance their roles as healthcare providers and educators, potentially hindering students' learning experiences [3, 19]. Similar concerns were expressed by Naali et al., highlighting insufficient supervision and guidance during activities, as some assigned supervisors did not offer adequate support [15]. Another study also revealed limited follow-up and guidance from lecturers, leaving students to independently achieve learning outcomes and address problems encountered during community visits [16]. In contrast, O'Sullivan et al. found that students received extensive supervision, feedback, and revision during their community learning [20].

Students in the study reported both positive and negative experiences in community-based activities. Positive experiences included the unique opportunity to interact with the community, hands-on learning methods, positive responses from the community and healthcare workers, and a sense of community contribution. Being welcomed and appreciated by the community positively impacted students' self-esteem and relationships with healthcare staff, influencing their overall experience [5]. Community-based activities provide students with real-life learning situations that simulate their future professional environment [21].

Furthermore, students in this study reported negative experiences related to distance and access, crowded environments, language barriers, and poor community responses. Another study found similar challenges, including language barriers affecting communication with the community [15]. CBME also presents challenges such as variability in learning experiences, travel time, and negative attitudes [2]. These findings differ from a study where students expressed satisfaction with infrastructure, accommodation, transport, and security [18]. Poor community acceptance may stem from the perceived lack of direct benefits and the community's limited involvement in CBME. CBME's focus on students' competence without considering community needs may treat the community as an object rather than involving them directly and benefiting them [22].

To enhance CBME effectiveness, we recommend offering community incentives, increasing student-community interactions, and strengthening faculty-community health center collaboration. Ensuring consistent schedules, clear guidelines, smaller groups, and pre-implementation surveys will improve engagement. Increasing facilitators will provide better guidance. These align with previous research emphasizing continuous CBME, addressing time constraints, and improving program design and implementation. Building trust, identifying community needs, and maintaining effective communication are crucial [1, 15, 17, 19]. Implementing these improvements will enhance student learning, optimize CBME outcomes, and strengthen faculty-community partnerships.

CONCLUSION

This study provided medical students' perceptions and experiences of the CBME program revealing key strengths such as meaningful community engagement, skill acquisition, learning opportunities, and supportive facilitators. However, it identified areas for improvement, including system-related challenges and inconsistent facilitator roles. These findings provided valuable input for educational institutions to enhance its educational impact and better support students' professional development.

ETHICS APPROVAL

This study was approved by the Research Ethics Committee of the Faculty of Medicine, Hasanuddin University, Makassar, Indonesia (Approval Number: 217/UN4.6.4.5.31/PP36/2023, dated April 10, 2023). All procedures performed in studies involving human participants were following the ethical standards of the institutional and/ or national research committee and the Helsinki Declaration.

CONSENT FOR PUBLICATION

All participants provided both written and verbal informed consent prior to their involvement in the study. Participation was voluntary, and participants were allowed to withdraw at any time without any consequences.

AVAILABILITY OF DATA

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality agreements, but are available from the corresponding author on reasonable request.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

The authors would like to thank all the study participants and Dimas Bayu, MD for helping in the data acquisition process.

AUTHOR'S CONTRIBUTION

Ratih Radiah Iskandar, as the Principal Investigator, was responsible for the conception and design of the study, as well as the acquisition, analysis, and interpretation of data. She also contributed to drafting and critically reviewing the manuscript, provided final approval for publication, and ensured the integrity and accuracy of the entire research process.

Ichlas Nanang Afandi, Asty Amalia Nurhadi, Rina Masadah, Haerani Rasyid, Nasrudin Andi Mappaware, and Irfan Idris, as Co-Authors, were involved in various aspects of the research, including methodological development, data analysis, and drafting and critically reviewing the manuscript. All Co-Authors approved the final version to be published and are accountable for the accuracy and integrity of the research.

As the Corresponding Author, Khaeriah Amru played a primary role in communication with the journal, ensuring that all revisions and responses to reviewer comments were handled appropriately. Additionally, she contributed to the study's concept, data analysis, and manuscript drafting and review.

SUPPLEMENTARY MATERIAL

Supplementary material is available on the journal's website.

GENERATIVE AI AND AI-ASSISTED TECHNOLOGIES IN THE WRITING PROCESS

During the preparation of this work the authors limitedly used ChatGPT (GPT-4, OpenAI) to get language suggestions and do minor proofreading in some parts of the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

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