Abstract
Background and context
Community-Based Education (CBE) integrates practical experiences within community settings to deepen students’ understanding of real-world issues. In July 2023, the University of Global Health Equity (UGHE) launched the Global Community-Based Education (G-CBE) program, designed to immerse international students in diverse settings across Rwanda and enhance their grasp of social determinants of health, community health and social medicine.
Objectives
This study explores the experiences and perceptions of the first cohort of the G-CBE program at UGHE. It aims to evaluate how the program influenced the learning, career development, and understanding of community health for the 10 participating students.
Methods
Qualitative methods were employed, including 10 in-depth interviews (IDIs) to gather insights into the participants’ experiences and the perceived benefits of the G-CBE program.
Key findings
Students reported gaining a comprehensive understanding of social determinants of health, developing a strong appreciation for community-driven approaches, and acquiring practical skills through hands-on experiences. The program also broadened their global health perspective and heightened their awareness of health inequities.
Conclusion
The findings underscore the significance of immersive community-based learning in global health education. The students’ experiences will inform ongoing improvements to the G-CBE program, enhancing its effectiveness in preparing future health professionals.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-024-06418-7.
Keywords: Community-based education, Global health, Experiential learning, Health equity, Social determinants of health
Introduction
Community-based education (CBE) is an innovative approach to learning that engages students directly with communities, offering practical experiences that enhance their understanding of real-world issues. This educational model has garnered global recognition for its ability to foster active learning, critical thinking, and practical skill development [1]. In CBE, medical schools leverage the community as a dynamic learning environment. This approach fosters interaction among students, healthcare professionals, and community members, allowing students to understand social determinants of health, appreciate community power, and learn how to effectively partner with local communities [2, 3]. By immersing students in real-world settings, CBE bridges the gap between theoretical knowledge and practical application, ensuring that future health professionals are well-prepared to tackle the challenges of global health [4].
Since its founding in 2015, the University of Global Health Equity (UGHE) has integrated CBE as a core element of its medical and master’s programs. This approach blends practical, community-focused experiences with academic learning to deepen students’ understanding of real-world health issues [5]. As emphasized by the late Paul Farmer and others, effective healthcare education must bridge the gap between public health and clinical medicine through a comprehensive approach that includes social medicine. With such an orientation, physicians might be better positioned to accelerate health system improvements and advocate for greater health equity globally [6, 7].
Hosted by the Department of Community Health and Social Medicine at UGHE, the CBE program enhances classroom learning with hands-on community experiences. This model helps students understand that health extends beyond hospital walls to include factors such as access to food, medicine, and other social determinants. Medical students engage directly with community health workers in rural villages near UGHE’s campus, participate in home visits, and shadow healthcare professionals at local health centers. These experiences provide valuable insights into the realities of healthcare in under-resourced settings [8].
UGHE’s community engagement strategy has established strong, mutually beneficial partnerships within Burera District, including with Butaro Hospital and other local health centers. This place-based learning approach highlights the importance of community involvement in healthcare education. In recognition of its impactful work, UGHE received the ASPIRE to Excellence Award in place-based health professions education from the Association for Medical Education in Europe (AMEE) in 2022 and was ranked eighth out of 117 sub-Saharan universities for teaching, research, and social impact by Times Higher Education in 2023 [8, 9].
In July 2023, UGHE launched the Global Community-Based Education (G-CBE) program, extending its innovative educational model to a global scale. The “Global” designation reflected the program’s focus on international students, providing them with the opportunity to immerse themselves in diverse settings across Rwanda. The inaugural cohort of the G-CBE included 10 students from various academic institutions worldwide, marking UGHE’s first experience offering CBE to such a diverse international group. The program combined 30% classroom-based learning with 70% field-based experiences. These field activities were concentrated in rural areas of Rwanda, including Burera District in the north, Rwinkwanvu in the east, and selected locations in the south. Students engaged with exemplary health interventions and decentralized healthcare services, working closely with healthcare professionals and Community Health Workers (CHWs), who played a crucial role in the Rwandan healthcare system. This immersive experience helped students understand the social determinants of health, community dynamics, and effective local partnerships.
The G-CBE program offered a thorough understanding of healthcare systems, highlighting their strengths, challenges, and best practices. By integrating theoretical knowledge with practical experience, the program equipped students to address global health issues effectively. It fostered a deep appreciation for community-driven approaches and provided insights into the cultural, social, and economic factors influencing health outcomes. Through community-based quality improvement projects, students developed essential skills in project management, needs assessment, and community engagement. The program’s exposure to health challenges in resource-constrained settings broadened students’ global health perspectives, preparing them to tackle complex issues in diverse environments.
As this was the first time UGHE introduced a CBE experience to an international cohort from multiple universities, it presents a unique opportunity to explore the benefits and challenges of this approach. No prior research has examined the experiences and perceptions of such a diverse international group within a CBE framework. This study aims to fill this gap by investigating the perspectives of the inaugural G-CBE cohort. Insights gained from the study will be crucial for evaluating the program’s impact on students’ learning and career development and for informing future refinements to enhance its effectiveness and contribution to global health education.
Methodology
Research design
This study utilized a phenomenological research design to explore and understand the lived experiences of participants in the G-CBE program. This design was chosen to capture the essence of participants’ perceptions and the impact of the program on their educational and professional development [10].
Data collection
Setting
Data collection took place in convenient locations within the Partners in Health facilities at the Rwinkwavu site in the Eastern part of Rwanda.
Participants
The study included 10 students who were admitted to the inaugural cohort of the G-CBE program. The participants represented a diverse group from countries including Haiti, the USA, Canada, Kenya, and Nigeria. Of the 10 participants, 8 were female and 2 were male. In terms of academic backgrounds: five participants were enrolled in medical school, two were pursuing nursing degrees, one was studying social work, and two were focused on global health.
Interview process
A semi-structured interview guide was developed for this study, drawing on a thorough review of literature on community-based education programs to identify key areas relevant to our research. Data collection occurred at the end of a three-week module in July 2023. Each student participated in an in-depth, semi-structured interview designed to elicit their views on the benefits and impact of the Global CBE program [11]. Audio recordings of these interviews were securely stored on a dedicated research team computer.
Data collectors
Three data collectors, who were not previously familiar with the G-CBE program, conducted the interviews. They received training prior to data collection to ensure the effective execution of the data collection process.
Ethical considerations
Participants were informed that their participation was voluntary and that they could withdraw from the interview at any time without any negative consequences. Informed consent was obtained before the interviews. The confidentiality of participants’ identities and responses was maintained, with data used solely for research purposes.
Data analysis
Thematic analysis was used to identify, analyze, and report patterns within the data [12].The process began with the transcription of the audio recordings from the interviews, which were then input into Dedoose software for systematic analysis. Initially, the research team conducted open reading of the transcripts. This involved three pairs of team members reading and re-reading the transcripts to familiarize themselves with the content and identify preliminary patterns and concepts. The team then developed an initial codebook, which included a set of codes representing significant features of the data. These codes were applied to a subset of transcripts to test their applicability and refine their definitions. Through iterative discussions and adjustments, the codebook was revised to better capture the nuances of the data. Once the final codebook was established, it was used to code all the transcripts systematically. This process involved organizing the data into meaningful categories and identifying recurring themes related to the students’ experiences and perceived benefits of the Global CBE program. Thematic analysis enabled the team to explore and understand how students experienced and valued the program, highlighting key aspects that contributed to their learning and development. The analysis was a collaborative effort, with regular team meetings to discuss and refine the thematic findings. During data analysis, the research team engaged in reflexive activities, such as writing memos and maintaining journals [12–15].
Results
The findings identified several key themes and sub-themes related to participants’ experiences in the G-CBE program. The four major themes are attitudes toward healthcare systems, knowledge acquisition and insights, development of practical skills, and behavioral transformations, each of which includes sub-themes that highlight different aspects of participants’ reflections on their learning and experiences.
Theme 1: attitudes toward healthcare systems
The attitudes toward healthcare systems theme encapsulates participants’ motivations, values, and perceptions about the healthcare system, which were notably influenced by their field experiences. The two sub-themes under this theme are inspiration from Rwanda’s decentralized health system and Partners in Health (PIH)’s Mission and recognition of the limitations of classroom-based learning.
Sub-theme 1.1: inspiration from Rwanda’s decentralized health system and PIH’s mission
Participants frequently remarked on how deeply they were inspired by Rwanda’s healthcare model, particularly its decentralized structure and the mission of PIH. These factors motivated them to engage more actively in the program and align their personal values with the goal of improving healthcare access for underserved populations. A recurring sentiment was that Rwanda’s success in healthcare and PIH’s global vision helped participants see themselves as part of a larger, transformative movement toward equitable health access.
One participant
noted: “I was deeply inspired by how Rwanda has built a healthcare system that is accessible even in the most remote communities. This model of healthcare resonates with the mission of PIH, which I admire.”
Another participant reflected
“The vision of Dr. Paul Farmer and the work of PIH really sparked my passion for providing healthcare in a more holistic and equitable way. It has completely shaped my career aspirations.”
Sub-theme 1.2: recognition of the limitations of classroom-based learning
A prevalent observation among participants was the recognition of the limitations inherent in traditional classroom-based learning. Many expressed that theoretical education alone often failed to provide real-world insights into the complexities of healthcare systems, emphasizing the need for more practical, hands-on learning. One common reflection was that field experiences they undertook during the G-CBE program offered a level of understanding and connection to healthcare delivery that no textbook could replicate.
A participant
said “Classroom-based learning sometimes feels disconnected from the real-world challenges we face in healthcare. The G-CBE program was the bridge that made it all click for me.”
Furthermore, another participant
noted “You can read about healthcare systems and policies in class, but when you see the community engagement in Rwanda, you understand it on a much deeper level.”
Theme 2: knowledge acquisition and insights
The knowledge acquisition and insight’s theme capture the expansion of participants’ understanding of healthcare systems, particularly in low-resource settings. The two sub-themes under this theme: understanding the role of CHWs and health system dynamics and field experiences—illustrate the knowledge gained through both theoretical instruction and field exposure.
Sub-theme 2.1: understanding the role of CHWs
A key takeaway for participants was the vital role that CHWs play in ensuring healthcare accessibility at the grassroots level. Many noted that they had not fully appreciated the scope and significance of the CHW role before their field experiences, with several participants acknowledging the complexity and importance of CHWs in overcoming barriers to healthcare access.
One participant
shared: “I never fully appreciated the role of CHWs until I saw them in action. They really are the backbone of healthcare delivery in underserved areas.”
Another participant
mentioned: “CHWs are essential in these settings. They don’t just provide medical care; they build trust, educate the public, and empower the community to take charge of their health.”
Sub-theme 2.2: health system dynamics and field experiences
Participants frequently highlighted the value of field experiences in broadening their understanding of healthcare system dynamics. One recurring insight was the realization that healthcare delivery must adapt to meet the unique needs of each community, which helped participants gain a deeper appreciation for the complexities involved in healthcare provision.
One participant
shared: “Visiting rural health centers and seeing how health systems function in low-resource settings opened my eyes to the real challenges healthcare professionals face.”
Another participant
noted: “The field experiences really taught me about the dynamics of healthcare systems. You can study policy in class but seeing how it works on the ground was an entirely different experience.”
Theme 3: development of practical skills
The Development of practical skills theme focuses on the enhancement of participants’ practical and interpersonal skills through the G-CBE program. This theme is divided into the sub-themes; practical skills in healthcare delivery and capacity building and interprofessional collaboration, which emphasize participants’ growth in both clinical competencies and teamwork in healthcare settings.
Sub-theme 3.1: practical skills in healthcare delivery
Participants consistently emphasized the importance of gaining practical healthcare delivery skills through hands-on engagement in real-world settings. These experiences allowed participants to deepen their clinical knowledge and build confidence in patient care, something they felt was not achievable through classroom learning alone.
A participant
mentioned that: “Working directly in healthcare settings gave me invaluable experience that textbooks can never provide. I gained confidence in providing care to patients.”
In the same vein, another participant
shared “This program taught me so much about practical healthcare delivery, from conducting health assessments to understanding the challenges of healthcare provision in resource-limited settings.”
Sub-theme 3.2: capacity building and interprofessional collaboration
The program also facilitated the development of participants’ ability to work in interdisciplinary teams, emphasizing the significance of collaboration with healthcare workers, community members, and local leaders. Several participants acknowledged the valuable skills gained in communication and cultural competence, which enhanced their ability to work in diverse healthcare settings.
One participant
reflected “The interprofessional collaboration during this program was a game changer. It taught me the importance of working with others who bring different expertise and perspectives.”
In alignment with this perspective, another participant
added “I developed so many new skills in communication, especially in diverse settings. Learning to collaborate effectively with healthcare teams and communities was invaluable.”
Theme 4: behavioral transformations
The Behavioral transformations theme focuses on the shifts in participants’ behaviors and attitudes toward healthcare after engaging with community-based healthcare practices. The two sub-themes under this theme are empowering communities for sustainable health solutions and adopting a holistic approach to healthcare, which reflect the transformative impact of the program on participants’ perspectives and future professional practices.
Sub-theme 4.1: empowering communities for sustainable health solutions
A recurring theme in participants’ reflections was the importance of community empowerment in achieving sustainable health outcomes. Many students observed the active involvement of Rwandan communities in healthcare initiatives and expressed how this participation was essential for ensuring long-term health improvements. The local engagement led participants to a stronger belief in community-driven healthcare solutions.
One participant
said: “Witnessing how local communities in Rwanda actively take ownership of their healthcare has truly empowered me. I saw CHWs encouraging community members to go for screenings for chronic conditions like diabetes and hypertension, and more importantly, educating the community about lifestyle changes to prevent them. This hands-on, community-driven approach showed me that lasting health solutions are born from within the community itself, where people learn to manage and prevent chronic diseases, reducing reliance on external healthcare providers.”
Another participant
highlighted: “The experience of seeing how Rwandan communities collectively contribute to their community-based health programs was eye-opening. Everyone I spoke to perceives community-based health insurance as a shared responsibility. This unity and local ownership have made me realize that sustainable healthcare solutions are rooted in community strength. Indeed, health improvements are best achieved when the community takes the lead.”
Sub-theme 4.2: adopting a holistic approach to healthcare
One of the most noted behavioral transformations was the shift toward a more holistic view of healthcare. Participants spoke about how the G-CBE program had expanded their understanding of healthcare to include not just the medical needs of patients but also the broader social, environmental, and cultural factors influencing health. This approach emphasized the interconnectedness of healthcare, community development, and social services.
In reflection, one participant
mentioned “This program has fundamentally transformed my perspective on healthcare. It’s no longer just about treating physical illness but about addressing the social, environmental, and cultural factors that influence health. I’ve learned that healthcare is a dynamic, interconnected system where the well-being of individuals is tied to their community and environment.”
Another participant
highlighted " The experience of learning about Rwanda’s patient-centered approach to healthcare made me realize the importance of looking at healthcare holistically. It’s about focusing not only on preventing and treating illnesses but also considering all aspects of a person’s well-being. This approach has shifted my attitude towards a more integrated and balanced perspective on healthcare.”
Discussion
Our findings underscore the positive impact of the G-CBE program on students’ educational journeys and career trajectories. Real-world exposure through community health initiatives significantly influences students’ motivation and shapes their career aspirations in global health [3, 16].
This is consistent with existing literature, which highlights the transformative effects of field-based learning. Research consistently shows that direct engagement with community health work not only enriches students’ understanding of healthcare challenges but also strengthens their commitment to global health careers [17]. Vučković and colleagues found that experiential learning significantly boosts enthusiasm for health-related studies and careers, fostering personal growth and global engagement [18].The G-CBE program mirrors this trend by emphasizing hands-on learning, complementing theoretical knowledge to develop competencies essential for effective healthcare practice [19, 20]. Dong and colleagues also highlight that experiential learning enhances students’ ability to translate knowledge into practice, fostering a deeper understanding of complex issues [21].
The G-CBE program’s structured curriculum, with 30% classroom teaching and 70% community-based fieldwork, facilitates this transformation. Students begin with foundational knowledge from experts and transition to hands-on experiences in diverse settings, such as home visits, health facilities, and local institutions. These placements expose students to healthcare practices in underserved areas, helping them gain relevant insights and develop a comprehensive understanding of healthcare delivery. The integration of reflection sessions, journaling, group work, and presentations encourages critical thinking, adaptability, and culturally sensitive healthcare practice [4, 22]. This approach models UGHE’s existing CBE framework, which emphasizes community engagement and real-world application of healthcare knowledge for both medical and master’s level students. They engage directly with local healthcare providers and community members in over 15 field-based learning sites, enabling them to experience first-hand the challenges of healthcare delivery in rural contexts.
Our findings also reinforce the critical role of community empowerment and collaborative partnerships in achieving sustainable health outcomes. Participants’ recognition of the impact of grassroots involvement and interdisciplinary collaboration resonates with the literature on the effectiveness of community-driven approaches in improving health outcomes [22]. The emphasis on community-led initiatives and collaborative efforts observed in the G-CBE program reflects a growing body of evidence suggesting that local engagement and partnerships are essential for addressing health disparities and promoting sustainable health solutions [23, 24].
Building on this, the strong endorsement of the G-CBE program’s community-centered approach and contextual learning by students emphasizes the importance of aligning educational practices with real-world applications. Participants’ experiences affirm the value of incorporating community engagement into educational curricula, which resonates with research highlighting the significance of contextually relevant learning experiences. Such experiences are crucial in preparing students to tackle complex healthcare challenges. By effectively bridging theoretical knowledge with practical application, the program demonstrates how integrating real-world experiences enhances students’ understanding and readiness to face real-world challenges. This approach underscores the pivotal role of contextualized education in developing healthcare professionals who are not only culturally competent but also empathetic and equipped to meet the diverse needs of the communities they serve [25–27].
In conclusion, our study provides compelling evidence of the benefits of community-based and experiential learning in shaping future healthcare professionals. The insights gained from the G-CBE program align with established literature on the importance of practical experience, community empowerment, and inspirational models in healthcare education.
Strengths and limitations
This study provides valuable insights into the G-CBE program, highlighting its key strengths. The qualitative approach allows for a detailed exploration of participants’ experiences, providing a rich understanding of how community-based education, integrated with theoretical learning, impacts students’ motivation and career aspirations in global health.
The study also identifies specific challenges faced by students. First, the physical demands of navigating rural communities led to fatigue among participants unaccustomed to extensive walking. Additionally, language barriers presented difficulties; while some Rwandan healthcare providers speak English, Kinyarwanda remains the primary language among community members, CHWs, and many local practitioners. This linguistic gap required students to adapt quickly, often relying on translation, which impacted their direct engagement with certain stakeholders. These challenges, however, were integral to the learning process, as students developed strategies to overcome them, enhancing their adaptability and cultural sensitivity.
The study’s limitations include potential biases from self-reported data and the challenge of generalizing findings due to the program’s unique context. Elements like the rural location and partnerships with local health facilities and grassroots organizations may not translate directly to other settings.
Conclusion
The findings from this study underscore the importance of integrating community-based education with academic learning to enhance students’ professional development and career aspirations in global health. The insights gained from participants underscore the value of practical, real-world experiences in enhancing students’ engagement and commitment to the field. These findings contribute to the broader understanding of how experiential learning can influence future healthcare professionals and provide guidance for developing similar educational programs.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We extend our heartfelt thanks to the inaugural cohort of the G-CBE students who participated in this study and to the PIH Rwinkwavu site for facilitating the data collection.
Author contributions
S.I. led the research proposal, data collection, analysis, and manuscript writing. F.B., G.I., D.N., A.U., and N.R. participated in data collection and analysis, and contributed to reviewing and writing the manuscript. Their support has been crucial in advancing this important work. All authors reviewed and approved the final manuscript.
Funding
The research did not receive any funding.
Data availability
Data from this article is available upon reasonable request to the authors. Sandra Isano is the corresponding author and will make the data available.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the University of Global Health Equity Institutional Review Board (Ref: UGHE-IRB/2023/041). The research team ensured that all research records were securely stored in a locked file. Written informed consent was obtained from all participants prior to their involvement in the study.
Consent for publication
Not applicable.
Clinical trial number
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data from this article is available upon reasonable request to the authors. Sandra Isano is the corresponding author and will make the data available.