Learning from the community: early medical students’ territory-based immersion with community health agents in Brazil

Abstract

Background

Early immersion of medical students in Primary Health Care (PHC) settings is vital for fostering socially accountable medical education. In Brazil, PHC is territorially organised, and Community Health Agents (CHAs) play a central role in mediating healthcare delivery. However, pedagogical descriptions of supervised, CHA-led student immersion experiences remain limited. This study addresses this gap by presenting an interpretive qualitative analysis of a structured, territory-based immersion designed for first-year medical students.

Methods

Between March and October 2025, seventy-six first-year medical students participated in a structured territory-based immersion across eighteen PHC units in Luís Eduardo Magalhães, Bahia, Northeast Brazil. Integrated into a Problem-Based Learning (PBL) curriculum [Supplementary File 3], CHAs acted as co-educators. Students documented their learning in reflective journals, structured response forms, and formal assessment responses (∼45,000 words); all 76 enrolled students contributed to the corpus without exclusions [Supplementary File 4]. Data were analysed using Reflexive Thematic Analysis (RTA) as both the methodological framework and analytical method, following Braun and Clarke’s six-phase framework [1, 2] and the RTARG reporting standards [3], underpinned by an interpretivist epistemology and informed by situated learning [4], Mezirow’s transformative learning theory [5], Fink’s taxonomy of significant learning [6], and Freirean critical pedagogy [7] as sensitising concepts. Analytical quality was assured through independent coding by two researchers, structured dialogical engagement, reflexive memoing, and triangulation across three complementary data sources, the first of which encompassed student-generated materials produced under three distinct conditions of accountability.

Results

Three interconnected themes emerged: (1) Territory as a living determinant actively shaping health beyond abstract notions; (2) CHAs and the interdisciplinary PHC team as relational facilitators and legitimate knowledge holders, enacting a distributed knowledge model that integrates specialised expertise with local knowledge, challenging traditional educational hierarchies, and promoting horizontal collaboration; and (3) Emergence of empathy and social awareness, catalysed by reflective engagement and pedagogical tensions, including students’ initial anxiety, emotional confrontation with structural inequality, and progressive development of critical empathy through CHA mediation and structured debriefing.

Conclusions

Early, structured immersion experiences mediated by CHA co-educators deepen medical students’ contextual understanding of PHC and foster essential humanistic competencies. These outcomes were inseparable from the emotional tensions, structural challenges, and critical dimensions of the experience—including initial anxiety, boundary discomfort, and the gap between structural awareness and agency—which are analytically significant dimensions of the learning process rather than peripheral to it. Grounded in situated learning, transformative learning theory, and critical pedagogy, this low-cost, scalable model offers a transferable approach to socially accountable medical education, especially for resource-limited settings. Future research should examine longitudinal impacts and the perspectives of CHAs as co-educational partners.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09858-5.

Background

Primary Health Care (PHC) constitutes the foundation of Brazil’s Unified Health System (Sistema Único de Saúde — SUS)—a constitutional right established in 1988 [8]—structured through territorially based, community-focused strategies, particularly the Family Health Strategy (FHS) [9–11]. PHC organisation is grounded in the concept of territorialisation: the systematic mapping of geographically defined responsibility areas by health teams to integrate social dynamics and local health needs [12, 13]. Within this framework, Community Health Agents (CHAs) function as essential mediators between households and health services [14–18].

For international readers, the Brazilian CHA role demands specific contextualisation: it is legally mandated by federal law [19], structurally embedded, and qualitatively distinct from community health worker roles in most other PHC systems. Each CHA holds continuous, longitudinal responsibility for a micro-area of approximately 750 residents—performing systematic household visits, monitoring priority population groups (pregnant and postpartum women, children, individuals with chronic conditions, and socially vulnerable older adults), conducting health surveillance and environmental risk assessment, carrying out active case finding, and providing culturally mediated health education [19–21]. Crucially, CHAs in Brazil are trained to perform basic clinical monitoring procedures during home visits, including blood pressure measurement, capillary blood glucose assessment, and anthropometric monitoring, alongside health education activities that span topics from immunisation adherence to mental health awareness and medication management [20, 21]. These activities position CHAs not merely as social navigators but as front-line operationalisers of clinical and preventive care within households—a role with no direct structural equivalent in most international PHC systems. This breadth of function is central to understanding why CHAs constitute uniquely powerful co-educators for medical students seeking to understand comprehensive, longitudinal, community-based care.

This educational encounter is further contextualised by a fundamental principle of Brazilian PHC: the National Primary Health Care Policy (PNAB) [10, 21] establishes resolutividade—the capacity to resolve health problems at the primary care level—as a core directive. Brazilian PHC is expected to address the substantial majority of health needs without referral to specialist care, acting as the coordinating hub of the health system [11, 22]. Medical students who observe PHC in practice—accompanying CHAs in households and debriefing real cases with faculty—develop an understanding of this comprehensive care mandate that didactic instruction about referral pathways cannot replicate.

Community-Based Medical Education (CBME) situates learning in community contexts to foster social accountability, early engagement with health inequalities, and critical awareness of structural determinants [23–26]. Three theoretical frameworks jointly inform this study. Situated learning [4] and place-based education [27] hold that knowledge is inseparable from the contexts of its production: the living territory is not a backdrop for learning but an active epistemic space. Mezirow’s transformative learning theory [5] provides a framework for understanding how disorienting dilemmas—experiences that destabilise prior meaning frameworks—initiate critical self-examination, perspective transformation, and revised professional action. Fink’s taxonomy of significant learning [6] identifies six interacting dimensions of deep learning—foundational knowledge, application, integration, human dimension, caring, and learning how to learn—all of which community immersion is specifically positioned to activate.

Freire’s critical pedagogy [7] provides the overarching political-epistemological orientation. In this study, immersion in the community territory is understood as a transformative act in which students confront power asymmetries, recognise the epistemic legitimacy of non-biomedical knowledge, and develop critical consciousness (“conscientização”)—the capacity to “read the world” as a site of structural inequality requiring ethical commitment and transformative praxis [7]. Critically, Freirean pedagogy does not project a comfortable or linear learning path: it frames the frustration, disorientation, and sense of limited agency that students encounter as necessary dialectical moments in the development of critical awareness, not as pedagogical failures to be managed away.

Prior literature documents positive outcomes of early community exposure—increased empathy, enhanced social determinants awareness [28–30]—but frequently underexplores the emotional complexity, structural contradictions, pedagogical tensions, and power dynamics that accompany these outcomes [31]. Early patient encounters, including home visits, are well documented as generating a wide range of affect-laden responses, positive and negative [32], and first-year immersion experiences have been shown to constitute fertile ground for professional identity formation precisely when structured with adequate faculty support and community mediation [32]. Published literature on CHA-co-facilitated, territory-based immersion specifically designed for first-year undergraduate medical students remains limited, and reflexive qualitative analyses that attend simultaneously to transformative and critical dimensions of such experiences are scant. The present study contributes to this emerging evidence base by offering an interpretive qualitative account grounded in the Brazilian Family Health Strategy—a model with structural features that distinguish it from community health worker programmes in most other PHC systems—with potential transferability to international CBME contexts.

Methods

Study design

This is an interpretive qualitative study employing Reflexive Thematic Analysis (RTA) as both the methodological framework and the analytical method [1, 2]. Within an interpretivist paradigm, knowledge is understood as socially situated, co-constructed, and contextually embedded; the aim is to generate theoretically informed interpretations of meanings and experiences rather than to evaluate outcomes as an intervention [33]. RTA was selected for its capacity to support inductive, theoretically driven exploration of complex experiential data while maintaining methodological coherence, reflexive transparency, and interpretive depth—qualities directly aligned with the RTARG standards for qualitative reporting [3]. The central analytical question guiding this study was: what meanings do first-year medical students construct from structured, CHA-mediated territory-based immersion, and what do these meanings reveal about the pedagogical conditions—reflective structure, CHA mediation, faculty support, and theoretical grounding—that may support durable reorientations in professional identity, structural health literacy, and socially accountable clinical reasoning? This question connects the analytical corpus—students’ reflective narratives, faculty debriefing records, and field observations—to the interpretive process and to the theoretical frameworks informing the analysis.

Setting and socioterritorial context

The study was conducted at the School of Medicine, Sulamérica Faculty, Luís Eduardo Magalhães, Bahia, Brazil, March–October 2025. The municipality of Luís Eduardo Magalhães presents a dynamic social and health territory, characterised by rapid urban expansion and the coexistence of diverse socioeconomic realities and community organisations. The municipality maintains an expanding Primary Health Care network, including Basic Health Units, Family Health Strategy teams, specialised services, a Psychosocial Care Centre (CAPS), an Emergency Care Unit (UPA), and a municipal hospital, with the ongoing aim of broadening access and care coverage for a continuously growing population. In this context, the territorial immersion enabled students to understand PHC beyond isolated epidemiological indicators or material conditions, recognising the SUS as a relational practice constructed in everyday encounters between professionals, CHAs, families, and the community. The experience provided contact with different ways of living, falling ill, caring, and accessing health services, contributing to a broader understanding of the social, cultural, familial, and territorial determinants of the health-disease process and of the formative potential of community-based learning. The immersion was integrated into first-year courses per the official curriculum syllabus (Supplementary File 4) and formally coordinated with the Municipal Health Secretariat (Supplementary File 5).

Prior student preparation

All students completed 80 h of mandatory preparatory training before territory entry, covering: SUS history and principles; PHC structure and FHS; territorialisation as a health method; the Programa Agente Comunitário de Saúde; social determinants of the health-disease process; health surveillance; promotion; planning; and intersectoral action [9, 10, 16, 17]. Students also received preparation in ethics, humanised communication, and professional conduct for fieldwork, including appropriate institutional attire with identification lanyard, confidentiality obligations, restrictions on unauthorised photography or recording, and respectful conduct within household environments [34, 35]. Prior to each field session, student groups participated in a structured territorial mapping exercise using digital mapping tools populated with CHA-provided data on priority population groups—including pregnant women, individuals with hypertension, diabetes, and other chronic conditions—enabling students to contextualise subsequent household encounters within a pre-existing epidemiological and social map of the micro-area. This preparation ensured students entered the territory equipped with both conceptual frameworks and territorial knowledge, not as uninstructed visitors. Completion was a prerequisite for participation [36–38].

Participants and immersion structure

Seventy-six first-year medical students (aged 17–22) were organised into groups of five to ten students, assigned to eighteen FHS PHC units, and paired with CHAs responsible for specific micro-areas. Three structured phases were implemented:

• Phase 1 — Preparatory Theoretical Module: Foundational preparation in SUS, PHC, territorialisation, social determinants, and CHA roles [9, 10, 14, 16].

• Phase 2 — Supervised Field Immersion: Students accompanied CHAs on territorial walks and longitudinal family follow-ups (Fig. 1). CHAs functioned as co-educators, mediating access, contextualising local dynamics, and modelling community-based relational practice. Upon return from each field session, students reunited with faculty supervisors at the PHC unit for structured group debriefing sessions (Fig. 2). These sessions used real cases observed during the visit—anonymised and contextualised—as the basis for discussion: what was observed, what surprised students, what clinical and social dimensions emerged, and what questions arose from the encounter. This case-based debriefing model, in which faculty await students’ return and facilitate structured reflection on real community cases, is consistent with validated models of case-based learning integrated with supervised reflection in primary care settings [39–41]. Faculty supervisors also randomly monitored groups in the field to ensure ethical conduct and pedagogical support.

• Phase 3 — Reflective Consolidation: Students maintained structured reflective journals, participated in guided group discussions, and delivered integrative seminars [39, 40].

Fig. 1.

Territorial walk with Community Health Agents (CHAs). Medical students accompany CHAs during territorial immersion, observing the community environment firsthand. (Photo credit: Z.F.B. Paschoalini, 2025)

Fig. 2.

Post-visit structured debriefing at the PHC unit. Immediately after returning from territorial walks, students reunite with faculty supervisors in a circle at the health unit. The faculty member facilitates discussion of real cases observed during the visit—anonymised and contextualised—connecting field observations to theoretical content. This structured debriefing was a core pedagogical element of each field session. (Photo credit: Z.F.B. Paschoalini, 2025)

Data sources

The analytical corpus comprised three complementary data sources, collectively generating approximately 45,000 words of analysable text. The first and primary source consisted of individual written materials produced by all 76 enrolled students across the full immersion period, encompassing three subcategories produced under structurally distinct conditions of accountability: reflective journals (unstructured narrative accounts written after each field session, private and exploratory in nature), structured response forms (a five-part semi-structured instrument addressing initial impressions and emotional responses, territorial and community learning, the CHA and health team role, medical training and personal transformation, and reflective commitment), and written open-ended responses to formal assessment questions directly addressing themes covered in the course syllabus [Supplementary File 4], including the role of CHAs, the interdisciplinary PHC team, and territorial health determinants, produced under conditions of academic evaluation. This internal differentiation meant that even within a single source type, cross-condition comparison was possible. All 76 enrolled students contributed materials to the corpus; no students were excluded from analysis. The curriculum-embedded, group-based structure of field activities—with subgroups of five to ten students per CHA—ensured that even students absent on specific dates had participated substantively in the immersion through their group’s collective engagement. The second source comprised eighteen faculty-produced debriefing session summaries, documenting the collective thematic patterns emerging from structured group discussions held at the PHC unit immediately following each field session, in which CHAs actively contributed contextual information about visited families—including health, social, and relational dimensions that could not be disclosed within the household itself—substantially enriching the analytical depth of each record. The third source comprised twelve pages of faculty field observation notes, recording observable student behaviour in the territory in real time, prior to and structurally independent of students’ own reflective processing, recorded during random supervisory monitoring of student groups in the field. The information power of this corpus [42] was considered adequate given the specificity of the research question, the depth and multi-modal nature of the data sources, and the theoretical framework guiding analysis. The PBL framework and curriculum integration are described in Supplementary File 3. Triangulation was operationalised through systematic cross-source comparison across these three complementary sources. Student preparation for fieldwork was conducted in classroom settings prior to each immersion session, and CHAs were briefed by the supervising faculty member before each visit on the pedagogical objectives and expected student conduct. No incidents of inappropriate behaviour were reported throughout the immersion period. For each candidate theme, both researchers independently identified patterns within each source before any cross-source comparison. Convergence was recorded when the same experiential pattern appeared across sources without prior inter-source discussion. Divergences and silences were actively sought: where individual written accounts appeared uniformly affirmative, comparison with debriefing summaries and field notes enabled detection of frustrations, ambivalences, and structural critiques that students expressed verbally in group settings but did not commit to individual written documents. These divergences were flagged as potential social desirability artefacts and interpreted with explicit analytical caution rather than treated as confirmatory evidence. Two of the three source types were produced by the supervising faculty member—field notes and debriefing summaries—capturing different observational and facilitated-group contexts respectively. The analytical independence in this study resided primarily between student-generated and faculty-produced records, rather than across all three sources equally. This constraint is addressed in the Limitations section.

Analytical process: six-phase reflexive thematic analysis

The following account describes the analytical process with full sequential transparency, including concrete coding examples, to ensure the traceability required by the RTARG [3] and by the reviewers of this manuscript. The four theoretical frameworks did not function as deductive coding templates but as sensitising concepts that informed analytical attention throughout all six RTA phases. Situated learning theory [4] directed attention to the territory itself as an active epistemic space—sensitising the analysis to moments where learning was produced by place, not by instruction. Mezirow’s transformative learning theory [5] oriented the researchers toward disorienting dilemmas: data segments expressing rupture, frustration, or destabilisation of prior assumptions were flagged as analytically significant rather than treated as peripheral affect. Fink’s taxonomy [6] provided a multi-dimensional lens for recognising learning that extended beyond foundational knowledge—specifically directing attention to integration, human dimension, and caring as analytically distinct from content acquisition. Freirean critical pedagogy [7] sensitised the analysis to power asymmetries, epistemic hierarchies, and structural contradictions—specifically directing attention to silences, resistances, and moments of critical consciousness alongside affirming narratives. These frameworks shaped the naming and definition of themes without predetermining their content.

Phase 1 — independent data familiarisation

Both researchers (Z.F.B.P. and M.d.S.P.) independently read and re-read all data sources in full before any coding began. Each researcher generated handwritten analytical notes and an initial reflexive memo documenting first impressions, preliminary patterns, and positionality as educators and analysts. Recurring patterns included: expressions of disorientation and anxiety during first household entries; contrasts between classroom-acquired theory and territorial observation; descriptions of structural living conditions; and references to CHAs’ relational knowledge. Discordant elements—frustration, helplessness, ethical discomfort—were flagged as analytically significant at this stage rather than treated as noise.

Phase 2 — independent initial code generation

Each researcher independently generated inductive codes across the full dataset, labelling any data segment relevant to the research question. Concrete coding examples: entries describing students’ first entries into community homes were coded as “initial boundary anxiety,” “role uncertainty,” and “fear of intrusion”; entries describing structural living conditions were coded as “epistemological rupture,” “territory as health determinant,” “structural shock,” and “biomedical assumption challenged”; entries about CHA knowledge were coded as “horizontal knowledge,” “trust as infrastructure,” and “legitimate epistemic partner”; entries expressing frustration were coded as “agency-awareness gap,” “emotional burden,” and “structural helplessness.” Approximately 340 initial codes were generated. Both researchers intentionally coded for negative, ambivalent, and critical dimensions alongside affirming ones.

Phase 3 — collaborative theme construction

The two researchers met to compare independently generated codes. Convergences and divergences were systematically documented. Points of analytical disagreement were resolved through dialogue and, where necessary, re-examination of primary data: for example, the question of whether “student frustration at structural helplessness” constituted a sub-theme within Theme 1 or a component of Theme 3 was resolved by tracing its specific function in each context across multiple data sources. Candidate themes were constructed to reflect shared analytical meanings, not mere topic categories.

Phase 4 — theme review and refinement

Each candidate theme was tested against the full dataset for internal coherence and external distinctiveness. Themes that did not cohere were reorganised. Debriefing summaries and faculty field notes were used to triangulate emerging interpretations: for example, the theme of student emotional distress and anxiety was corroborated across all three data sources, validating its status as a genuine and analytically significant dimension of the experience rather than a social desirability artefact.

Phase 5 — theme definition and naming

Each theme was defined as an analytical claim about the dataset—not a topical label—and named to signal its interpretive and theoretical content: e.g., “Navigating Emotional Complexity” rather than “Emotions,” and “CHAs as Epistemic Partners and Structural Mirrors” rather than “CHA Role.”

Phase 6 — analytical report writing

Themes were developed into extended analytical narratives integrating student excerpts and theoretical interpretation. Student excerpts were originally produced in Brazilian Portuguese and translated into English by Z.F.B.P. (a native Portuguese speaker) with semantic, conceptual, and contextual consistency reviewed by M.d.S.P. Translation aimed to preserve the meaning and affective tone of the original expressions rather than achieving formal linguistic equivalence; where a direct translation would distort the student’s intended meaning, the closest semantically equivalent phrase was used and this decision was documented in the analytical memo. Excerpts were selected to illustrate each theme’s analytical claim and its critical dimensions, not simply to confirm its most affirming instances. Reflexive memos were maintained throughout this phase, documenting evolving analytical decisions.

Analytical quality

Quality in RTA is assessed through methodological coherence and reflexive rigour, not through positivist criteria such as inter-rater reliability or participant validation of thematic accuracy—which are epistemologically incongruent with the interpretivist stance adopted here [1–3]. Four RTA-congruent quality practices were implemented: (1) reflexive transparency: detailed memos throughout all analytical phases documenting evolving interpretations, positionality, and analytical decisions; (2) dialogical depth: independent coding followed by structured researcher dialogue to expand interpretive range and surface disagreements; (3) thick contextual description: sufficient detail of setting, participants, and analytical process to support reader judgement of transferability; (4) triangulation: systematic cross-source comparison across three complementary data sources, specifically used to corroborate both the affirming and the critical dimensions of the experience.

The positionality of both researchers is explicitly acknowledged, in accordance with RTARG standards [3]. Z.F.B.P. is a faculty member involved in community-based medical education and Primary Health Care teaching, with direct pedagogical experience in territory-based immersion activities, who served as supervising professor for the immersion. She contributed direct pedagogical knowledge of the curricular context and established relational knowledge of the CHAs, students, and PHC units involved. The institutional pedagogical plan for the course was established by the School of Medicine; faculty members were responsible for its implementation and for the pedagogical adjustments made during the immersion. M.d.S.P. is a physician and medical educator with expertise in qualitative research and community-based medical education, who contributed to the analytical design and interpretation without direct involvement in the immersion delivery. This complementary positioning—faculty-insider and external analyst—was a deliberate analytical strategy: the insider perspective contributed contextual depth and data richness, while the external analytical position supported critical distance and reflexive challenge. Both researchers maintained reflexive memos documenting how their professional backgrounds and pedagogical commitments shaped analytical interpretations, and these tensions were explicitly surfaced and discussed throughout all analytical phases.

Ethical considerations

This study utilised anonymised pedagogical data collected within the curricular framework. Although the educational activity was institutionally characterised as a curricular practice exempt from formal ethics committee review under Brazilian regulations (CNS Resolution 510/2016 [43]; CONEP Circular Letter 01/2018 [12]), the present manuscript constitutes a secondary interpretive qualitative analysis of anonymised materials conducted after the completion of the curricular activity. The institutional ethics exemption declaration is provided as Supplementary File 2. Verbal informed consent was obtained from all participants at the outset of the immersion period, communicated by the supervising faculty member in a formal classroom session, and documented in the course attendance record. Participants were informed of the voluntary nature of participation in the use of reflective materials for research purposes, the absence of any influence on academic evaluation or grades, and the full anonymisation of all data prior to analysis. The study adhered to the Declaration of Helsinki. The enrolment agreement at Sulamérica Faculty explicitly authorises student images for educational purposes (Clause Eight, Section IV). No identifiable images of patients, community households, or community members were included in the manuscript or supplementary files; all visual materials depict exclusively educational activities involving students and were reviewed to ensure full anonymity of all community participants.

Results

Three analytically distinct themes emerged from the dataset. Each theme is presented as an interpretive analytical claim, supported by student excerpts (translated from Portuguese), cross-source corroboration, and theoretical interpretation. Learning tensions, structural challenges, and critical dimensions are treated as analytically significant throughout—not peripheral to the three themes but constitutive of them.

Theme 1: epistemological rupture and the territory as a living determinant of health

Analytical claim: direct territorial encounter produced disorienting dilemmas that challenged biomedical assumptions and activated structural health literacy—alongside learning tensions between awareness and structural agency

The most pervasive pattern across all three data sources was a fundamental shift from theoretical to embodied understanding of health’s social production. Students entered the immersion having studied SUS, FHS, and social determinants conceptually; they encountered these abstractions as concrete, lived realities in specific families’ homes. This shift is consistent with Mezirow’s [5] disorienting dilemma: the encounter with structural living conditions destabilised prior biomedical meaning frameworks and required new interpretive tools.

“Walking through the territory showed that the map is alive—it breathes, moves, and tells the story of the people who live there.”

This illustrates the transformative power of situated learning [4] in fostering critical epistemological shifts and heightened awareness of social and environmental health inequities—a movement from Fink’s [6] foundational knowledge through application and integration. Faculty field notes confirmed this progression was observable from the third week of immersion, when students began spontaneously referencing preparatory curriculum concepts to contextualise their field observations.

“The visited territory presents many vulnerabilities: vacant lots, stray animals, accumulated waste. These are not aesthetic problems—they are direct risk factors for arboviruses and other conditions affecting collective health.” (Fig. 3)

Fig. 3.

Field observation of socio-environmental determinants. Students and CHAs document housing conditions and environmental risk factors during community mapping. (Photo credit: Z.F.B. Paschoalini, 2025)

Debriefing summaries corroborated this analytical pattern, recording students’ consistent use of structural rather than individual-behavioural explanatory frameworks for the health profiles they observed. However, it is crucial to acknowledge the institutional and environmental constraints that students also documented as limiting the depth of immersion in some circumstances. Heavy rain rendered certain territorial routes inaccessible on specific dates; faculty field notes recorded adaptive responses—relocating debriefing sessions under trees or covered outdoor spaces, continuing reflective practice in informal configurations that, students noted, themselves produced learning about the material conditions of community health work. Areas characterised by social conflict, including zones of organised crime activity and sites of environmental hazard, required route modifications in coordination with CHAs and health units. These adaptations were not minor logistical inconveniences: they were themselves pedagogically significant, demonstrating to students how structural and environmental conditions shape the deliverability of health care and community health work in real PHC contexts.

The most analytically significant tension within this theme was the gap students experienced between critical structural awareness and structural agency:

“We understand the problems differently now. But I sometimes feel helpless. What can a first-year student actually do about inadequate housing or lack of sanitation? The reality is much harder than what any theory prepares you for.”

Several students described this frustration explicitly, reporting emotional distress when confronting poverty, environmental degradation, and social inequality without the tools or authority to intervene. This is consistent with the evidence that early patient home visits generate "wide range of affect-laden responses, positive and negative" [32] and with Mezirow’s [5] account of the emotional phases—including guilt and disorientation—that necessarily accompany perspective transformation. From a Freirean perspective [7], this tension between conscientização and praxis is not a defect to be eliminated but a productive dialectical moment: the recognition that awareness alone does not produce change, and that change requires sustained structural engagement, is itself a form of critical learning that distinguishes genuine political education from humanitarian sentiment.

Several groups also documented the territorial paradox directly—the territory as simultaneously enabling and constraining care:

“The territory can both support and hinder care. Where infrastructure and the UBS are nearby, families can access services. But where structure is absent—unpaved roads, no sanitation, vacant lots—the same territory becomes a barrier to the health it should protect.”

This observation illustrates what the territory-as-living-determinant means concretely: not an abstract social concept, but a material infrastructure whose presence or absence directly conditions whether health care reaches those who need it. Debriefing summaries confirmed that this paradox was one of the most analytically consistent insights across groups, arising spontaneously without faculty prompting—an indicator of genuine epistemological learning rather than performance of expected answers.

Theme 2: CHAs as epistemic partners and structural mirrors

Analytical claim: students recognised CHA knowledge as constitutive of effective PHC while structural critique of CHAs’ working conditions produced political learning about health system inequity

A second major theme concerned students’ epistemological repositioning of CHAs: from logistical guides to epistemic partners whose relational, biographical, and territorial knowledge was not supplementary to clinical expertise but constitutive of effective PHC. This repositioning was unexpected for many students.

“The CHA didn’t just take us to the houses—he taught us how to listen, how to ask questions, how to be welcomed. He knows things about these families that no medical record will ever contain. This knowledge is essential, not auxiliary.”

Debriefing summaries recorded students’ consistent recognition that CHAs’ territorial knowledge enabled perception of health-relevant dimensions—family dynamics, social isolation, economic fragility, caregiver burden, longitudinal changes in family circumstances—that are structurally invisible in standard clinical encounters. This aligns with Lave and Wenger’s [4] legitimate peripheral participation: students, positioned initially as peripheral observers, came to recognise CHAs as central practitioners within a community of practice whose epistemic norms challenged biomedical educational hierarchies. It also directly enacts Fink’s [6] integration dimension: connecting university-based clinical frameworks with territorially grounded community knowledge on equal epistemic terms.

“The CHA is the bridge between the patient and the FHS. The warm reception they receive when they arrive at homes shows a trust built over years. He is treated as part of the family. That trust is the true infrastructure of primary care.”

The concept of trust as infrastructure—not as a soft professional attribute but as a structural condition of PHC effectiveness constructed through years of longitudinal household presence—has direct implications for medical curriculum design. It implies that effective PHC competency requires not only clinical skill but relational continuity, cultural sensitivity, and biographical knowledge of communities that cannot be developed through episodic clinical encounters.

However, students also observed that this relational trust is not universal and cannot be assumed. The data revealed an important tension: not all families receive CHAs with openness.

“In some families, the CHA was well received as a trusted friend and health ally. But in others, the CHA was seen as an intruder or even a threat—and we needed to understand why. This discomfort was uncomfortable for us too, and made us reflect on what the relationship between health professionals and communities really requires.”

This observation is analytically significant for two reasons. First, it demonstrates that community trust is constructed longitudinally and is not guaranteed by the CHA’s institutional role alone; it must be earned through repeated, respectful, and non-judgmental engagement. Second, it produced a reflexive learning moment for students: the recognition that health professionals can be perceived as agents of surveillance rather than care, and that this perception is shaped by structural and historical factors that extend beyond individual interactions.

A further dimension of Theme 2 emerged when students encountered the integration of popular and biomedical knowledge in household practice:

“In the home of a patient—Dona Andrelina—we saw how she combined her medical treatment with mastruz, a traditional medicinal plant used in Brazilian folk medicine for respiratory and anti-inflammatory conditions. The CHA knew this and treated it with respect, not dismissal. I realised that legitimate knowledge about health is broader than what we learn in the classroom.”

This encounter illustrates what Freire [7] identifies as the dialogic encounter of different epistemic traditions: the CHA’s territorial knowledge enabled students to perceive the integration of popular healing practices with biomedical treatment as a contextually meaningful health strategy rather than a deviation from clinical protocol. Debriefing discussion of this case became an occasion for exploring the boundaries between evidence-based medicine and culturally situated health knowledge—a form of learning that no classroom case study can replicate.

The critical dimension of this theme demands equal analytical weight. Several students moved explicitly beyond appreciation to structural critique of CHAs’ working conditions:

“The CHA carries enormous responsibility. She knows every problem in the community and feels personally accountable for all of them. But the system does not adequately value or support her. That is a structural injustice affecting both the CHA and the community she serves.”

This observation is empirically grounded: research documents the significant demands placed on CHAs in Brazil, including workload intensity, emotional investment, and complex role responsibilities [15, 16, 44]. Students’ awareness of these realities—observed directly through the intensity of CHAs’ daily work and their longitudinal commitment to families—deepened their respect for community health work and their understanding of what sustainable, equitable PHC requires. This awareness may represent an early form of the professional reflexivity that socially accountable medical practice demands [23, 28].

Theme 3: navigating emotional complexity — from anxiety and disorientation to critical empathy

Analytical claim: initial anxiety, boundary discomfort, and confrontation with inequality gave way, through CHA mediation and structured reflection, to multidimensional critical empathy and professional identity formation anchored in social accountability

The third theme attends to the affective, ethical, and professional identity dimensions of the immersion, and specifically to the role of emotional complexity and pedagogical tensions in catalysing what we term critical empathy: a multidimensional professional orientation that encompasses affective responsiveness, structural understanding, ethical reflexivity, and incipient political awareness.

Students consistently reported significant anxiety before and during the first household visits — anxiety that was transient, structurally produced, and pedagogically significant, as described below. This initial emotional response was not peripheral to the experience but one of its analytically significant entry points: a marker of the social distance that CHA-mediated immersion is specifically structured to traverse. The literature on early patient encounters in home settings identifies first-year home visits as generating both positive and negative affect-laden responses, with students frequently experiencing fear, discomfort, role confusion, and ethical uncertainty alongside curiosity and engagement [32]. Our data confirm this complexity — and document its resolution.

“I was genuinely nervous before arriving. I did not know what to say, how to behave, or how I would be received. I was afraid of being an intruder in someone’s home. That discomfort stayed with me throughout the first visits.”

Faculty field notes specifically recorded this anxiety as observable and persistent in the first weeks of immersion across multiple groups—not as an individual response but as a collective and structurally produced reaction to crossing social and class boundaries into private domestic spaces. This boundary crossing is theoretically significant: it surfaces the social distance between medical students’ typical class background and the communities they will serve, a dimension of professional education that the hidden curriculum of biomedical training typically leaves unexamined [45].

“The first time I entered a home in a vulnerable area, I felt the weight of that inequality in a way I had never felt before. I understood intellectually that poverty exists. But feeling it—smelling it, seeing it in the eyes of a child—is a completely different thing.”

This affective confrontation with inequality—what students described as a physical, sensory, embodied encounter with structural conditions—corresponds to what Mezirow [5] identifies as the emotional phase following the disorienting dilemma: an experience that cannot be processed through prior conceptual frameworks and therefore demands a new epistemic orientation. The CHA’s mediating role was crucial in making this emotional confrontation pedagogically generative rather than merely destabilising.

“At first, I was nervous about what to say. But the CHA showed me how to be present, and the families welcomed us so warmly. By the end, I didn’t want to leave.”

This trajectory—from transient initial anxiety through CHA-mediated guidance to genuine relational engagement and learning that exceeded students’ own expectations—is the analytically central finding of this theme. The anxiety documented in the first visits was real and structurally significant, as described above; but it was also time-limited. Faculty field observations and debriefing records consistently documented that it diminished substantially within the first weeks of immersion, as CHA mediation and repeated community presence normalised the experience of crossing class and social boundaries. What replaced it was qualitatively different from what students had anticipated: not merely comfort or familiarity, but a form of learning that multiple students described as beyond what they had expected from their first year. The excerpt — *"By the end, I didn’t want to leave"* — is not a minor detail but the experiential summary of a pedagogical process in which theory, territory, relationship, and reflection converged into something students could not have constructed in the classroom alone. This convergence is precisely what structured early CHA-mediated immersion is designed to produce — and what this study documents as its most durable outcome. This trajectory is consistent with the evidence that structured early patient encounters, when well-supported by community mediation and faculty facilitation, catalyse professional identity formation grounded in person-centred care [36–38] [32, 46, 47]. The caring and human dimension aspects of Fink’s taxonomy [6] are directly activated: students developed new values about what the physician-community relationship requires and what effective care demands beyond clinical competence (Fig. 4).

Fig. 4.

Humanistic practice during a household visit. A first-year medical student, supervised by faculty and guided by a CHA, measures the blood pressure of an elderly resident, embodying early development of clinical empathy, person-centred care, and the connection between technical competence and relational presence in community-based training. (Photo credit: Z.F.B. Paschoalini, 2025)

However, not all tensions were resolved. Some students developed a critical reflexive stance toward their own institutional position within the community encounter—a dimension that is analytically more sophisticated than simple empathy:

“The families were so welcoming and open. But I kept asking myself: do they really want us here? Do they have a real choice about opening their homes to medical students? The warmth is beautiful, but it made me question my own position and what the institution asks of these families.”

This reflexive ethical questioning represents the human dimension of significant learning [6] and the form of critical social awareness that Freirean critical pedagogy aims to cultivate [7]. It is analytically important to clarify the structural basis of the community encounter: the families’ openness was not organised or solicited by the academic institution. The household visits followed the CHAs’ pre-existing, federally mandated visitation routines — visits that families receive as part of their constitutional right to primary health care, independent of any educational programme [19, 21]. Students accompanied CHAs in their established practice; they did not arrive as institutional emissaries requesting access. Nevertheless, the student’s reflexive question — whether families experience this accompaniment as genuinely chosen — is legitimate and analytically significant: even within a pre-existing relational structure, students’ presence introduces a power asymmetry that the educational encounter must acknowledge rather than naturalise. Students who named this asymmetry were demonstrating a more sophisticated professional ethical sensibility than those who accepted community warmth uncritically — a form of positional self-awareness that Freirean pedagogy [7] identifies as the beginning of critical consciousness. This reflexivity is also relevant to debates about power dynamics in CBME, which remain underexplored in the international literature [31].

“In class, we learned about the Family Health Strategy. With the CHA, we lived it. Now I understand not only what it is, but why it matters and how it works—and how much harder it is than the textbooks suggest.”

Several students expressed a related but distinct insight: that the immersion transformed abstract institutional knowledge into something human and located:

“The experience profoundly changed our understanding of the SUS and primary health care. They ceased to be only names in a textbook and gained a face and an address. We saw that primary care demands complete, challenging medicine—and that the SUS has both its power and its bureaucratic fragilities.”

The phrase “gained a face and an address” captures precisely the epistemological shift that situated learning theory [4] identifies as the essential product of contextualised education: abstract institutional frameworks became concrete, biographical, and spatially located. Notably, this same student also acknowledged the SUS’s “bureaucratic fragilities”—demonstrating that the immersion did not produce uncritical identification with the health system, but a more nuanced understanding of both its strengths and its structural limitations. This is the kind of critical awareness that socially accountable medical education aims to cultivate [23, 28].

This final set of excerpts illustrates what Fink’s taxonomy [6] identifies as the integration dimension of significant learning: students connected theoretical frameworks, community observation, relational experience, and personal values into a more comprehensive and critically grounded understanding of what PHC practice requires. Medical education that begins inside communities may extend beyond technical content toward the relational and socially accountable dimensions of care.

Discussion

This interpretive qualitative study examined how CHA-mediated territory-based immersion shapes first-year medical students’ learning, critical awareness, and professional identity formation. The three themes reveal mechanisms of learning in CBME that extend beyond the documentation of positive outcomes to illuminate the epistemological, relational, emotional, and political dimensions of this pedagogical encounter—including its tensions, structural challenges, and limitations.

Territory, structural inequality, and the productive tension between awareness and agency

Students’ shift from abstract to embodied understanding of social determinants aligns with situated learning [4] and place-based education [27]: knowledge produced through contextualised territorial encounter is qualitatively different from classroom knowledge even when the conceptual content is identical. The territory appeared to function as an active epistemic space that made visible the structural production of health inequality—what Marmot [48] characterises as the social gradient operating across all dimensions of daily life—in ways that theoretical instruction alone may not replicate. This finding extends the CBME evidence base [23–25, 30] by suggesting that CHA-facilitated immersion may produce the interpretive shifts and critical reflection necessary for genuine professional development.

The tension between critical structural awareness and a sense of limited agency that students experienced is analytically central and must not be treated as a curriculum failure. Mezirow [5] describes this as a necessary emotional phase in perspective transformation; Freire [7] identifies it as the dialectical relationship between conscientização and praxis. Educational programmes that prematurely resolve this tension—by reassuring students that their role is observation, not intervention—risk producing a passive witnessing orientation rather than the active structural engagement that social accountability requires. The appropriate response is structured support for students navigating this productive discomfort: facilitated reflection on the sources of the structures they observe, on the political determinants of health, and on their developing responsibilities as future physicians and citizens.

The environmental and logistical constraints documented in this study—weather events, areas of social conflict, geographic barriers—are also analytically significant. They demonstrate that PHC operates under material constraints that profoundly shape what care can be delivered to whom, and that these constraints are structurally produced rather than coincidental. Encountering these constraints directly is part of what it means to receive a territorially grounded medical education.

CHAs as co-educators: epistemic partnership and structural critique

Students’ recognition of CHAs as legitimate knowledge holders challenges the hierarchical epistemological assumptions of conventional medical education [7] [49, 50]. The distributed knowledge model enacted in this immersion—integrating CHAs’ relational and territorial expertise with students’ clinical frameworks on equal epistemic terms—offers a concrete model for interprofessional and community-engaged education that goes beyond formal interprofessional curricula [51–53].

Students’ recognition of the demands and responsibilities inherent in CHAs’ work is equally significant. Research documents the significant workload, emotional investment, and complex role responsibilities that characterise CHA practice in Brazil [15, 16, 44]. Students who observed this intensity directly—seeing CHAs’ longitudinal commitment to families across social, clinical, and environmental dimensions—developed a more nuanced understanding of what sustainable PHC requires from its workforce. Programmes that formally recognise CHAs as co-educators, as in this study, may contribute to the institutional visibility and professional appreciation of their role, complementing the formal recognition already established in Brazilian legislation [19].

Emotional complexity, critical empathy, and professional identity formation

The multidimensional critical empathy documented in this study—shaped by anxiety, boundary discomfort, structural confrontation, ethical reflexivity, and CHA mediation—constitutes a more robust professional competency than empathy conceived as affective resonance [28, 29]. Students who experienced and processed emotional complexity, rather than suppressing it, developed a more sophisticated ethical orientation: one that encompasses structural awareness, critical self-examination of positional power, and commitment to person-centred longitudinal care. The emotional tensions documented across all three data sources—initial anxiety, boundary discomfort, and the gap between structural awareness and agency—were transient rather than persistent features of the immersion experience. Faculty field observations and debriefing records consistently documented that anxiety was most acute during the first household entries and diminished substantially within the first weeks of immersion, as CHA mediation and repeated exposure normalised the experience of crossing class and social boundaries. This trajectory is consistent with Romanholi and Cyrino’s documentation of home visits as a “critical node” in community-based medical education: pedagogically productive precisely because the discomfort is bounded, structured, and processed rather than unresolved [47]. However, the analytical implications of these tensions extend beyond their resolution. The fact that initial anxiety was structurally produced—reflecting the social distance between medical students’ typical class background and the communities they visited in Luís Eduardo Magalhães—indicates that what students experienced as personal discomfort was in fact an encounter with structural inequality made embodied. Programmes that treat initial anxiety as a problem to be managed risk suppressing a productive epistemological signal. Programmes that treat it as data—as this study did through structured debriefing facilitated by both faculty and CHAs—transform discomfort into the first form of structural health literacy. Similarly, the sense of helplessness students reported when confronting poverty without tools to intervene is not a curriculum failure; it is, from a Freirean perspective [7], the necessary first stage of conscientização—the recognition that awareness precedes and requires action, not replaces it. The reflexive questioning that some students directed at their own positional role in the community encounter—asking whether families experienced their presence as genuinely chosen, even within the CHAs’ pre-existing, federally mandated visitation routines [19, 21] that families receive as a constitutional right independent of any academic programme—represents the most analytically sophisticated dimension of the emotional trajectory documented in this study. This form of positional self-awareness goes beyond empathy as individual affect: it constitutes the beginning of a structural ethical sensibility that recognises education itself as a site of power relations. Rather than treating this reflexive discomfort as a sign of programme failure or student resistance, programmes should design deliberately for it: creating structured debriefing spaces in which students can name, theorise, and hold the ethical ambiguities of their educational encounters. The CHA-mediated debriefing model used in this study—in which students returned from the territory to discuss real cases with both faculty and CHAs, integrating clinical, social, and relational dimensions—was specifically structured to support this kind of critical processing [41, 47]. Students who moved through this process reported not a resolution of tension, but an expanded capacity to hold complexity: a more differentiated understanding of care, community, and their own developing responsibilities as physicians. This outcome—expanded capacity for ethical ambiguity rather than premature resolution of it—may be one of the most clinically and socially significant products of early community immersion.

These implications are directly relevant to how CBME programmes are designed and supported. Early community encounters, including home visits, are productive grounds for professional identity formation. Structured CHA-mediated territory-based immersion in the first year of medical education — before the hidden curriculum of biomedical training consolidates a reductionist clinical gaze [45] — builds the contextual and relational foundations within which all subsequent clinical encounters acquire structural meaning [32, 46, 47]. When a student who has accompanied a CHA through real family territories later encounters a patient with poorly controlled diabetes in a consultation room, they do not see only the patient in front of them: they see the family, the food environment, the social network, and the territorial conditions that shape that patient’s health. This expanded clinical perception — constructed in the territory rather than the classroom, and impossible to replicate through hospital-based clinical exposure alone — is the defining educational product of early CHA-mediated community immersion. Structured reflection through journals and debriefings [39, 40] was essential in this study for making emotional experience pedagogically generative rather than merely challenging. The hidden curriculum of biomedical training has been documented to teach students to suppress emotion [45] — a tendency that CHA-mediated community immersion directly counteracts by creating conditions in which emotional response is acknowledged, reflected upon, and theoretically engaged from the earliest weeks of formation. Programmes should design for this explicitly: not by eliminating discomfort, but by providing the reflective structures, CHA co-facilitation, and faculty support through which discomfort becomes the first form of structural health literacy.

Operational considerations and structural challenges

Effective implementation required careful planning and institutional coordination: student preparation, ethical fieldwork protocols, coordination with CHAs and health unit teams, and formal teaching-service integration with the Municipal Health Secretariat [10,] [28, 34, 35–54–55]. Operational challenges—family availability, environmental conditions, route modifications in high-risk zones—required flexible adaptive responses. These challenges were not merely logistical: they were pedagogically productive, demonstrating to students the material and structural conditions under which PHC actually operates. The model’s most transferable elements are: structured student-CHA pairing with co-educator framing; pre-immersion preparation in ethics, cultural humility, and power dynamics; protected time for structured critical reflection; and explicit curricular attention to the political economy of community health work.

Limitations and transferability

This study was conducted at a single institution within a specific municipal PHC network in Luís Eduardo Magalhães, Bahia, Brazil. Data capture proximal rather than longitudinal learning outcomes; follow-up studies are needed to assess whether critical awareness and humanistic competencies are sustained across the curriculum or eroded by the hidden curriculum of subsequent biomedical training [45]. Social desirability effects in student-generated reflective materials cannot be fully eliminated in curricular contexts where students are assessed by the same faculty member who supervises the immersion. Triangulation across three complementary data sources—including real-time field observations and CHA-enriched debriefing records—enabled detection of divergences between written and verbal student responses, as described in "Data sources" section. Nevertheless, the possibility that some negative or ambivalent responses remained unexpressed across all data sources cannot be excluded, and interpretations of the immersion’s transformative dimensions should be read with this constraint in mind. CHA perspectives were not collected as a primary data source: the CHA experience of co-educating students deserves investigation as a research question in its own right, including its demands, rewards, and structural tensions. Future research should adopt participatory designs positioning CHAs as research collaborators. The transferability of this model to international contexts depends on identifying structurally equivalent community health worker roles; settings without equivalent roles should develop co-educational partnerships with community organisations that can perform analogous functions.

Educational impact

The territory-based immersion was consistent with all six dimensions of Fink’s taxonomy of significant learning [6]:

• Foundational knowledge: territorial observation concretised and contextualised theoretical concepts of social determinants, territorialisation, and PHC that students had previously encountered only in the classroom.

• Application: students connected structural observations to epidemiological, social, and political frameworks, diagnosing the structural rather than individual determinants of the health conditions they witnessed.

• Integration: students connected biomedical training, territorial knowledge, CHA expertise, personal values, and emotional experience into a more comprehensive and contextually grounded understanding of what medical practice requires.

• Human dimension: students developed critical self-awareness of their own institutional position, class background, and power dynamics within community encounters—and of what this implies for their responsibilities as future physicians.

• Caring: students developed new and more complex values about what legitimate health knowledge is, what person-centred longitudinal care requires, and what professional social accountability demands.

• Learning how to learn: students recognised the limits of classroom-based epistemic frameworks and identified the kinds of knowledge—relational, territorial, biographical, structural—that PHC competence requires and that medical education rarely cultivates.

Students’ narratives reflected dimensions aligned with Mezirow’s [5] reflective learning sequence: disorienting dilemma → critical self-examination → perspective shift → revised professional action orientation. These shifts were not uniform, linear, or without cost: they were accompanied by emotional distress, frustration, and ethical discomfort that are analytically significant dimensions of the learning process. Future iterations should incorporate formal longitudinal evaluation tools to assess whether these reflective orientations are sustained across the full medical curriculum.

Conclusions

In Primary Health Care, future physicians learn that equity, listening, longitudinal care, and social context are not abstract educational objectives—they are the substance of everyday medical practice. Medical education that begins inside communities may extend beyond technical content toward relational and socially accountable professional practice.

This interpretive qualitative study indicates that structured, CHA-mediated territory-based immersion was analytically consistent with learning processes across all six dimensions of Fink’s taxonomy [6], supported reflective engagement aligned with Mezirow’s [5] perspective transformation framework, and deepened students’ critical awareness of social determinants, health inequity, and the structural conditions of PHC work. These outcomes were inseparable from the tensions, frustrations, emotional distress, and structural challenges students encountered: these difficulties are not programme defects but analytically significant dimensions of the learning process.

The learning tensions, ambiguities, and structural challenges documented in this study—the gap between awareness and agency, the structural vulnerabilities of CHAs, the ethical ambiguity of the educational encounter, the environmental and logistical barriers of real PHC—are not failures of the immersion model. They reflect what it means to learn medicine in and from the community rather than about it from a distance. The first year of medical education represents a critical and underutilised window for this formation [32, 47]: before the hidden curriculum of the biomedical model consolidates a reductionist clinical gaze [45], immersion in living territories—mediated by CHAs who know each family’s history, vulnerabilities, and strengths, and who bring to the debriefing what cannot be said inside the household—builds the contextual and relational framework within which all subsequent clinical encounters acquire structural meaning. This is the distinctive contribution of the Brazilian CHA as co-educator: not merely a guide to the territory, but a bearer of longitudinal, relational, and structural knowledge that no classroom instruction can replicate. Students who engage with these realities in their first weeks of formation are not simply better prepared for socially accountable practice—they are formed differently, from the ground up, as physicians who understand that the patient in front of them is inseparable from the family, the territory, and the social conditions that produced their illness.

The evidence base on high-quality primary care consistently demonstrates that first-contact, longitudinal, and comprehensive care—the hallmarks of the Brazilian Family Health Strategy—produces superior health outcomes [26]. Physicians formed within these territories from their first year of training are better positioned to enact this model not as an abstract competency, but as an embodied and contextually grounded professional practice. The integration between university, SUS, Primary Health Care, and living territories may constitute one of the most productive educational encounters in the formation of more humane, critical, and socially committed physicians. For the international medical education community, the Brazilian CHA—a continuously embedded, longitudinally engaged, legally mandated community health professional with deep knowledge of individual families and territories—offers a powerful and underutilised model for CBME co-education. Future research should examine longitudinal impacts on professional identity and PHC competencies, incorporate CHA perspectives through participatory designs, and explore how this model may be adapted across diverse international PHC contexts.

Authors’ contributions

M.d.S.P. contributed to curriculum design, led the analytical framework, conducted independent coding and interpretation, and critically revised the manuscript. Z.F.B.P. acted as supervising faculty member during the immersion activities, contributed to pedagogical implementation, participated in qualitative data analysis, and drafted the manuscript. Both authors read and approved the final version.

Funding

No external funding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the data and the potential risk of participant identification, but anonymised excerpts and additional information may be available from the corresponding author upon reasonable request and subject to institutional ethical considerations.

Declarations

Ethics approval and consent to participate

This study utilised anonymised pedagogical data collected within the curricular framework. Although the educational activity was institutionally characterised as a curricular practice exempt from formal ethics review under Brazilian regulations (CNS Resolution 510/2016 [50]; CONEP Circular Letter 01/2018 [43]), the present manuscript constitutes a secondary interpretive qualitative analysis of anonymised materials conducted after the completion of the curricular activity. The institutional ethics exemption declaration is provided as Supplementary File 2. Verbal informed consent was obtained from all participants at the outset of the immersion period, communicated by the supervising faculty member in a formal classroom session and documented in the course attendance record. Participants were informed of the voluntary nature of participation, the absence of any influence on academic evaluation, and the full anonymisation of all data prior to analysis. All materials were de-identified prior to analysis. The study adhered to the Declaration of Helsinki. The enrolment agreement at Sulamérica Faculty explicitly authorises student images for educational purposes (Clause Eight, Section IV). No identifiable images of patients, community households, or community members were included; all visual materials depict exclusively educational activities involving students. The institutional declaration of curricular integration is provided as Supplementary File 1.

Consent for publication

All participant data and images have been anonymised.

Competing interests

The authors declare no competing interests.