Relationships do matter! In fact, medicine cannot be learned without them, and community-based medical education (CBME) curricula that ignore them or take them for granted do so at their students' peril. As CBME is becoming more popular, there is a need to develop appropriate frameworks for describing quality in CBME to ensure that it remains a principle-driven, not formatdriven, initiative. In this paper, I provide evidence for a simple model of four key relationships, the four Rs, in which the medical student must be immersed to facilitate high quality learning. These four Rs are the relationships between (1) clinicians and patients, (2) health service and university research, (3) government and community, and (4) personal principles and professional expectations. As a result of this synthesis of the current medical education literature, I propose that this model of clinical, social, institutional and interpersonal relationships is a valid framework for articulating the important principles in CBME, and that it describes why communitybased medical education is such an attractive alternative. Relationships do matter!

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Relationships do matter! In fact, medicine cannot be learned without them, and community-based medical education (CBME) curricula that ignore them or take them for granted do so at their students peril! Could these assertions provide a key to quality in CBME curricula? In a previous paper, I provided evidence for a simple model of four key relationships, the four Rs, to act as a framework to analyse CBME. These four Rs are the relationships between (1) clinicians and patients, (2) health service and university research, (3) government and community, and (4) personal principles and professional expectations. In this paper I describe a key to discerning quality in this model. This key is integrity— that coalition of soundness and interdependence that enables the quality of the whole to be greater than the sum of the parts. I will also discuss the implications of this model for CBME with particular reference to reform of student selection, curricular goals, course structure, and assessment. Whilst further research based on this model is needed, as a result of this synthesis of the current medical education literature, I propose that it is its capacity to produce clinical, social, institutional and interpersonal integrity in its graduates that makes communitybased medical education such an attractive alternative. Relationships do matter!

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Background: As in other former Soviet republics, Moldova's health system has been dependent upon multispecialty and hospital care. The government has undertaken a planning process to develop a primary care-based system utilizing family physicians. Carelift International and Moldova State Medical and Pharmaceutical University joined together to design an educational program to help create a family medicine specialty in the country. Methods: Introductory concepts were incorporated into a workshop co-sponsored by the World Health Organization, Carelift International, UNICEF and the Moldova Ministry of Health. Faculty teams participated in Carelift's 8-week US program, comprising a range of topics in family medicine: educational development at all levels, public health applications, health care organization, insurance, .nancing, and technology. Training also included 1 week in Finland, a fellowship in Lithuania, an in-country workshop on rural health, and a supplemental 5-week US immersion program. Outcomes: A Department of Family Medicine was established, and a residency program instituted. It has already been strengthened with a 2-week introduction to the specialty, and rotations in family practice centers. Continued improvements and updates are planned. Urban and rural model family practice centers serve concurrent purposes of teaching, demonstration and health care. Carelift shipped equipment for the principal center and a departmental library, and is equipping a teaching family practice center near the university. The Society of Family Physicians of Moldova was founded. The introduction of family medicine as a discipline into the health system of Moldova could be a valuable model for other former Soviet republics.

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Context: Although innovative, community-oriented and PHC-focused medical education programmes have been in operation in some medical schools in Nigeria for over a decade, they are yet to be comprehensively evaluated. Objective: This study therefore aimed at evaluating some impacts of the programmes on medical education in the country. Methods: The study was conducted in three innovative medical schools in South-Western Nigeria. Two traditional medical schools were selected as control. Questionnaires were used for the collection of data from random samples of 44 .nal year medical students in the innovative medical schools (SIMS) and 40 .nal year medical students in the traditional medical schools (STMS). Forty (40) medical graduates of the innovative medical schools (GIMS) and 33 graduates of the traditional medical schools (GTMS) also participated in the study. In addition, in-depth interviews of key stakeholders of the programmes and focus group discussions of selected members of the communities were conducted. Findings: Findings revealed that the graduates of the innovative schools were better exposed to PHC education than those in the traditional schools. Their perceptions of the objectives of, and functions during, the PHC education were signi.cantly different. Methods of learning during the programmes appear to be more experiential and inductive. Attitudes of members of rural communities were also favourable to the programmes. Conclusion: The innovative programmes appear to have impacted positively on medical education in the country. A major de.ciency of the programmes is inadequacy of human and material resources for their effective functioning.

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The aim of health education is to encourage health behaviors that promote a better quality of life and longer life expectancy. In the late 1960s, universities in the US began offering degree programs in health education. Most programs today require that at least one class be taken in epidemiology, where epidemiology involves the study of the distribution and determinants of disease frequency in human populations. In recent years, several competency areas have been set forth for health educators by the US National Commission for Health Education Credentialing. This paper speci.cally describes how training in epidemiology provides health educators with the ability to satisfy, in large part, these competency areas. The intent of this paper is to clarify to students and advisors of health education the rationale for requiring course work in epidemiology, as well as to emphasize that epidemiology is the cornerstone to all health education, whether conducted by physicians, nurses, or formally trained health educators.

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This paper assumes the reader (1) has little knowledge about program evaluation, and (2) is interested in evaluation to improve a community-based health professions education program. There are other important and useful approaches that can be used to address an evaluation of a community-based health professions education program, and readers are encouraged to explore them— they appear in health education, public health education, in evaluation, and in program theory literature. The paper is organized around a group of questions as a reference or organizer for the reader. These include topics like why evaluation is wanted, what kinds of questions can be addressed through evaluation, who stakeholders are, who should conduct the evaluation, what methods can be used, and how to analyze data and report results from the evaluation. In the paper, I have attempted to include examples that are related to community-based health professions programs. Finally, the paper ends with the recognition that there is much more to learn in the .eld of evaluation and suggestions for ways to continue pursuit of knowledge in this topical area.

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This paper discusses the impact of the community-based medical school on mental health services. The Gezira mental health programme represents a collaborative work involving the university, the community and the government. It aims at achieving speci.ed objectives: (1) to modify community concepts, attitudes and practices concerning mental health, (2) to ensure community involvement and participation, (3) to extend mental health services, (4) to train PHC staff, and (5) to encourage research. The programme was implemented in three phases: preparatory, implementation, and evaluation. In the evaluation of the impact of the programme on changing community attitudes, the training of staff, the extension of mental health services, and on research, qualitative assessment, through interviews, focus group discussion, supervision visits, and review of reports are used. There is an overall agreement that the programme helped in raising public awareness regarding the concept of mental health, the care of the mentally ill and community participation. Members of the health team who received training as part of the programme reported a better understanding of mental health problems and an improvement in their handling of the mentally disturbed patients. Teachers reported an increased awareness of mental health problems in school children and a better collaboration with those involved in the handling of such problems. Social workers and psychologists updated their knowledge and skills and were well prepared to participate in the programme. Members of the different sectors involved reported a better standard of collaboration regarding mental health activities. These .ndings indicate that this programme, by providing a new model for health services in this .eld, has induced a large policy change within the Sudan. The community-based activities at the FMUG have resulted in a major change in the delivery of mental health services in Gezira State. The programme has resulted in a major shift in mental health services being provided by central hospitals to PHC settings. In addition it has stimulated research, thereby providing much original information that will help in preparing for future plans.

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Context: Medical students need learning experiences outside the classroom, clinic room and hospital room if they are to become integral parts of the communities in which they will practice medicine. Service-learning incorporated into the traditional medical school curriculum can provide a vehicle to accomplish this goal, and provide an avenue to enhance the professional development of the physician in training. Methods: This paper describes efforts to incorporate community service and servicelearning into a traditional medical school curriculum. The unique nature of our location in a rural state with several required rural rotations with our local community partners has facilitated this effort. Conclusion: Incorporation of service-learning into a medical curriculum can be accomplished and will enhance the professional development of the students.

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Introduction: There are few published studies that address the problem of dysfunctional tutorial groups. Most studies are restricted to student or faculty opinions separately and to speci.c aspects affecting the tutorial group function. This study examined teacher and student perceptions of frequency and importance of problems observed in tutorial groups in a new PBL program. Methods: Tutors (n=30) and students in the second (n=75) and third (n=53) year completed a questionnaire at the beginning of the 1999 academic year. The questionnaire had 33 items grouped as seven ''factors'' related to tutor performance, feedback, assessment, educational resources, student performance, educational problems and external factors Results: The most important problems identi.ed were related to tutors (mainly in training aspects) and students (mainly in problem discussion). Students and feedback (quality) were the most frequent. There were statistically signi.cant differences between tutors' and students' (higher) and between second and third year (higher) students' perceptions of different factors. Conclusions: (1) Marilia Medical School (FAMEMA) has problems in the tutorial group function mainly related to contributions of students and tutors. (2) Students' and tutors' opinions, as well as those of second and third year students, differ and therefore all need to be consulted to solve tutorial group problems. (3) It is necessary to develop a better student training program and also to improve the tutors training program. (4) There is a need for continued evaluation of problem-based learning at FAMEMA. We must look at perceptions of students from all years.

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Introduction: The attitude of medical students towards psychiatry has been studied extensively in the developed world. The inability to attract medical students to specialize in psychiatry has always been a serious challenge to psychiatric recruitment. Objective: This study evaluates the attitude of medical students towards psychiatry and identifies associated factors. Methods: Medical students from years 1, 4 and 7 at the College of Medicine and Medical Sciences (CMMS), Arabian Gulf University (AGU), constituted the study sample. One hundred and twenty two (87.1%) medical students completed the Attitude Towards Psychiatry – 30 (ATP-30) scale and the study questionnaire. Results: The attitude towards psychiatry was moderately positive (mean ATP score = 105.79, SD = 13.34). Twenty two (15.7%) students selected psychiatry as one of the top three career choices. Fifty .ve (72.3%) of the pre-clinical students agreed that teaching at the college is good or acceptable, compared to 11 students (44%) from the clinical phase. Female, younger and junior students had more positive attitudes than male, older and senior students. Factors such as exposure to material related to psychiatry, having a close relation with psychiatric illness and having a romantic relationship with a psychiatric patient were signi.cantly related to the ATP score. Conclusion: The results of the study did not support the hypothesis that the greater the exposure to psychiatry, the higher the ATP. Possible explanations for the low attraction of graduates to psychiatry in spite of the initial high ATP and ways to overcome this problem are discussed.

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CIESPAC (Centre inter-états d'Enseignement en Santé Publique pour l'Afrique centrale), a sub-regional public health training institution, originally located in Brazzaville, was created with the vocation of providing Central African countries with quali.ed health services managers (the turbulent events that occurred in Brazzaville in June 1997 prompted the transfer of the institution to Yaoundé in Cameroon). It offers several courses, the most recent of which culminates with a professional diploma in public health and targets mainly potential health district managers (DPSP— Diplome Professionnel en Santé Publique). This paper reviews the .rst four-year experience of implementing the ''community-oriented problem-based learning'' (PBL) pedagogic approach in francophone Africa. About 70 health professionals (mainly MD and diploma nurses) were trained, using the PBL approach, within a period of three years. Practical .eld training activities involving the neighbouring urban communities of the institution as training sites were given a key place in the course and thus allowed trainees to perceptively appraise the priority health problems of a district. The most important thing trainees learnt during this course was how to learn. Some of them were also able to participate in some operational research. From this experience, it is clear that trainees are coached to learn solving problems on their own for the rest of their professional career. The neighbouring community of a training institution, when properly approached, can provide a very fertile teaching ground where trainees can acquire .rst hand practical experience in learning to collaborate with local communities. However, the PBL pedagogic approach requests a mutual understanding between trainees and trainers. As such there is a need for a careful selection of trainees and, even more importantly, for a critical mass of competent and motivated trainers.

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