Program evaluation of an urban community diagnosis program incorporating fieldwork using a realist approach

Understanding social determinants of health is essential for medical education, particularly in complex urban settings. This study evaluated a fieldwork-based community diagnosis program designed to help medical students identify community health issues, appreciate diverse social contexts, and integrate theoretical frameworks into practical learning.

The program was integrated into a two-week general medicine clerkship at X Medical School in Tokyo in 2022-2023. It included an orientation on ecological systems theory and phenomenological reduction, followed by urban fieldwork, student presentations, peer and faculty feedback, and a final report. A realist approach using Context-Mechanism-Outcome (CMO) framework guided the evaluation, focusing on how contextual factors influenced learning mechanisms to produce specific outcomes. Data sources included students' reports, reflective writings, and feedback session transcripts. Qualitative analysis was conducted to identify patterns of learning and interaction. Students' understanding of community health and ability to apply theoretical models were assessed using structured rubrics.

The program significantly improved students' ability to observe, analyze, and interpret complex urban community dynamics. Orientation sessions helped students overcome theory-laden biases and expand their observational skills. Fieldwork, coupled with iterative feedback, facilitated double-loop learning, enabling students to reassess assumptions and refine their perspectives. Positionality theory encouraged reflection on power dynamics, leading students to critically examine implicit biases and understand the perspectives of marginalized populations. Through phenomenological reduction, students recognized biases in their biomedical training and shifted toward a holistic understanding of community health, encompassing ecological and social determinants. Peer and faculty feedback promoted intersubjectivity, allowing students to develop a layered appreciation of urban diversity and social complexity. Students reported an increased ability to connect theoretical knowledge with real-world health disparities, proposing actionable, sustainable interventions for urban communities.

This realist approach demonstrated that integrating fieldwork with reflective learning and theory-based frameworks can foster transformative educational experiences. The findings highlight the importance of incorporating community-based programs into medical curricula to prepare future physicians to address health disparities and complex social determinants effectively.