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

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.

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.

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.

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.