Training medical students in health promotion: twenty years of experience at the Faculty of Medicine of the University of Geneva

Background: In most cases, the work of medical doctors, be they general practitioners or specialists, involves some dimension of health promotion (HP). There is thus ample justification for increasing the awareness of medical students vis-à-vis HP and its relevance for their future practice. Methods: In the context of a major curriculum reform (problem-based learning [PBL]) at the Faculty of Medicine of the University of Geneva in the mid-1990s, several steps were taken to strengthen HP throughout the curriculum and include HP in its key domains as defined by the Ottawa Charter (OC). Results: First, the political dimension of HP was developed in a series of first- and fifth-year lectures and third-year workshops; second, community action was strengthened through a third-year one-month community immersion program; third, the development of personal skills was integrated into second- and third-year PBL cases and into fourth-and fifth-year learning activities in clinical settings as well as second- and third-year HP electives; in terms of reorienting health services, the chosen approach included the development of a HP-specific track in the context of a Certificate of Advanced Studies (CAS) in Community Health and a Master of Advanced Studies(MAS) in Public Health. Furthermore, a supportive intra-university environment was created through a collaborative convention with Health Promotion Switzerland, which is in charge of coordinating HP in Switzerland. Conclusion: In our view, HP teaching for medical students seems all the more relevant given that future medical doctors will have to take care of an increasing number of patients likely to develop chronic non-communicable diseases.


Introduction
In most cases, the work of medical doctors, be they general practitioners or specialists, involves some dimension of health promotion (HP). There is thus ample justification for increasing the awareness of medical students vis-à-vis HP and its relevance for their future practice. 1 Marc Lalonde, the Canadian Minister of National Health and Welfare in the 1970s, first shaped the concept of HP in his report on the health of Canadians. 2 Ultimately, his reflections were key to the development of the Ottawa Charter (OC) in 1986 and its main approaches, i.e., "advocacy, empowerment and mediation" in 5 action areas, namely building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services. 3 In 2003 the General Medical Council's Tomorrow's Doctors (second edition) further stressed the importance of exposing medical students to HP topics. 4 In the context of a major curriculum reform (problembased learning [PBL]) at the Faculty of Medicine of the University of Geneva in the mid-1990s, 5 several steps were taken to strengthen community health 6 and HP throughout the curriculum.
Our article presents the HP training activities HPP progressively implemented at the Faculty of Medicine of the University of Geneva over a 20-year period.

Materials and Methods
Considering HP in its key action areas as defined by the OC, the Faculty progressively implemented a series of HP learning activities ranging from the first year of medical studies to the fifth (the sixth being a clinical clerkship rotation year); furthermore, a Certificate of Advanced Studies (CAS) in Community Health 7 and a Master of Advanced Studies (MAS) in Public Health 8 were modified, i.e., for each a specific HP track was elaborated in collaboration with Health Promotion Switzerland, which is in charge of coordinating HP programs at the national level.

Results
Keys to the successful implementation of HP teaching activities were the following elements: • It was part of a major curriculum reform with a switch from frontal lectures to PBL during the preclinical years and more bedside teaching during the clinical years. • It benefited from the fact that in the context of the curriculum reform, the public health dimension was considered as deserving of more consideration. This was a critical point, and the support from the various curriculum coordination committees was crucial. • Its development was facilitated by the introduction of elective courses according to the recommendations of the Bologna Process. • Its introduction and strengthening took place progressively over a period of several years. • It has received support from Health Promotion Switzerland, which has mobilized teachers and has made available its network of contacts (field professionals). The developed and implemented HP training activities can be summarized as follows: • OC action area -Building healthy public policy The political dimension of HP was developed in a series of first-and fifth-year lectures and third-year workshops focusing on the socio-economic role of the physician and on the organization of the health system. The topics discussed are summarized in Table 1.

• OC action area -Strengthening community action
Community action was strengthened through a thirdyear one-month community immersion program where small groups of students had to investigate the bio-medico-social and economic dimensions of a given health problem in the community by meeting and interviewing patients and families affected by the problem, health professionals in charge of the problem (general practitioners [GPs], medical specialists, public health officers, health economists, nurses, social workers, etc) as well as political authorities, researchers in the specific field and representatives of non-governmental organizations (NGO) active in the field. At the end of the month, each group had to present their work in a report, an oral presentation in front of their peers and a poster that summed up the network involved with the investigated topic. 9  The development of personal skills was integrated into second-and third-year PBL cases and into fourth-and fifth-year learning activities in clinical settings as well as second-and third-year HP Table 1. Examples of topics taught/discussed (OC action area "Building healthy public policy")

Topics
Year 1 Social and environmental health determinants Health determinants in professional settings Determinants of disease chronicity Health promotion and disease prevention in general practice Motivational interviewing Year 3 Organization of the health system and the role of various actors Regulations, incentives and constraints of medical practice Cost control of the health system: challenges and opportunities Economic evaluation of health care activities and public health measures Health care and disease prevention reimbursement mechanisms Year 5 Public health screening strategies Health promotion and disease prevention strategies Occupational health issues and prevention measures Evidence-based health promotion and disease prevention electives. Table 2 shows some integrated diseaseprevention and health-promotion topics discussed in the basic-science and clinical-science PBL modules. During the HP electives, which represent 10% of the total ECTS points and were taken by roughly 10% of the students, students were put into active learning situations and assigned to elaborating HP projects. Developed projects targeting University of Geneva students included Reduction of stress; Promotion of physical activities; Promotion of tools to enhance good sleep. Evaluations of the electives program by the students showed high satisfaction, continued interest and strong commitment.

• OC action area -Reorienting health services
Given the academic setting, the chosen approach for reorienting health services included the development of a HP-specific track in the context of a CAS in Community Health and a MAS in Public Health.
Since the 2 programs are heavily community and project centered, the objective was to initiate the planning and implementation of community HP programs and HP research projects. Examples of such projects appear in Table 3.

• OC action area -Creating a supportive environment
Furthermore, a supportive intra-university environment was created through a collaborative convention with Health Promotion Switzerland, which is in charge of coordinating HP in Switzerland. The collaboration allowed mobilizing the Foundation's HP experts as teachers, tutors and project supervisors. It also ensured funding for HP activities at the Faculty of Medicine and provided the basis for joint research activities related to the federal non-communicable diseases strategy. 11 In the 20 years since the curriculum reform, over 2500 students have been exposed to the various HP activities.
The difficulties encountered had various origins. Here are some of the most striking examples: • Some tutors of the basic-science PBL modules were Box 1. Cumulated perception (main points) the students had of the community immersion program over the years (OC action area "Strengthening community action") collected in a SWOT (strengths, weaknesses, opportunities, threats) grid not comfortable with the integrated HP topics, which meant that these topics got less attention during PBL sessions and over the years were even in danger of disappearing. • The organizational and logistical aspect of the community immersion activities proved to be quite time consuming, as did the tutoring of the students: this strained the resources of the teaching staff in charge of the program. • So far, the HP electives failed to meet expectations with regard to students' interest and participation: HP electives are in competition with many other courses, some of which are perceived by students as more important or more interesting in light of their future profession. • The long-term upkeep of HP community projects initiated by the CAS and MAS students could frequently not been ensured.

Discussion
In the aftermath of the OC, the World Conference on Medical Education in Edinburgh stated that medical education should "produce doctors who will promote the health of all people. " 12 The drive for more HP education has been kept alive over the years, with, e.g., the report of a medical students conference in Bristol in 2006 proposing such HP learning objectives as being able "to promote the health of individuals and society" or being familiar with "the strategies of prevention. " 13 The issue has further been raised/supported by political authorities stressing the importance of developing HP competencies among health care professionals, e.g., in Britain with the program Putting Prevention First 14 or more recently in Switzerland with the program Health2020. 15 The HP education activities implemented at the Faculty of Medicine of the University of Geneva go, in our view, in the direction of those recommendations.
We were faced with several challenges in implementing those HP teaching activities, even though we benefited from favorable conditions in the context of the curriculum reform. Indeed, the support of the various curriculum committees was key in implementing HP teaching activities. Furthermore, a close collaboration with the persons in charge of teaching public health and community medicine was crucial to accessing "teaching slots" and developing shared teaching activities. One of the major challenges we faced was the availability of competent staff in the field of HP to set up and carry out the program over the long term. Here we benefited from the support of Health Promotion Switzerland, which provided some of the HP expertise and teaching staff. Another challenge lay in identifying teaching methods attractive enough for students to engage in enthusiastically; the community immersion program was part of the solution in that it allowed students to explore any given health problem in its bio-psycho-social dimensions and the HP and disease prevention interventions likely to decrease the problem. A third challenge, as yet unresolved, was to ensure the longterm upkeep of HP community projects initiated by the CAS and MAS students. In many cases to date, long-term funding could not be obtained, which brought the projects to an early end.
Through the variety of educational approaches adopted (lectures, workshops, community investigations, integrated HP topics in basic-science and clinical-science PBL modules, project planning and implementation in the community), their distribution over the length of the curriculum and their adherence to the five OC action areas, the developed HP education activities respect, in our view, the recommendations of educational experts. Indeed, the community immersion program and the community project as implemented by the Geneva medical and public health students are coherent with Naidoo & Orme's vision of an "expanding role for medical doctors in planning HP activities for local populations. " 16 The integration of HP topics into clinical-science PBL modules responds to one of the challenges HP topics face in a medical curriculum, namely the clinical relevance, which would ultimately raise student interest as has been reported. 17,18 The integration of HP topics into all the years of the curriculum, as was done in Geneva, is also recommended in the literature. 19 Finally, the signing of a cooperation agreement between the University of Geneva and Health Promotion Switzerland allows us to envision Table 3. Examples of implemented projects (OC action area "Reorienting health services")

Research projects
Access to health services for the migrant populations in Switzerland: findings and limitations Access to health care for victims of female genital mutilation in Switzerland The challenges and expectations of relatives of people suffering from mental disorders Medico-economic evaluation of maternal and perinatal care services of a new model of midwifery care

Intervention projects
"Croque & bouge" (chew& move): an obesity prevention program for young children Development and implementation of cantonal tobacco prevention programs Planning and implementing a sensory screening program in schools in a Swiss canton Implementing a community health promotion project with nursing students further developments in HP education for medical students and health personnel in general.
Perhaps one setback that should be mentioned: the difficulty of developing HP activities in an integrative, multi-professional way, i.e., HP workshops and HP community projects that include students from medical schools, nursing schools, dietetics schools and physical therapy schools, a multidisciplinary and multi-professional approach as advocated by a large panel of experts. 20 Each institution/track has its own catalogue of objectives and its own timeline, but each institution also has its prejudices regarding the others, which can be difficult to overcome.

Conclusion
The various HP teaching activities developed at the Faculty of Medicine of the University of Geneva benefited from a specific dynamic related to a major curriculum reform. Their implementation was progressive and done in close collaboration with the persons in charge of public health and community medicine of the university. The support of Health Promotion Switzerland boosted the project and provided access to a HP-competent workforce.
In our view, HP teaching for medical students seems all the more relevant given that future medical doctors will have to take care of an increasing number of patients likely to develop chronic non-communicable diseases.

Ethical approval
None to be declared.