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The importance of ensuring that medical students are adequately prepared to work in increasingly diverse and multi-ethnic societies is well recognised from international research.1-5 This has resulted in efforts to incorporate the teaching of culture and cultural competencies in medical schools in the US,3 Canada,4 Sweden,6 and New Zealand.7 These efforts include language training, lectures, workshops, electives, rotations and cultural immersion programmes.7-13Medical schools are challenged to teach students how to integrate clinical knowledge and expertise with an understanding of the society they live in, so they are better able to respond to needs in the community.14 The significant implications for students, staff and the community make culture and cultural competence an important subject in medical education.14-16 Some studies have reported positive changes from the inclusion of "culture and medicine" in the curriculum.13,17 For example, the evaluation of knowledge, attitude and skills in cultural competence appeared to improve following cultural teaching for medical students.15The literature identifies the importance of having a longitudinal thread of "culture and medicine" teaching in the curriculum.18,19 Isolated or disconnected lectures may not enable students to acquire adequate knowledge and skill. Some research however found cultural training failed to show a change in the knowledge and attitudes of medical students.16 There is caution about continuing disparities if physicians are not able to engage effectively with at-risk communities.18,20The proper evaluation of education in "culture and medicine" and assessment of students' competencies require investment of time and adequate resources. The areas that can be assessed in cross-cultural education are students' attitudes, knowledge and skills.1 Assessment of knowledge and skills is relatively easy to do but assessing students' attitudes remains a challenge.9 For example, quantitative tools based on social cognitive theory used by social psychologists to assess attitudes are long and cumbersome.21Students may also elect to answer questions in a socially desirable way. A review of the literature on cross cultural experiences and their benefits identified 42 studies,22 and articulated the need for more rigorous methods to assess outcomes. The development of appropriate assessment and evaluation methods on how "culture and medicine" teaching impacts on students' learning was recommended.Pacific peoples: a migrant population in New ZealandNew Zealand has had a unique relationship and influence as a colonial power in the Pacific Islands over many years.23In the 1950s, many Pacific workers were actively recruited from the Pacific Islands to provide the workforce New Zealand needed for many industries and manufacturing sectors.24,25 This was during economic prosperous times after World War 2.The New Zealand Government changed its attitude towards Pacific workers during the economic recession in the 1970s.26 Previously, the government and employers ignored Pacific workers' requirements to have appropriate work permits or renewal of these permits when they expired. During the recession, the government's solution to addressing economic problems was to expel Pacific overstayers through the unfortunate "dawn raids". This affected the health and wellbeing of all Pacific peoples living in New Zealand, and stimulated the organisation of Pacific peoples as a political group. Pacific peoples now living in New Zealand make up approximately 7% of the total New Zealand population, and are a diverse minority group.27In contrast to the total population, the Pacific population has a younger age structure (median age 21 compared to 36 in the total population), and is predicted to grow to 9.6% of the total population by 2026.27. Pacific peoples suffer disproportionately from poor health and other socioeconomic disadvantages compared to the total population.28Only 1% of all doctors working in New Zealand have Pacific ethnicity,29 therefore most Pacific peoples who access health services will be cared for by non-Pacific health professionals. It is very important to provide opportunities for all medical students to learn about Pacific peoples, their cultures and factors that influences their health.The New Zealand Medical Council recently published a resource booklet for health professionals outlining practice implications when working with Pacific peoples.30 The Ministry of Health has guidelines on Pacific cultural competencies,31 and a national Pacific plan to assist health professionals working with Pacific communities.32University of Otago and community engagementEngaging at-risk communities in the work of training institutions is seen as important in making a difference for these communities.33 For example, Duke University and the city of Durham developed a set of "Principles of Community Engagement" to assist in the training of health professionals.The University of Otago had already worked successfully with a Maori community to teach medical students about indigenous health through an immersion programme.7 A similar approach had not previously been explored for teaching involving migrant communities in New Zealand. A Pacific Immersion Programme was developed where students would spend time living with a local Pacific family. Funds for the programme were made available through the Dean's Office.Faculty of Medicine trainingSchool leavers who wish to train in Medicine at the University are required to do a prescribed competitive Health Science First Year course.34 Some students are admitted as competitive graduates, and others as "Other category" students. The Faculty of Medicine currently accepts 270 students into the second year of training. Those who are successful enter the Early Learning in Medicine programme (which lasts 2 years). Students then progress to the Advanced Learning in Medicine programme, and are distributed to either Christchurch, Dunedin or Wellington.The development of a new medical curriculum at the Faculty of Medicine in 2008 provided the opportunity to introduce a longitudinal approach to teaching Pacific Health. Teaching of Pacific Health in the new Early Learning in Medicine programme (Years 2 and 3 of a 6-year programme) was delivered through whole class lecture series. Following this, the Pacific Immersion Programme was incorporated into Year 4 at the Dunedin Campus (one of the three campuses which run the Advanced Learning in Medicine (Years 4, 5 and 6) in 2010. Teaching in Pacific Health in Year 5 was incorporated into the curriculum as a whole class lecture series. Students were encouraged to consider conducting their medical electives in the final year (sixth year) of training in one of the Pacific Islands.Pacific Immersion Programme developmentThe Pacific Immersion Programme was part of the Public Health attachment at the Department of Preventive and Social Medicine. The Department has a senior lecturer position in Pacific Health. This assisted discussions about developing a Pacific Immersion Programme within the local community.The objectives of the attachment for students were to: Experience Pacific family life in NZ Observe how culture, religion and socioeconomic environment influence health Practise and observe cross cultural communication Provide opportunities for the community to teach students about their health, and how best to engage with them in the clinical setting Determine from observations and information shared, what could be useful for them in the future Students were well prepared prior to engagement with the local community. Year 4 students have had training in confidentiality issues and professional development. Students were ambassadors for the University, and a high level of professionalism was expected.There were four rotations during the year. Year 4 students attended in groups of approximately 20. Christianity plays a large part in the lives of many Pacific peoples and a weekend attachment enabled students to observe how religion influenced their lives. Three options were given to students : "Whole weekend stay", "Day stay only" and "Opt out". Those who opted out, were required to register a reason for doing so.Information was provided to students about the programme objectives, guidance on learning opportunities, cultural protocols and processes specific to the Pacific community involved. The information provided also assisted students in writing a reflective essay about what they learnt.Leaders from the Pacific community met students at the University the day before each attachment. This meeting provided opportunities for students to ask questions. The community welcomed students and staff in line with usual cultural protocols at the beginning of the programme. These included a traditional kava ceremony (a ceremonial welcome drink), singing, dancing and gifting of leis (traditional flower necklaces). Students were then introduced to their host families.Everyone shared a morning tea together before students left with their host families. The wider community (including families not involved in the programme) gathered again the following day (Sunday) after church services for a combined celebration meal before the farewells. A debrief meeting with University staff the following day (Monday) gave students the opportunity to discuss observations, issues and experiences from the weekend. The students were also invited to complete a feedback form.Community consultationsConsultation with the wider Pacific community was initiated in August 2009 when funding for the Pacific Immersion Programme was approved. The Pacific Immersion Programme catered for four groups of students (attachments) through the year. The three largest Pacific ethnic groups in New Zealand were Samoans, Cook Islands and Tongans, and it was agreed the first attachment was with the Samoan group, followed by the Cook Islands and Tongan groups.The last attachment was allocated to combined smaller Pacific ethnic groups. Each group was involved once only during the year. The objectives and expectations of the programme was translated for Pacific families who wished to participate. Each community group nominated a coordinator to liaise closely with the University on all aspects of programme development.These coordinators were leaders within their own communities, and responsible for matching students to host families. Coordinators also ensured excellent communication between the University and the local Pacific community. Community coordinators met with University staff after each attachment for a debrief and feedback meeting. Feedback from the community about the programme was well received.Programme feedbackThere were 77 fourth-year medical students enrolled at the Dunedin School of Medicine in 2010, and 57 (74 %) participated in the programme. Of the 20 who opted out, one was unwell and others had prior commitments. All student participants reported they enjoyed the programme, felt welcomed by the local community and were comfortable in the host environment.Most students felt the programme helped their understanding of Pacific cultures, and gave them confidence to work across cultures (Table 1). Approximately, three quarters reported their upbringing was different from that of their hosts, however most felt there were able to communicate with them. Table 1. Feedback from medical students in the Pacific Immersion Programme Question Yes n(%) No n(%) Don't Know n(%) Do you feel this programme helped your understanding of a Pacific Islands culture? 55(96.5) 1(1.8) 1(1.8) Were there any differences in your upbringing compared to what you observed? 42(73.7) 10(17.5) 3(5.3) Did you feel you were able to communicate with people? 54(94.7) 1(1.8) 2(3.2) Did you feel there were any barriers with respect to communication? 10(17.5) 37(64.9) 8(14) Did this experience give you confidence to work within a different culture? 47(82.5) 2(3.5) 6(10.5) Community coordinators reported their community felt the medical students had a positive influence on their young people inspiring some to consider further education after high school. They also felt empowered through the opportunity to shape the training of future doctors. The Dean of the Dunedin School of Medicine and senior staff members attended some of the attachments. The community appreciated the level of engagement and commitment from the University. Lessons learned Make the programme a required component of learning—The programme was offered as an optional part of medical training. Twenty students did not take part in the programme. Many who missed out requested for another opportunity to take part in the programme. Unfortunately, this could not be arranged. The cultural immersion programme was a unique opportunity to learn about the health of an underserved community in New Zealand. In 2011, all students will be expected to undertake the programme. This requirement has been endorsed by the Dean of the Dunedin School of Medicine. Value cultural training in health—The teaching of "culture and health" should be seen to be valued by the institutional leadership.18 Support from the Dean and senior staff provided endorsement at this level. The literature in this area suggested a number of core components were required in the teaching of "culture and health" in undergraduate medical education.18 One of these was community participation as the "expert teacher". Subjects critical to students' education should be clearly defined, articulated and examinable.10 Students were motivated to learn subjects that were assessed.35 Incorporating Pacific Health as part of the examinable component of medical education will ensure students value it as an important part of the medical curriculum. Clear communication and transparent processes are essential—The work and commitment of Pacific community coordinators were critical in ensuring the Programme's success through excellent communication between the community and the University. They also assisted to ensure University processes were transparent and clear to the local community. This ensured the success of the programme. Empowering community—The Pacific community was empowered by the experience, because they felt what they had to share was valued. All families who participated wanted to be involved in future programmes. Many felt they could influence the care they receive in the future by teaching future doctors about how best to engage with them. Others believed they were also helping the wider Pacific community and society in New Zealand by contributing to the training of future health professionals. Looking ahead : Extension of the programme—The Pacific Immersion Programme at the University of Otago medical programme could be explored as a method for teaching Pacific health in other campuses and universities in New Zealand. It could also provide a template for the engagement of other minority community groups in the training of health professionals. Developing relationships—The development of good relationships through these types of programmes could lead to establishing excellent networks for service, research and teaching. This will benefit not only tertiary education institutions but also underserved communities. Conclusion The Pacific Immersion Programme was explored as a way to dramatically enhance Pacific Health learning for medical students at the University of Otago, New Zealand. Students and staff felt it was an effective way of teaching students about Pacific health and engaging the community in the work of the University. Community relationships and networks developed formed a basis for further work and collaborations in the future. Lessons learnt from developing this programme may be useful for other health training institutions.

Summary

Abstract

Aim

Medical schools are required to adequately prepare students to work in increasingly diverse and multi-ethnic societies. Students need to be able to integrate clinical knowledge with an understanding of the society they live in. Pacific peoples are a disadvantaged migrant minority ethnic group in New Zealand. This paper discusses the development of, and lessons learnt from a Pacific Immersion Programme for medical students at the University of Otago, New Zealand.

Method

A cultural programme was developed where fourth-year medical students spent a week-end with a local Pacific family in Dunedin. Students were invited as part of the programme evaluation to provide feedback on their experiences and lessons learnt. Student evaluations were analysed and are reported here in summary form.

Results

Medical students were able to learn from observations, participation in activities and stories shared by families about issues that influenced the health of the community. This provided insight about factors that are important to consider, when working with Pacific peoples in New Zealand. The programme also provided positive benefits for the local community.

Conclusion

This cultural immersion programme provided important learning opportunities for medical students. It is important to value and empower communities when developing cultural teaching programmes. The incorporation of the programme as part of the curriculum, and its implications for overall assessment and performance of students, makes it a valued part of learning.

Author Information

Faafetai Sopoaga, Senior Lecturer, Pacific Health, Department of Preventive and Social Medicine, University of Otago, Dunedin; Jennie L Connor, Professor and HoD, Department of Preventive and Social Medicine, University of Otago, Dunedin; John D Dockerty, Associate Dean, Undergraduate Education, Dunedin School of Medicine, University of Otago; John Adams, Dean, Dunedin School of Medicine, University of Otago, Dunedin (and Chair of the New Zealand Medical Council); Lynley Anderson, Senior Lecturer, Bioethics Centre, Faculty of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Faafetai Sopoaga, Department Preventive and Social Medicine, P O Box 913, University of Otago, Dunedin, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

tai.sopoaga@otago.ac.nz

Competing Interests

None declared.

Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for teaching and learning. Med Educ. 2009;43:229-237.Rapp DE. Integrating cultural competency into the undergraduate medical curriculum. Med Educ. 2006;40:704-710.Dolhun EP, Munoz C, Grumbach K. Cross-cultural education in US medical schools: Development of an assessment tool. Acad Med. 2003;78:615-622.Taylor JS. Confronting \"culture\" in medicine's \"culture of no culture\". Acad Med. 2003;78:555-559.Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31:990-993.Wachtler C, Troein M. A hidden curriculum: mapping cultural competency in a medical programme. Med Educ. 2003;37:861-868.Dowell A, Crampton P, Parkin C. The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Med Educ. 2001;35:242-249.Gupta AR DT, Johnston MA. Incorporating multiculturalism into a doctor-patient course. Acad Med. 1997;72:428.Mao C BC, Harway EC, Khalsa SK. A workshop on ethnic and cultural awareness for second-year students. J Med Educ. 1988;63:624-628.Esfandiari A DC, Wilerson L, Gill G. An international health/tropical medicine elective. Acad Med. 2001;76:516.Takayama JI CC, Pearl DB. A one-month cultural competency rotation for pediatrics residents. Acad Med. 2001;76:514-515.Godkin M WL. A pathway on serving multicultural and underserved population. Acad Med. 2001;76:513-514.Dogra N. The development and evaluation of a programme to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232-241.Durey A. Reducing racism in Aboriginal Australia: where does cultural education fit. Aust N Z J Public Health, 2010; S87-S92.Roberts JH, Sanders T, Wass V. Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study. Med Educ. 2008;42:45-52.Crampton P, Dowell A, Parkin C, Thompson C. Combating effects of racism through a cultural immersion medical education program. Acad Med. 2003;78:595-598.Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588-594.Tervalon M. Components of culture in health for medical students' education. Acad Med. 2003;78:570-576.Wear D. Insurgent multiculturalism: Rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549-554.Beagan BL. Teaching social and cultural awareness to medical students: \"it's all very nice to talk about it in theory, but ultimately it makes no difference\". Acad Med. 2003;78:605-614.Bandura A. Social Cognitive Theory: An agentive perspective. Annual Review of Psychology. 2001;52:1-26.Mutchnick IS, Stern DT. Expanding the Boundary of Medical Education : Evidence for Cross-cultural Exchanges. Acad Med. 2003;78:S1-S5.Denoon D. The Cambridge History of the Pacific Islands. Cambridge Cambridge University Press; 1997.Spoonley P. A contemporary political economy of labour migration in New Zealand. Tijdschrift voor Economische en Sociale Georgrafie. 2006;97:17-25.Robyn R, Iredale CH, Castles S. Migration in the Asia Pacific : population, settlement and citizenship issues. Edward Elgar Publishing Inc; 2003.Ministry for Culture and Education NZ. History and Migration. The Encyclopedia of New Zealand, Wellington, 2005-2011.Statistics New Zealand. Demographics of New Zealand's Pacific Population. 2006.http://www.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-demography.aspx[Accessed 22 November 2010.]Ministry of Health. A Portrait of Health. Key results of the 2006/7 New Zealand Health Survey. 2008.http://www.moh.govt.nz/moh.nsf/0/6910156be95e706e4c2568800002e403?OpenDocument [Accessed 23 November 2010.]Ministry of Health. Pacific Health and Disability Workforce Development Plan. 2004.http://www.moh.govt.nz/moh.nsf/pagesmh/3681 [Accessed 17 November 2010 ]New Zealand Medical Council. Best Outcomes for Pacific Peoples : Practice Implications. 2010.http://www.mcnz.org.nz/portals/0/publications/Best%20health%20outcomes%20for%20Pacific%20Peoples.pdf [Accessed November 17, 2010 ]Tiatia J. Pacific Cultural Competencies : A Literature Review. 2008. http://www.moh.govt.nz/moh.nsf/indexmh/pacific-cultural-competencies-literature-review [Accessed 29 November.]Ministry of Health and Ministry of Pacific Island Affairs. 'Ala Mo'ui : Pathways to Pacific Health and Wellbeing 2010-2014. 2010. http://www.moh.govt.nz/moh.nsf/pagesmh/10007/$File/ala-moui-pathways-to-pacific-health-wellbeing2010-2014.pdf[Accessed 29 November 2010]Michener JL, Yaggy S, Lyn M, et al. Improving the Health of the Community: Duke's Experience with Community Engagement. Acad Med. 2008;83:408-413.University of Otago. University of Otago Calendar. Applications for admission to medicine. 2010.http://www.healthsci.otago.ac.nz/admissions/micn2011.html [Accessed 22 November 2010.]Newble D. Assessment. Medical Education in the Millenium. 1998:131-142.

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The importance of ensuring that medical students are adequately prepared to work in increasingly diverse and multi-ethnic societies is well recognised from international research.1-5 This has resulted in efforts to incorporate the teaching of culture and cultural competencies in medical schools in the US,3 Canada,4 Sweden,6 and New Zealand.7 These efforts include language training, lectures, workshops, electives, rotations and cultural immersion programmes.7-13Medical schools are challenged to teach students how to integrate clinical knowledge and expertise with an understanding of the society they live in, so they are better able to respond to needs in the community.14 The significant implications for students, staff and the community make culture and cultural competence an important subject in medical education.14-16 Some studies have reported positive changes from the inclusion of "culture and medicine" in the curriculum.13,17 For example, the evaluation of knowledge, attitude and skills in cultural competence appeared to improve following cultural teaching for medical students.15The literature identifies the importance of having a longitudinal thread of "culture and medicine" teaching in the curriculum.18,19 Isolated or disconnected lectures may not enable students to acquire adequate knowledge and skill. Some research however found cultural training failed to show a change in the knowledge and attitudes of medical students.16 There is caution about continuing disparities if physicians are not able to engage effectively with at-risk communities.18,20The proper evaluation of education in "culture and medicine" and assessment of students' competencies require investment of time and adequate resources. The areas that can be assessed in cross-cultural education are students' attitudes, knowledge and skills.1 Assessment of knowledge and skills is relatively easy to do but assessing students' attitudes remains a challenge.9 For example, quantitative tools based on social cognitive theory used by social psychologists to assess attitudes are long and cumbersome.21Students may also elect to answer questions in a socially desirable way. A review of the literature on cross cultural experiences and their benefits identified 42 studies,22 and articulated the need for more rigorous methods to assess outcomes. The development of appropriate assessment and evaluation methods on how "culture and medicine" teaching impacts on students' learning was recommended.Pacific peoples: a migrant population in New ZealandNew Zealand has had a unique relationship and influence as a colonial power in the Pacific Islands over many years.23In the 1950s, many Pacific workers were actively recruited from the Pacific Islands to provide the workforce New Zealand needed for many industries and manufacturing sectors.24,25 This was during economic prosperous times after World War 2.The New Zealand Government changed its attitude towards Pacific workers during the economic recession in the 1970s.26 Previously, the government and employers ignored Pacific workers' requirements to have appropriate work permits or renewal of these permits when they expired. During the recession, the government's solution to addressing economic problems was to expel Pacific overstayers through the unfortunate "dawn raids". This affected the health and wellbeing of all Pacific peoples living in New Zealand, and stimulated the organisation of Pacific peoples as a political group. Pacific peoples now living in New Zealand make up approximately 7% of the total New Zealand population, and are a diverse minority group.27In contrast to the total population, the Pacific population has a younger age structure (median age 21 compared to 36 in the total population), and is predicted to grow to 9.6% of the total population by 2026.27. Pacific peoples suffer disproportionately from poor health and other socioeconomic disadvantages compared to the total population.28Only 1% of all doctors working in New Zealand have Pacific ethnicity,29 therefore most Pacific peoples who access health services will be cared for by non-Pacific health professionals. It is very important to provide opportunities for all medical students to learn about Pacific peoples, their cultures and factors that influences their health.The New Zealand Medical Council recently published a resource booklet for health professionals outlining practice implications when working with Pacific peoples.30 The Ministry of Health has guidelines on Pacific cultural competencies,31 and a national Pacific plan to assist health professionals working with Pacific communities.32University of Otago and community engagementEngaging at-risk communities in the work of training institutions is seen as important in making a difference for these communities.33 For example, Duke University and the city of Durham developed a set of "Principles of Community Engagement" to assist in the training of health professionals.The University of Otago had already worked successfully with a Maori community to teach medical students about indigenous health through an immersion programme.7 A similar approach had not previously been explored for teaching involving migrant communities in New Zealand. A Pacific Immersion Programme was developed where students would spend time living with a local Pacific family. Funds for the programme were made available through the Dean's Office.Faculty of Medicine trainingSchool leavers who wish to train in Medicine at the University are required to do a prescribed competitive Health Science First Year course.34 Some students are admitted as competitive graduates, and others as "Other category" students. The Faculty of Medicine currently accepts 270 students into the second year of training. Those who are successful enter the Early Learning in Medicine programme (which lasts 2 years). Students then progress to the Advanced Learning in Medicine programme, and are distributed to either Christchurch, Dunedin or Wellington.The development of a new medical curriculum at the Faculty of Medicine in 2008 provided the opportunity to introduce a longitudinal approach to teaching Pacific Health. Teaching of Pacific Health in the new Early Learning in Medicine programme (Years 2 and 3 of a 6-year programme) was delivered through whole class lecture series. Following this, the Pacific Immersion Programme was incorporated into Year 4 at the Dunedin Campus (one of the three campuses which run the Advanced Learning in Medicine (Years 4, 5 and 6) in 2010. Teaching in Pacific Health in Year 5 was incorporated into the curriculum as a whole class lecture series. Students were encouraged to consider conducting their medical electives in the final year (sixth year) of training in one of the Pacific Islands.Pacific Immersion Programme developmentThe Pacific Immersion Programme was part of the Public Health attachment at the Department of Preventive and Social Medicine. The Department has a senior lecturer position in Pacific Health. This assisted discussions about developing a Pacific Immersion Programme within the local community.The objectives of the attachment for students were to: Experience Pacific family life in NZ Observe how culture, religion and socioeconomic environment influence health Practise and observe cross cultural communication Provide opportunities for the community to teach students about their health, and how best to engage with them in the clinical setting Determine from observations and information shared, what could be useful for them in the future Students were well prepared prior to engagement with the local community. Year 4 students have had training in confidentiality issues and professional development. Students were ambassadors for the University, and a high level of professionalism was expected.There were four rotations during the year. Year 4 students attended in groups of approximately 20. Christianity plays a large part in the lives of many Pacific peoples and a weekend attachment enabled students to observe how religion influenced their lives. Three options were given to students : "Whole weekend stay", "Day stay only" and "Opt out". Those who opted out, were required to register a reason for doing so.Information was provided to students about the programme objectives, guidance on learning opportunities, cultural protocols and processes specific to the Pacific community involved. The information provided also assisted students in writing a reflective essay about what they learnt.Leaders from the Pacific community met students at the University the day before each attachment. This meeting provided opportunities for students to ask questions. The community welcomed students and staff in line with usual cultural protocols at the beginning of the programme. These included a traditional kava ceremony (a ceremonial welcome drink), singing, dancing and gifting of leis (traditional flower necklaces). Students were then introduced to their host families.Everyone shared a morning tea together before students left with their host families. The wider community (including families not involved in the programme) gathered again the following day (Sunday) after church services for a combined celebration meal before the farewells. A debrief meeting with University staff the following day (Monday) gave students the opportunity to discuss observations, issues and experiences from the weekend. The students were also invited to complete a feedback form.Community consultationsConsultation with the wider Pacific community was initiated in August 2009 when funding for the Pacific Immersion Programme was approved. The Pacific Immersion Programme catered for four groups of students (attachments) through the year. The three largest Pacific ethnic groups in New Zealand were Samoans, Cook Islands and Tongans, and it was agreed the first attachment was with the Samoan group, followed by the Cook Islands and Tongan groups.The last attachment was allocated to combined smaller Pacific ethnic groups. Each group was involved once only during the year. The objectives and expectations of the programme was translated for Pacific families who wished to participate. Each community group nominated a coordinator to liaise closely with the University on all aspects of programme development.These coordinators were leaders within their own communities, and responsible for matching students to host families. Coordinators also ensured excellent communication between the University and the local Pacific community. Community coordinators met with University staff after each attachment for a debrief and feedback meeting. Feedback from the community about the programme was well received.Programme feedbackThere were 77 fourth-year medical students enrolled at the Dunedin School of Medicine in 2010, and 57 (74 %) participated in the programme. Of the 20 who opted out, one was unwell and others had prior commitments. All student participants reported they enjoyed the programme, felt welcomed by the local community and were comfortable in the host environment.Most students felt the programme helped their understanding of Pacific cultures, and gave them confidence to work across cultures (Table 1). Approximately, three quarters reported their upbringing was different from that of their hosts, however most felt there were able to communicate with them. Table 1. Feedback from medical students in the Pacific Immersion Programme Question Yes n(%) No n(%) Don't Know n(%) Do you feel this programme helped your understanding of a Pacific Islands culture? 55(96.5) 1(1.8) 1(1.8) Were there any differences in your upbringing compared to what you observed? 42(73.7) 10(17.5) 3(5.3) Did you feel you were able to communicate with people? 54(94.7) 1(1.8) 2(3.2) Did you feel there were any barriers with respect to communication? 10(17.5) 37(64.9) 8(14) Did this experience give you confidence to work within a different culture? 47(82.5) 2(3.5) 6(10.5) Community coordinators reported their community felt the medical students had a positive influence on their young people inspiring some to consider further education after high school. They also felt empowered through the opportunity to shape the training of future doctors. The Dean of the Dunedin School of Medicine and senior staff members attended some of the attachments. The community appreciated the level of engagement and commitment from the University. Lessons learned Make the programme a required component of learning—The programme was offered as an optional part of medical training. Twenty students did not take part in the programme. Many who missed out requested for another opportunity to take part in the programme. Unfortunately, this could not be arranged. The cultural immersion programme was a unique opportunity to learn about the health of an underserved community in New Zealand. In 2011, all students will be expected to undertake the programme. This requirement has been endorsed by the Dean of the Dunedin School of Medicine. Value cultural training in health—The teaching of "culture and health" should be seen to be valued by the institutional leadership.18 Support from the Dean and senior staff provided endorsement at this level. The literature in this area suggested a number of core components were required in the teaching of "culture and health" in undergraduate medical education.18 One of these was community participation as the "expert teacher". Subjects critical to students' education should be clearly defined, articulated and examinable.10 Students were motivated to learn subjects that were assessed.35 Incorporating Pacific Health as part of the examinable component of medical education will ensure students value it as an important part of the medical curriculum. Clear communication and transparent processes are essential—The work and commitment of Pacific community coordinators were critical in ensuring the Programme's success through excellent communication between the community and the University. They also assisted to ensure University processes were transparent and clear to the local community. This ensured the success of the programme. Empowering community—The Pacific community was empowered by the experience, because they felt what they had to share was valued. All families who participated wanted to be involved in future programmes. Many felt they could influence the care they receive in the future by teaching future doctors about how best to engage with them. Others believed they were also helping the wider Pacific community and society in New Zealand by contributing to the training of future health professionals. Looking ahead : Extension of the programme—The Pacific Immersion Programme at the University of Otago medical programme could be explored as a method for teaching Pacific health in other campuses and universities in New Zealand. It could also provide a template for the engagement of other minority community groups in the training of health professionals. Developing relationships—The development of good relationships through these types of programmes could lead to establishing excellent networks for service, research and teaching. This will benefit not only tertiary education institutions but also underserved communities. Conclusion The Pacific Immersion Programme was explored as a way to dramatically enhance Pacific Health learning for medical students at the University of Otago, New Zealand. Students and staff felt it was an effective way of teaching students about Pacific health and engaging the community in the work of the University. Community relationships and networks developed formed a basis for further work and collaborations in the future. Lessons learnt from developing this programme may be useful for other health training institutions.

Summary

Abstract

Aim

Medical schools are required to adequately prepare students to work in increasingly diverse and multi-ethnic societies. Students need to be able to integrate clinical knowledge with an understanding of the society they live in. Pacific peoples are a disadvantaged migrant minority ethnic group in New Zealand. This paper discusses the development of, and lessons learnt from a Pacific Immersion Programme for medical students at the University of Otago, New Zealand.

Method

A cultural programme was developed where fourth-year medical students spent a week-end with a local Pacific family in Dunedin. Students were invited as part of the programme evaluation to provide feedback on their experiences and lessons learnt. Student evaluations were analysed and are reported here in summary form.

Results

Medical students were able to learn from observations, participation in activities and stories shared by families about issues that influenced the health of the community. This provided insight about factors that are important to consider, when working with Pacific peoples in New Zealand. The programme also provided positive benefits for the local community.

Conclusion

This cultural immersion programme provided important learning opportunities for medical students. It is important to value and empower communities when developing cultural teaching programmes. The incorporation of the programme as part of the curriculum, and its implications for overall assessment and performance of students, makes it a valued part of learning.

Author Information

Faafetai Sopoaga, Senior Lecturer, Pacific Health, Department of Preventive and Social Medicine, University of Otago, Dunedin; Jennie L Connor, Professor and HoD, Department of Preventive and Social Medicine, University of Otago, Dunedin; John D Dockerty, Associate Dean, Undergraduate Education, Dunedin School of Medicine, University of Otago; John Adams, Dean, Dunedin School of Medicine, University of Otago, Dunedin (and Chair of the New Zealand Medical Council); Lynley Anderson, Senior Lecturer, Bioethics Centre, Faculty of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Faafetai Sopoaga, Department Preventive and Social Medicine, P O Box 913, University of Otago, Dunedin, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

tai.sopoaga@otago.ac.nz

Competing Interests

None declared.

Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for teaching and learning. Med Educ. 2009;43:229-237.Rapp DE. Integrating cultural competency into the undergraduate medical curriculum. Med Educ. 2006;40:704-710.Dolhun EP, Munoz C, Grumbach K. Cross-cultural education in US medical schools: Development of an assessment tool. Acad Med. 2003;78:615-622.Taylor JS. Confronting \"culture\" in medicine's \"culture of no culture\". Acad Med. 2003;78:555-559.Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31:990-993.Wachtler C, Troein M. A hidden curriculum: mapping cultural competency in a medical programme. Med Educ. 2003;37:861-868.Dowell A, Crampton P, Parkin C. The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Med Educ. 2001;35:242-249.Gupta AR DT, Johnston MA. Incorporating multiculturalism into a doctor-patient course. Acad Med. 1997;72:428.Mao C BC, Harway EC, Khalsa SK. A workshop on ethnic and cultural awareness for second-year students. J Med Educ. 1988;63:624-628.Esfandiari A DC, Wilerson L, Gill G. An international health/tropical medicine elective. Acad Med. 2001;76:516.Takayama JI CC, Pearl DB. A one-month cultural competency rotation for pediatrics residents. Acad Med. 2001;76:514-515.Godkin M WL. A pathway on serving multicultural and underserved population. Acad Med. 2001;76:513-514.Dogra N. The development and evaluation of a programme to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232-241.Durey A. Reducing racism in Aboriginal Australia: where does cultural education fit. Aust N Z J Public Health, 2010; S87-S92.Roberts JH, Sanders T, Wass V. Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study. Med Educ. 2008;42:45-52.Crampton P, Dowell A, Parkin C, Thompson C. Combating effects of racism through a cultural immersion medical education program. Acad Med. 2003;78:595-598.Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588-594.Tervalon M. Components of culture in health for medical students' education. Acad Med. 2003;78:570-576.Wear D. Insurgent multiculturalism: Rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549-554.Beagan BL. Teaching social and cultural awareness to medical students: \"it's all very nice to talk about it in theory, but ultimately it makes no difference\". Acad Med. 2003;78:605-614.Bandura A. Social Cognitive Theory: An agentive perspective. Annual Review of Psychology. 2001;52:1-26.Mutchnick IS, Stern DT. Expanding the Boundary of Medical Education : Evidence for Cross-cultural Exchanges. Acad Med. 2003;78:S1-S5.Denoon D. The Cambridge History of the Pacific Islands. Cambridge Cambridge University Press; 1997.Spoonley P. A contemporary political economy of labour migration in New Zealand. Tijdschrift voor Economische en Sociale Georgrafie. 2006;97:17-25.Robyn R, Iredale CH, Castles S. Migration in the Asia Pacific : population, settlement and citizenship issues. Edward Elgar Publishing Inc; 2003.Ministry for Culture and Education NZ. History and Migration. The Encyclopedia of New Zealand, Wellington, 2005-2011.Statistics New Zealand. Demographics of New Zealand's Pacific Population. 2006.http://www.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-demography.aspx[Accessed 22 November 2010.]Ministry of Health. A Portrait of Health. Key results of the 2006/7 New Zealand Health Survey. 2008.http://www.moh.govt.nz/moh.nsf/0/6910156be95e706e4c2568800002e403?OpenDocument [Accessed 23 November 2010.]Ministry of Health. Pacific Health and Disability Workforce Development Plan. 2004.http://www.moh.govt.nz/moh.nsf/pagesmh/3681 [Accessed 17 November 2010 ]New Zealand Medical Council. Best Outcomes for Pacific Peoples : Practice Implications. 2010.http://www.mcnz.org.nz/portals/0/publications/Best%20health%20outcomes%20for%20Pacific%20Peoples.pdf [Accessed November 17, 2010 ]Tiatia J. Pacific Cultural Competencies : A Literature Review. 2008. http://www.moh.govt.nz/moh.nsf/indexmh/pacific-cultural-competencies-literature-review [Accessed 29 November.]Ministry of Health and Ministry of Pacific Island Affairs. 'Ala Mo'ui : Pathways to Pacific Health and Wellbeing 2010-2014. 2010. http://www.moh.govt.nz/moh.nsf/pagesmh/10007/$File/ala-moui-pathways-to-pacific-health-wellbeing2010-2014.pdf[Accessed 29 November 2010]Michener JL, Yaggy S, Lyn M, et al. Improving the Health of the Community: Duke's Experience with Community Engagement. Acad Med. 2008;83:408-413.University of Otago. University of Otago Calendar. Applications for admission to medicine. 2010.http://www.healthsci.otago.ac.nz/admissions/micn2011.html [Accessed 22 November 2010.]Newble D. Assessment. Medical Education in the Millenium. 1998:131-142.

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The importance of ensuring that medical students are adequately prepared to work in increasingly diverse and multi-ethnic societies is well recognised from international research.1-5 This has resulted in efforts to incorporate the teaching of culture and cultural competencies in medical schools in the US,3 Canada,4 Sweden,6 and New Zealand.7 These efforts include language training, lectures, workshops, electives, rotations and cultural immersion programmes.7-13Medical schools are challenged to teach students how to integrate clinical knowledge and expertise with an understanding of the society they live in, so they are better able to respond to needs in the community.14 The significant implications for students, staff and the community make culture and cultural competence an important subject in medical education.14-16 Some studies have reported positive changes from the inclusion of "culture and medicine" in the curriculum.13,17 For example, the evaluation of knowledge, attitude and skills in cultural competence appeared to improve following cultural teaching for medical students.15The literature identifies the importance of having a longitudinal thread of "culture and medicine" teaching in the curriculum.18,19 Isolated or disconnected lectures may not enable students to acquire adequate knowledge and skill. Some research however found cultural training failed to show a change in the knowledge and attitudes of medical students.16 There is caution about continuing disparities if physicians are not able to engage effectively with at-risk communities.18,20The proper evaluation of education in "culture and medicine" and assessment of students' competencies require investment of time and adequate resources. The areas that can be assessed in cross-cultural education are students' attitudes, knowledge and skills.1 Assessment of knowledge and skills is relatively easy to do but assessing students' attitudes remains a challenge.9 For example, quantitative tools based on social cognitive theory used by social psychologists to assess attitudes are long and cumbersome.21Students may also elect to answer questions in a socially desirable way. A review of the literature on cross cultural experiences and their benefits identified 42 studies,22 and articulated the need for more rigorous methods to assess outcomes. The development of appropriate assessment and evaluation methods on how "culture and medicine" teaching impacts on students' learning was recommended.Pacific peoples: a migrant population in New ZealandNew Zealand has had a unique relationship and influence as a colonial power in the Pacific Islands over many years.23In the 1950s, many Pacific workers were actively recruited from the Pacific Islands to provide the workforce New Zealand needed for many industries and manufacturing sectors.24,25 This was during economic prosperous times after World War 2.The New Zealand Government changed its attitude towards Pacific workers during the economic recession in the 1970s.26 Previously, the government and employers ignored Pacific workers' requirements to have appropriate work permits or renewal of these permits when they expired. During the recession, the government's solution to addressing economic problems was to expel Pacific overstayers through the unfortunate "dawn raids". This affected the health and wellbeing of all Pacific peoples living in New Zealand, and stimulated the organisation of Pacific peoples as a political group. Pacific peoples now living in New Zealand make up approximately 7% of the total New Zealand population, and are a diverse minority group.27In contrast to the total population, the Pacific population has a younger age structure (median age 21 compared to 36 in the total population), and is predicted to grow to 9.6% of the total population by 2026.27. Pacific peoples suffer disproportionately from poor health and other socioeconomic disadvantages compared to the total population.28Only 1% of all doctors working in New Zealand have Pacific ethnicity,29 therefore most Pacific peoples who access health services will be cared for by non-Pacific health professionals. It is very important to provide opportunities for all medical students to learn about Pacific peoples, their cultures and factors that influences their health.The New Zealand Medical Council recently published a resource booklet for health professionals outlining practice implications when working with Pacific peoples.30 The Ministry of Health has guidelines on Pacific cultural competencies,31 and a national Pacific plan to assist health professionals working with Pacific communities.32University of Otago and community engagementEngaging at-risk communities in the work of training institutions is seen as important in making a difference for these communities.33 For example, Duke University and the city of Durham developed a set of "Principles of Community Engagement" to assist in the training of health professionals.The University of Otago had already worked successfully with a Maori community to teach medical students about indigenous health through an immersion programme.7 A similar approach had not previously been explored for teaching involving migrant communities in New Zealand. A Pacific Immersion Programme was developed where students would spend time living with a local Pacific family. Funds for the programme were made available through the Dean's Office.Faculty of Medicine trainingSchool leavers who wish to train in Medicine at the University are required to do a prescribed competitive Health Science First Year course.34 Some students are admitted as competitive graduates, and others as "Other category" students. The Faculty of Medicine currently accepts 270 students into the second year of training. Those who are successful enter the Early Learning in Medicine programme (which lasts 2 years). Students then progress to the Advanced Learning in Medicine programme, and are distributed to either Christchurch, Dunedin or Wellington.The development of a new medical curriculum at the Faculty of Medicine in 2008 provided the opportunity to introduce a longitudinal approach to teaching Pacific Health. Teaching of Pacific Health in the new Early Learning in Medicine programme (Years 2 and 3 of a 6-year programme) was delivered through whole class lecture series. Following this, the Pacific Immersion Programme was incorporated into Year 4 at the Dunedin Campus (one of the three campuses which run the Advanced Learning in Medicine (Years 4, 5 and 6) in 2010. Teaching in Pacific Health in Year 5 was incorporated into the curriculum as a whole class lecture series. Students were encouraged to consider conducting their medical electives in the final year (sixth year) of training in one of the Pacific Islands.Pacific Immersion Programme developmentThe Pacific Immersion Programme was part of the Public Health attachment at the Department of Preventive and Social Medicine. The Department has a senior lecturer position in Pacific Health. This assisted discussions about developing a Pacific Immersion Programme within the local community.The objectives of the attachment for students were to: Experience Pacific family life in NZ Observe how culture, religion and socioeconomic environment influence health Practise and observe cross cultural communication Provide opportunities for the community to teach students about their health, and how best to engage with them in the clinical setting Determine from observations and information shared, what could be useful for them in the future Students were well prepared prior to engagement with the local community. Year 4 students have had training in confidentiality issues and professional development. Students were ambassadors for the University, and a high level of professionalism was expected.There were four rotations during the year. Year 4 students attended in groups of approximately 20. Christianity plays a large part in the lives of many Pacific peoples and a weekend attachment enabled students to observe how religion influenced their lives. Three options were given to students : "Whole weekend stay", "Day stay only" and "Opt out". Those who opted out, were required to register a reason for doing so.Information was provided to students about the programme objectives, guidance on learning opportunities, cultural protocols and processes specific to the Pacific community involved. The information provided also assisted students in writing a reflective essay about what they learnt.Leaders from the Pacific community met students at the University the day before each attachment. This meeting provided opportunities for students to ask questions. The community welcomed students and staff in line with usual cultural protocols at the beginning of the programme. These included a traditional kava ceremony (a ceremonial welcome drink), singing, dancing and gifting of leis (traditional flower necklaces). Students were then introduced to their host families.Everyone shared a morning tea together before students left with their host families. The wider community (including families not involved in the programme) gathered again the following day (Sunday) after church services for a combined celebration meal before the farewells. A debrief meeting with University staff the following day (Monday) gave students the opportunity to discuss observations, issues and experiences from the weekend. The students were also invited to complete a feedback form.Community consultationsConsultation with the wider Pacific community was initiated in August 2009 when funding for the Pacific Immersion Programme was approved. The Pacific Immersion Programme catered for four groups of students (attachments) through the year. The three largest Pacific ethnic groups in New Zealand were Samoans, Cook Islands and Tongans, and it was agreed the first attachment was with the Samoan group, followed by the Cook Islands and Tongan groups.The last attachment was allocated to combined smaller Pacific ethnic groups. Each group was involved once only during the year. The objectives and expectations of the programme was translated for Pacific families who wished to participate. Each community group nominated a coordinator to liaise closely with the University on all aspects of programme development.These coordinators were leaders within their own communities, and responsible for matching students to host families. Coordinators also ensured excellent communication between the University and the local Pacific community. Community coordinators met with University staff after each attachment for a debrief and feedback meeting. Feedback from the community about the programme was well received.Programme feedbackThere were 77 fourth-year medical students enrolled at the Dunedin School of Medicine in 2010, and 57 (74 %) participated in the programme. Of the 20 who opted out, one was unwell and others had prior commitments. All student participants reported they enjoyed the programme, felt welcomed by the local community and were comfortable in the host environment.Most students felt the programme helped their understanding of Pacific cultures, and gave them confidence to work across cultures (Table 1). Approximately, three quarters reported their upbringing was different from that of their hosts, however most felt there were able to communicate with them. Table 1. Feedback from medical students in the Pacific Immersion Programme Question Yes n(%) No n(%) Don't Know n(%) Do you feel this programme helped your understanding of a Pacific Islands culture? 55(96.5) 1(1.8) 1(1.8) Were there any differences in your upbringing compared to what you observed? 42(73.7) 10(17.5) 3(5.3) Did you feel you were able to communicate with people? 54(94.7) 1(1.8) 2(3.2) Did you feel there were any barriers with respect to communication? 10(17.5) 37(64.9) 8(14) Did this experience give you confidence to work within a different culture? 47(82.5) 2(3.5) 6(10.5) Community coordinators reported their community felt the medical students had a positive influence on their young people inspiring some to consider further education after high school. They also felt empowered through the opportunity to shape the training of future doctors. The Dean of the Dunedin School of Medicine and senior staff members attended some of the attachments. The community appreciated the level of engagement and commitment from the University. Lessons learned Make the programme a required component of learning—The programme was offered as an optional part of medical training. Twenty students did not take part in the programme. Many who missed out requested for another opportunity to take part in the programme. Unfortunately, this could not be arranged. The cultural immersion programme was a unique opportunity to learn about the health of an underserved community in New Zealand. In 2011, all students will be expected to undertake the programme. This requirement has been endorsed by the Dean of the Dunedin School of Medicine. Value cultural training in health—The teaching of "culture and health" should be seen to be valued by the institutional leadership.18 Support from the Dean and senior staff provided endorsement at this level. The literature in this area suggested a number of core components were required in the teaching of "culture and health" in undergraduate medical education.18 One of these was community participation as the "expert teacher". Subjects critical to students' education should be clearly defined, articulated and examinable.10 Students were motivated to learn subjects that were assessed.35 Incorporating Pacific Health as part of the examinable component of medical education will ensure students value it as an important part of the medical curriculum. Clear communication and transparent processes are essential—The work and commitment of Pacific community coordinators were critical in ensuring the Programme's success through excellent communication between the community and the University. They also assisted to ensure University processes were transparent and clear to the local community. This ensured the success of the programme. Empowering community—The Pacific community was empowered by the experience, because they felt what they had to share was valued. All families who participated wanted to be involved in future programmes. Many felt they could influence the care they receive in the future by teaching future doctors about how best to engage with them. Others believed they were also helping the wider Pacific community and society in New Zealand by contributing to the training of future health professionals. Looking ahead : Extension of the programme—The Pacific Immersion Programme at the University of Otago medical programme could be explored as a method for teaching Pacific health in other campuses and universities in New Zealand. It could also provide a template for the engagement of other minority community groups in the training of health professionals. Developing relationships—The development of good relationships through these types of programmes could lead to establishing excellent networks for service, research and teaching. This will benefit not only tertiary education institutions but also underserved communities. Conclusion The Pacific Immersion Programme was explored as a way to dramatically enhance Pacific Health learning for medical students at the University of Otago, New Zealand. Students and staff felt it was an effective way of teaching students about Pacific health and engaging the community in the work of the University. Community relationships and networks developed formed a basis for further work and collaborations in the future. Lessons learnt from developing this programme may be useful for other health training institutions.

Summary

Abstract

Aim

Medical schools are required to adequately prepare students to work in increasingly diverse and multi-ethnic societies. Students need to be able to integrate clinical knowledge with an understanding of the society they live in. Pacific peoples are a disadvantaged migrant minority ethnic group in New Zealand. This paper discusses the development of, and lessons learnt from a Pacific Immersion Programme for medical students at the University of Otago, New Zealand.

Method

A cultural programme was developed where fourth-year medical students spent a week-end with a local Pacific family in Dunedin. Students were invited as part of the programme evaluation to provide feedback on their experiences and lessons learnt. Student evaluations were analysed and are reported here in summary form.

Results

Medical students were able to learn from observations, participation in activities and stories shared by families about issues that influenced the health of the community. This provided insight about factors that are important to consider, when working with Pacific peoples in New Zealand. The programme also provided positive benefits for the local community.

Conclusion

This cultural immersion programme provided important learning opportunities for medical students. It is important to value and empower communities when developing cultural teaching programmes. The incorporation of the programme as part of the curriculum, and its implications for overall assessment and performance of students, makes it a valued part of learning.

Author Information

Faafetai Sopoaga, Senior Lecturer, Pacific Health, Department of Preventive and Social Medicine, University of Otago, Dunedin; Jennie L Connor, Professor and HoD, Department of Preventive and Social Medicine, University of Otago, Dunedin; John D Dockerty, Associate Dean, Undergraduate Education, Dunedin School of Medicine, University of Otago; John Adams, Dean, Dunedin School of Medicine, University of Otago, Dunedin (and Chair of the New Zealand Medical Council); Lynley Anderson, Senior Lecturer, Bioethics Centre, Faculty of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Faafetai Sopoaga, Department Preventive and Social Medicine, P O Box 913, University of Otago, Dunedin, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

tai.sopoaga@otago.ac.nz

Competing Interests

None declared.

Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for teaching and learning. Med Educ. 2009;43:229-237.Rapp DE. Integrating cultural competency into the undergraduate medical curriculum. Med Educ. 2006;40:704-710.Dolhun EP, Munoz C, Grumbach K. Cross-cultural education in US medical schools: Development of an assessment tool. Acad Med. 2003;78:615-622.Taylor JS. Confronting \"culture\" in medicine's \"culture of no culture\". Acad Med. 2003;78:555-559.Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31:990-993.Wachtler C, Troein M. A hidden curriculum: mapping cultural competency in a medical programme. Med Educ. 2003;37:861-868.Dowell A, Crampton P, Parkin C. The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Med Educ. 2001;35:242-249.Gupta AR DT, Johnston MA. Incorporating multiculturalism into a doctor-patient course. Acad Med. 1997;72:428.Mao C BC, Harway EC, Khalsa SK. A workshop on ethnic and cultural awareness for second-year students. J Med Educ. 1988;63:624-628.Esfandiari A DC, Wilerson L, Gill G. An international health/tropical medicine elective. Acad Med. 2001;76:516.Takayama JI CC, Pearl DB. A one-month cultural competency rotation for pediatrics residents. Acad Med. 2001;76:514-515.Godkin M WL. A pathway on serving multicultural and underserved population. Acad Med. 2001;76:513-514.Dogra N. The development and evaluation of a programme to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232-241.Durey A. Reducing racism in Aboriginal Australia: where does cultural education fit. Aust N Z J Public Health, 2010; S87-S92.Roberts JH, Sanders T, Wass V. Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study. Med Educ. 2008;42:45-52.Crampton P, Dowell A, Parkin C, Thompson C. Combating effects of racism through a cultural immersion medical education program. Acad Med. 2003;78:595-598.Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588-594.Tervalon M. Components of culture in health for medical students' education. Acad Med. 2003;78:570-576.Wear D. Insurgent multiculturalism: Rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549-554.Beagan BL. Teaching social and cultural awareness to medical students: \"it's all very nice to talk about it in theory, but ultimately it makes no difference\". Acad Med. 2003;78:605-614.Bandura A. Social Cognitive Theory: An agentive perspective. Annual Review of Psychology. 2001;52:1-26.Mutchnick IS, Stern DT. Expanding the Boundary of Medical Education : Evidence for Cross-cultural Exchanges. Acad Med. 2003;78:S1-S5.Denoon D. The Cambridge History of the Pacific Islands. Cambridge Cambridge University Press; 1997.Spoonley P. A contemporary political economy of labour migration in New Zealand. Tijdschrift voor Economische en Sociale Georgrafie. 2006;97:17-25.Robyn R, Iredale CH, Castles S. Migration in the Asia Pacific : population, settlement and citizenship issues. Edward Elgar Publishing Inc; 2003.Ministry for Culture and Education NZ. History and Migration. The Encyclopedia of New Zealand, Wellington, 2005-2011.Statistics New Zealand. Demographics of New Zealand's Pacific Population. 2006.http://www.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-demography.aspx[Accessed 22 November 2010.]Ministry of Health. A Portrait of Health. Key results of the 2006/7 New Zealand Health Survey. 2008.http://www.moh.govt.nz/moh.nsf/0/6910156be95e706e4c2568800002e403?OpenDocument [Accessed 23 November 2010.]Ministry of Health. Pacific Health and Disability Workforce Development Plan. 2004.http://www.moh.govt.nz/moh.nsf/pagesmh/3681 [Accessed 17 November 2010 ]New Zealand Medical Council. Best Outcomes for Pacific Peoples : Practice Implications. 2010.http://www.mcnz.org.nz/portals/0/publications/Best%20health%20outcomes%20for%20Pacific%20Peoples.pdf [Accessed November 17, 2010 ]Tiatia J. Pacific Cultural Competencies : A Literature Review. 2008. http://www.moh.govt.nz/moh.nsf/indexmh/pacific-cultural-competencies-literature-review [Accessed 29 November.]Ministry of Health and Ministry of Pacific Island Affairs. 'Ala Mo'ui : Pathways to Pacific Health and Wellbeing 2010-2014. 2010. http://www.moh.govt.nz/moh.nsf/pagesmh/10007/$File/ala-moui-pathways-to-pacific-health-wellbeing2010-2014.pdf[Accessed 29 November 2010]Michener JL, Yaggy S, Lyn M, et al. Improving the Health of the Community: Duke's Experience with Community Engagement. Acad Med. 2008;83:408-413.University of Otago. University of Otago Calendar. Applications for admission to medicine. 2010.http://www.healthsci.otago.ac.nz/admissions/micn2011.html [Accessed 22 November 2010.]Newble D. Assessment. Medical Education in the Millenium. 1998:131-142.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

The importance of ensuring that medical students are adequately prepared to work in increasingly diverse and multi-ethnic societies is well recognised from international research.1-5 This has resulted in efforts to incorporate the teaching of culture and cultural competencies in medical schools in the US,3 Canada,4 Sweden,6 and New Zealand.7 These efforts include language training, lectures, workshops, electives, rotations and cultural immersion programmes.7-13Medical schools are challenged to teach students how to integrate clinical knowledge and expertise with an understanding of the society they live in, so they are better able to respond to needs in the community.14 The significant implications for students, staff and the community make culture and cultural competence an important subject in medical education.14-16 Some studies have reported positive changes from the inclusion of "culture and medicine" in the curriculum.13,17 For example, the evaluation of knowledge, attitude and skills in cultural competence appeared to improve following cultural teaching for medical students.15The literature identifies the importance of having a longitudinal thread of "culture and medicine" teaching in the curriculum.18,19 Isolated or disconnected lectures may not enable students to acquire adequate knowledge and skill. Some research however found cultural training failed to show a change in the knowledge and attitudes of medical students.16 There is caution about continuing disparities if physicians are not able to engage effectively with at-risk communities.18,20The proper evaluation of education in "culture and medicine" and assessment of students' competencies require investment of time and adequate resources. The areas that can be assessed in cross-cultural education are students' attitudes, knowledge and skills.1 Assessment of knowledge and skills is relatively easy to do but assessing students' attitudes remains a challenge.9 For example, quantitative tools based on social cognitive theory used by social psychologists to assess attitudes are long and cumbersome.21Students may also elect to answer questions in a socially desirable way. A review of the literature on cross cultural experiences and their benefits identified 42 studies,22 and articulated the need for more rigorous methods to assess outcomes. The development of appropriate assessment and evaluation methods on how "culture and medicine" teaching impacts on students' learning was recommended.Pacific peoples: a migrant population in New ZealandNew Zealand has had a unique relationship and influence as a colonial power in the Pacific Islands over many years.23In the 1950s, many Pacific workers were actively recruited from the Pacific Islands to provide the workforce New Zealand needed for many industries and manufacturing sectors.24,25 This was during economic prosperous times after World War 2.The New Zealand Government changed its attitude towards Pacific workers during the economic recession in the 1970s.26 Previously, the government and employers ignored Pacific workers' requirements to have appropriate work permits or renewal of these permits when they expired. During the recession, the government's solution to addressing economic problems was to expel Pacific overstayers through the unfortunate "dawn raids". This affected the health and wellbeing of all Pacific peoples living in New Zealand, and stimulated the organisation of Pacific peoples as a political group. Pacific peoples now living in New Zealand make up approximately 7% of the total New Zealand population, and are a diverse minority group.27In contrast to the total population, the Pacific population has a younger age structure (median age 21 compared to 36 in the total population), and is predicted to grow to 9.6% of the total population by 2026.27. Pacific peoples suffer disproportionately from poor health and other socioeconomic disadvantages compared to the total population.28Only 1% of all doctors working in New Zealand have Pacific ethnicity,29 therefore most Pacific peoples who access health services will be cared for by non-Pacific health professionals. It is very important to provide opportunities for all medical students to learn about Pacific peoples, their cultures and factors that influences their health.The New Zealand Medical Council recently published a resource booklet for health professionals outlining practice implications when working with Pacific peoples.30 The Ministry of Health has guidelines on Pacific cultural competencies,31 and a national Pacific plan to assist health professionals working with Pacific communities.32University of Otago and community engagementEngaging at-risk communities in the work of training institutions is seen as important in making a difference for these communities.33 For example, Duke University and the city of Durham developed a set of "Principles of Community Engagement" to assist in the training of health professionals.The University of Otago had already worked successfully with a Maori community to teach medical students about indigenous health through an immersion programme.7 A similar approach had not previously been explored for teaching involving migrant communities in New Zealand. A Pacific Immersion Programme was developed where students would spend time living with a local Pacific family. Funds for the programme were made available through the Dean's Office.Faculty of Medicine trainingSchool leavers who wish to train in Medicine at the University are required to do a prescribed competitive Health Science First Year course.34 Some students are admitted as competitive graduates, and others as "Other category" students. The Faculty of Medicine currently accepts 270 students into the second year of training. Those who are successful enter the Early Learning in Medicine programme (which lasts 2 years). Students then progress to the Advanced Learning in Medicine programme, and are distributed to either Christchurch, Dunedin or Wellington.The development of a new medical curriculum at the Faculty of Medicine in 2008 provided the opportunity to introduce a longitudinal approach to teaching Pacific Health. Teaching of Pacific Health in the new Early Learning in Medicine programme (Years 2 and 3 of a 6-year programme) was delivered through whole class lecture series. Following this, the Pacific Immersion Programme was incorporated into Year 4 at the Dunedin Campus (one of the three campuses which run the Advanced Learning in Medicine (Years 4, 5 and 6) in 2010. Teaching in Pacific Health in Year 5 was incorporated into the curriculum as a whole class lecture series. Students were encouraged to consider conducting their medical electives in the final year (sixth year) of training in one of the Pacific Islands.Pacific Immersion Programme developmentThe Pacific Immersion Programme was part of the Public Health attachment at the Department of Preventive and Social Medicine. The Department has a senior lecturer position in Pacific Health. This assisted discussions about developing a Pacific Immersion Programme within the local community.The objectives of the attachment for students were to: Experience Pacific family life in NZ Observe how culture, religion and socioeconomic environment influence health Practise and observe cross cultural communication Provide opportunities for the community to teach students about their health, and how best to engage with them in the clinical setting Determine from observations and information shared, what could be useful for them in the future Students were well prepared prior to engagement with the local community. Year 4 students have had training in confidentiality issues and professional development. Students were ambassadors for the University, and a high level of professionalism was expected.There were four rotations during the year. Year 4 students attended in groups of approximately 20. Christianity plays a large part in the lives of many Pacific peoples and a weekend attachment enabled students to observe how religion influenced their lives. Three options were given to students : "Whole weekend stay", "Day stay only" and "Opt out". Those who opted out, were required to register a reason for doing so.Information was provided to students about the programme objectives, guidance on learning opportunities, cultural protocols and processes specific to the Pacific community involved. The information provided also assisted students in writing a reflective essay about what they learnt.Leaders from the Pacific community met students at the University the day before each attachment. This meeting provided opportunities for students to ask questions. The community welcomed students and staff in line with usual cultural protocols at the beginning of the programme. These included a traditional kava ceremony (a ceremonial welcome drink), singing, dancing and gifting of leis (traditional flower necklaces). Students were then introduced to their host families.Everyone shared a morning tea together before students left with their host families. The wider community (including families not involved in the programme) gathered again the following day (Sunday) after church services for a combined celebration meal before the farewells. A debrief meeting with University staff the following day (Monday) gave students the opportunity to discuss observations, issues and experiences from the weekend. The students were also invited to complete a feedback form.Community consultationsConsultation with the wider Pacific community was initiated in August 2009 when funding for the Pacific Immersion Programme was approved. The Pacific Immersion Programme catered for four groups of students (attachments) through the year. The three largest Pacific ethnic groups in New Zealand were Samoans, Cook Islands and Tongans, and it was agreed the first attachment was with the Samoan group, followed by the Cook Islands and Tongan groups.The last attachment was allocated to combined smaller Pacific ethnic groups. Each group was involved once only during the year. The objectives and expectations of the programme was translated for Pacific families who wished to participate. Each community group nominated a coordinator to liaise closely with the University on all aspects of programme development.These coordinators were leaders within their own communities, and responsible for matching students to host families. Coordinators also ensured excellent communication between the University and the local Pacific community. Community coordinators met with University staff after each attachment for a debrief and feedback meeting. Feedback from the community about the programme was well received.Programme feedbackThere were 77 fourth-year medical students enrolled at the Dunedin School of Medicine in 2010, and 57 (74 %) participated in the programme. Of the 20 who opted out, one was unwell and others had prior commitments. All student participants reported they enjoyed the programme, felt welcomed by the local community and were comfortable in the host environment.Most students felt the programme helped their understanding of Pacific cultures, and gave them confidence to work across cultures (Table 1). Approximately, three quarters reported their upbringing was different from that of their hosts, however most felt there were able to communicate with them. Table 1. Feedback from medical students in the Pacific Immersion Programme Question Yes n(%) No n(%) Don't Know n(%) Do you feel this programme helped your understanding of a Pacific Islands culture? 55(96.5) 1(1.8) 1(1.8) Were there any differences in your upbringing compared to what you observed? 42(73.7) 10(17.5) 3(5.3) Did you feel you were able to communicate with people? 54(94.7) 1(1.8) 2(3.2) Did you feel there were any barriers with respect to communication? 10(17.5) 37(64.9) 8(14) Did this experience give you confidence to work within a different culture? 47(82.5) 2(3.5) 6(10.5) Community coordinators reported their community felt the medical students had a positive influence on their young people inspiring some to consider further education after high school. They also felt empowered through the opportunity to shape the training of future doctors. The Dean of the Dunedin School of Medicine and senior staff members attended some of the attachments. The community appreciated the level of engagement and commitment from the University. Lessons learned Make the programme a required component of learning—The programme was offered as an optional part of medical training. Twenty students did not take part in the programme. Many who missed out requested for another opportunity to take part in the programme. Unfortunately, this could not be arranged. The cultural immersion programme was a unique opportunity to learn about the health of an underserved community in New Zealand. In 2011, all students will be expected to undertake the programme. This requirement has been endorsed by the Dean of the Dunedin School of Medicine. Value cultural training in health—The teaching of "culture and health" should be seen to be valued by the institutional leadership.18 Support from the Dean and senior staff provided endorsement at this level. The literature in this area suggested a number of core components were required in the teaching of "culture and health" in undergraduate medical education.18 One of these was community participation as the "expert teacher". Subjects critical to students' education should be clearly defined, articulated and examinable.10 Students were motivated to learn subjects that were assessed.35 Incorporating Pacific Health as part of the examinable component of medical education will ensure students value it as an important part of the medical curriculum. Clear communication and transparent processes are essential—The work and commitment of Pacific community coordinators were critical in ensuring the Programme's success through excellent communication between the community and the University. They also assisted to ensure University processes were transparent and clear to the local community. This ensured the success of the programme. Empowering community—The Pacific community was empowered by the experience, because they felt what they had to share was valued. All families who participated wanted to be involved in future programmes. Many felt they could influence the care they receive in the future by teaching future doctors about how best to engage with them. Others believed they were also helping the wider Pacific community and society in New Zealand by contributing to the training of future health professionals. Looking ahead : Extension of the programme—The Pacific Immersion Programme at the University of Otago medical programme could be explored as a method for teaching Pacific health in other campuses and universities in New Zealand. It could also provide a template for the engagement of other minority community groups in the training of health professionals. Developing relationships—The development of good relationships through these types of programmes could lead to establishing excellent networks for service, research and teaching. This will benefit not only tertiary education institutions but also underserved communities. Conclusion The Pacific Immersion Programme was explored as a way to dramatically enhance Pacific Health learning for medical students at the University of Otago, New Zealand. Students and staff felt it was an effective way of teaching students about Pacific health and engaging the community in the work of the University. Community relationships and networks developed formed a basis for further work and collaborations in the future. Lessons learnt from developing this programme may be useful for other health training institutions.

Summary

Abstract

Aim

Medical schools are required to adequately prepare students to work in increasingly diverse and multi-ethnic societies. Students need to be able to integrate clinical knowledge with an understanding of the society they live in. Pacific peoples are a disadvantaged migrant minority ethnic group in New Zealand. This paper discusses the development of, and lessons learnt from a Pacific Immersion Programme for medical students at the University of Otago, New Zealand.

Method

A cultural programme was developed where fourth-year medical students spent a week-end with a local Pacific family in Dunedin. Students were invited as part of the programme evaluation to provide feedback on their experiences and lessons learnt. Student evaluations were analysed and are reported here in summary form.

Results

Medical students were able to learn from observations, participation in activities and stories shared by families about issues that influenced the health of the community. This provided insight about factors that are important to consider, when working with Pacific peoples in New Zealand. The programme also provided positive benefits for the local community.

Conclusion

This cultural immersion programme provided important learning opportunities for medical students. It is important to value and empower communities when developing cultural teaching programmes. The incorporation of the programme as part of the curriculum, and its implications for overall assessment and performance of students, makes it a valued part of learning.

Author Information

Faafetai Sopoaga, Senior Lecturer, Pacific Health, Department of Preventive and Social Medicine, University of Otago, Dunedin; Jennie L Connor, Professor and HoD, Department of Preventive and Social Medicine, University of Otago, Dunedin; John D Dockerty, Associate Dean, Undergraduate Education, Dunedin School of Medicine, University of Otago; John Adams, Dean, Dunedin School of Medicine, University of Otago, Dunedin (and Chair of the New Zealand Medical Council); Lynley Anderson, Senior Lecturer, Bioethics Centre, Faculty of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Faafetai Sopoaga, Department Preventive and Social Medicine, P O Box 913, University of Otago, Dunedin, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

tai.sopoaga@otago.ac.nz

Competing Interests

None declared.

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