Do indigenous health curricula in health science education reduce disparities in health care outcomes?

Indigenous health curricula are a mandated accreditation requirement in many health science courses in Australia and New Zealand, most explicitly in basic medical education1 and dental education programs.2 Indigenous health curricula have been in place in some health science courses for at least a decade, while many others are just developing this aspect. However, it is unclear what impacts such changes in health science education are having (if any) on health outcomes for indigenous peoples. As an emerging discipline, educational approaches and pedagogies are evolving, as are evaluation methods.

To determine the documented impacts of including indigenous health curricula in health science courses, we conducted a systematic review of published literature related to university indigenous health curricula. The following databases were searched between March and October 2011: Australasian Medical Index, ATSIhealth (Aboriginal and Torres Strait Islander Health Bibliography), CINAHL PLUS, MEDLINE, SCOPUS version 4, and Web of Science. The keyword search “Indigenous AND health AND curric* AND university” yielded 1247 results. The more refined search of “University AND (Indigenous OR Aboriginal OR Maori OR Native American OR American Indian OR Alaska Native OR Native Hawaiian OR First Nation OR Metis OR Inuit) AND health AND curriculum AND (postgraduate OR undergraduate)” yielded 57 results. Grey literature was excluded from this search.

We all separately reviewed each of the 57 articles. Articles were selected if their subject matter included indigenous health-related curricula within university health science courses and they were published in English in 1999 or later.

Articles were excluded if:

• the curriculum had no specific focus on indigenous health (eg, if they described a generic cross-cultural curriculum);

• the indigenous focus of the curriculum was only incidental (eg, if a placement happened to be in a location with an indigenous population but was not designed with an indigenous health focus); and

• the curriculum was predominantly for indigenous students.

We analysed articles to determine the stated aims, rationales and evaluation of curricula, and to identify whether the curricula discussed were integrated or stand-alone, and optional or compulsory. Consensus was reached in selecting and analysing articles through discussion and clarification.

Thirty-six articles3-38 met the inclusion criteria and were reviewed. Significantly, 10 of the articles were published in 2011, indicating a recent spike in publications in this area. We note that seven of these13,21,26,28,33,34,36 were published together in a special edition of Focus on health professional education featuring initiatives in indigenous medical education, based on invited contributions from the international LIME (Leaders in Indigenous Medical Education) Connection III conference held in Melbourne in December 2009.

The literature review was international in scope, but most articles in the last decade (34 out of 36) referred to Australian and New Zealand contexts.

Seventeen articles referred exclusively to medical curricula, and an additional seven referred to multidisciplinary curricula (which tended to also include medicine, usually where the curricula were faculty-wide). Ten articles focused on nursing curricula, six on pharmacy curricula, and five on dentistry curricula. Four or fewer articles covered other disciplines.

Of the articles that met the criteria for our review, most focused on Australian and New Zealand curricula that included medicine and a compulsory indigenous health element. A significant proportion were recent, and half specified integration of the indigenous health component.

In our experience, “integrated” curricula can be simply vertically collocated, rather than meaningfully integrated, which is consistent with other findings that integrated indigenous health curricula tend to be relatively opportunistic and ad hoc.31

Our finding that indigenous health curriculum evaluation is not patient outcome-focused is in common with reviews of other literature examining cross-cultural training curricula.39-41 Despite increasing calls for a focus on patient outcome evaluation,27,33,36,39,41-43 there still appears to be a widespread assumption in the literature that increasing practitioner skills, knowledge and attitudes will lead to improvements in indigenous health, as evidenced by the primary rationale for inclusion of indigenous health content. Impact on patient outcomes is an area that could benefit from greater attention. As stated by researchers in New Zealand:

There are, of course, other motivations, in addition to improving indigenous patient health outcomes, for including indigenous-specific curricula in health science training. These include rights-based approaches, ensuring indigenous students are able to “see themselves” in the curriculum,44 and drawing upon indigenous examples where these are exemplars to illustrate the learning objectives. The exclusion or inclusion of any population group carries with it implicit messages that are absorbed by the learners and other educators across a faculty.

The foundations upon which effective indigenous health curricula are based need to be acknowledged. To do this calls for both philosophical and empirical shifts in the way indigenous health curricula are understood and evaluated. Philosophically, the pre-eminent disciplinary basis of many schools of medicine is in science, rather than in humanities. Assumptions that “medicine is a culture of no culture” are increasingly being exposed as erroneous45 and harmful.46,47 Many of the challenges to reducing differential patient outcomes for indigenous peoples are not a result of health professionals’ lack of technical or scientific skill. What is missing in health science education is a broad and foundational understanding of the contexts in which indigenous people and health professionals meet and interact (with, in most cases, limited previously shared experience), and of the consequent impacts of these contexts on health and health care outcomes.

We caution that medical schools should not use these findings as an excuse for inactivity. Rather, they should participate in building the evidence that demonstrates the utility and positive outcomes of indigenous health curricula for indigenous peoples. Curriculum evaluation should continue to be carried out in an ordered, planned way, such that the impact of indigenous health curricula on the learner can be further understood, before the more difficult extension to evaluation of patient outcomes.

Along with other commentators evaluating medical education,48,49 we recognise the “complexity of linking cross-cultural curricula to health outcomes in a simplistic way” and that “the challenge of this type of evaluation cannot be overstated”.48 Establishing the evidence to demonstrate whether specific indigenous health curricula have a positive impact on health outcomes for indigenous peoples is a complex and long-term project. The challenge for indigenous health curriculum developers is to begin to design methods that focus on evaluating the impacts of the curricula on patient outcomes, while continuing to measure the impact on the learner.