The post-GHCR questionnaire response rate was 85% (74/87) (
Table 1). Interviews were undertaken with six students from two Christchurch groups, seven students from two Dunedin groups, and six students from the single Samoa group.
The self-reported learning has been categorised into the framework of learning levels outlined by Frenk et al: informative learning; formative learning; transformative learning (Table 2) (3). According to this framework: informative learning is about acquisition of knowledge and skills; formative learning involves socialising students around values in order to produce professionals; and transformative learning is about developing leadership attributes in order to produce enlightened change agents to address health inequities.
Table 2 also shows the two major themes regarding students’ reported experiences in GHCR, these being innovation and connectivity. All quantitative data are shown in Table 3, Table 4, and Table 5. Quantitative data derived from the questionnaire are shown as percent responses. Illustrative quotes are provided for each theme emerging from the qualitative data analysis.
Reported learning outcomes in GHCR
Informative global health learning
Most students (88%) agreed that they gained insight into the differences in presentation and care of common medical conditions between Samoa and New Zealand (Table 3). This included learning about differences in investigations and treatments, and how availability of resources influenced overall care:
I like comparing the treatments, the local treatments, and the NZ treatment, it's really good to have a look at what we are doing compared to that [New Zealand treatment]. (Samoa)
… the resources constraint is quite a big thing to keep in mind of things they would like to do but can’t because it is more difficult for them. That just being able to order the test, that makes it a lot easier on us than for them. They have more diagnostic uncertainty, which kind of came through in the case. (Christchurch)
Overall, 86% of students agreed they learnt about their partner country’s health system and its impact on patient outcomes. Learning included aspects of initial community and primary-based care, differences in referral pathways for hospital care and follow-up:
It is the care that New Zealand provides on discharge and the follow-up strategies, and the prevention is really good. Regarding when you compare it to us, here it's somewhat very simple. (Samoa)
Having time for unscripted discussion really let us get an insight as to healthcare and promotion in Samoa, as well as what life is like for medical students. (Dunedin)
Students commented that the case presentations helped contextualise global health learning:
Learning about the Samoan case helped contextualise the difference between our two health systems. (Christchurch)
Most students (82%) agreed that GHCR increased their understanding of how culture influences health in their partner country (Table 3). Students reported their increased understanding of culture provides insights into patients’ ideas, attitudes, and behaviours regarding healthcare:
Personally, [the most valuable aspect of GHCR was] the impact culture has; whether good, bad, or none, on health. (Samoa)
I was really surprised that in Samoa traditional healers are so prominent. You see a patient you don’t understand why they are not taking their antibiotics… the reason behind that will be very different [compared to a New Zealand European]. (Christchurch)
Most (75%) students found that GHCR increased their understanding of the importance of learning about the determinants of health to improve the care of their patients (Table 3). Samoan students commented on changes in their perspectives and greater understanding of multiple barriers to accessing healthcare for some Samoan patients:
In the doctor’s head, it is always carelessness [by patients], but then you can’t understand it is the money, financial support, the transport. We have to look at all those factors, the factors that stop them from access to healthcare. (Samoa)
Almost all students (89%) agreed that GHCR increased their awareness of barriers to accessing healthcare:
Things are really different just in terms of the amount of doctors they have who can service areas, like learning there were only three doctors for an entire population of people on one of their Islands was mind-blowing in a sense. (Dunedin)
Students also noted that across both countries there is commonality in the healthcare challenges and inequities:
I guess also the striking similarities, even though New Zealand and Samoa seem a world apart, both struggle with access to healthcare, education around healthcare and inequity in health. (Christchurch)
Students’ structured case presentations required them to collate the patient information and relevant local data related to global health, for their integrated learning. Students reported that finding and explaining local data for their partner group helped them develop their research and analysis skills, as well as hone their presentation abilities:
It made us re-evaluate how we do things because when you present to someone who understands the system you do it differently [compared to] when you present to someone who doesn’t. (Christchurch)
Epidemiology is the most challenging aspect of the [presentation] slides … because we have to find the raw data from the admissions books in the wards or the discharge summaries. (Samoa)
In summary, informative learning in the GHCR format enabled students to compare and contrast the clinical presentations and care of common medical conditions, the health systems, determinants of health and cultural impacts on healthcare between New Zealand and Samoa, and discuss how these factors influence patient outcomes.
Formative learning related to global health in GHCR
Most students agreed (79%) that collaboration with their international peers in the GHCR was valuable to their learning. Comments from students in both countries indicated that the face-to-face, student-led format in the shared virtual classroom provided a collegial forum for socialising as health professionals-in-training. They expressed reciprocal commitment to each other’s learning and mutual respect:
I like the idea that the classroom is about sharing our case with the Samoan students, and they would share their case with us. (Dunedin)
Positive is learning from each other, learning about the different cultures. (Samoa)
This sense of collegiality created a safe environment for sensitive discussions around cultural values and ethics, as well as equity:
It was when they asked, “Why is this such a big difference between Māori (indigenous people of New Zealand) and European statistics?” and everyone looks at each other and how do you answer that question? (Christchurch)
It was good to be prompted to think about how sexual health is a much more taboo subject in Samoa and how this impacts on sexual health education and access to care. (Dunedin)
Students particularly valued the spontaneous discussions that followed their formal presentations (Table 4). These peer interactions helped establish engagement between students within the virtual classroom:
The classroom session as a whole is just great, but I think just getting to talk to people at the end outside of our scripted presentations was really cool, to have that back and forth, to talk about things as they came up, and that we found to be really interesting. (Christchurch)
Samoan and New Zealand students socialised with values of collegiality, equality and reciprocity, expressing mutual commitment to learn together:
... a great learning experience for me. Understanding especially how culture, environment and health systems do affect healthcare immensely for different populations. The online video conferencing really does help in sharing similarities and differences. (Samoa)
Transformative learning related to global health in GHCR
Students reported their interactions in GHCR exposed them to diverse opinions and new perspectives from their international peers. For some this triggered changes in their viewpoints and aspirations for their future medical practice. A number of Samoan students expressed a vision for progress to improve their own healthcare system and become agents of change:
Primary health care is the change I want to improve here, going out to rural places, creating awareness programmes. (Samoa)
New Zealand and Samoan students recognised the importance of comparing their health systems in order to recognise strengths of each country’s system, as well as areas for improvement for each:
So, if we are able to spend more time listening to how things are done in other countries, I think that would increase our appreciation of what we have got here. And maybe change our mind about some of the things that we do for the better, and we can also help other people of course. (Christchurch)
Perspective and insight on how to improve on healthcare services [were the most valuable aspects of GHCR]. Some things are done better in another country, which can be used to adapt new ideas for future development. (Samoa)
For some students, GHCR provided a fresh view of their own culture, through contrast with another culture and gaining an outsider’s perspective:
So, it was just one of those things, of like, becoming aware of your own culture through experiencing someone else’s culture. (Dunedin)
I think every time that you are made aware of your own culture makes you realise how important culture identity and systems are. (Dunedin)
Student experiences in GHCR
Students found GHCR innovative and a “cool” and “tangible” way to learn about global health and broaden their perspectives. They found it more effective than didactic learning methods (Table 5):
This is based on making global health seem like a more real and tangible thing (for lack of a better description). We talked to people who are in a different health system with different, but also surprisingly similar in some instances, health problems. It seems so much more accessible than learning about global health on a purely theoretical basis. (Christchurch)
I doubt it would have made as much of an impact if I had just read about it or had lecturer talk about it. I think student taught sessions is useful and can be more interesting and engaging. (Dunedin)
Students reported that the videoconference created a collegial, shared virtual classroom:
Just the fact that we were talking and having a lesson with students in Samoa, and that is kind of special really, that we could break down geographical barriers with technology. (Dunedin)
The fact that they were right there, and we could ask them questions live. It was really cool to see how our curriculums and lifestyles contrasted to theirs. (Christchurch)
Samoan students particularly appreciated being able to learn about global health, without having to travel:
It can be easily accessed through videoconferencing and we don’t have to travel with a lot of expense and a lot of other issues. But it’s something we can do from where we are, and we can be exposed. We can learn from each other over the videoconferencing. (Samoa)
Poor connectivity in audio and video streaming arose in several sessions. However, as long as the audio and shared desktop connections were maintained the sessions proceeded without significant problems and no sessions were abandoned due to inadequate connectivity.