Transformative Learning and Medical Students Global Health Essays – A Qualitative Study

Corresponding author: Dr Ann Wylie ann.wylie@kcl.ac.uk Institution: 1. King's College London, 2. Guy’s and St Thomas’ NHS Foundation Trust, 3. King’s Centre for Global Health & Health Partnerships, School of Population Health and Environmental Sciences, Weston Education Centre, King’s College London Categories: Educational Theory, Learning Outcomes/Competency, Teaching and Learning, Undergraduate/Graduate


Introduction
With an increasingly globalised and interdependent world it is only appropriate that we prepare medical students for them to address the health needs of the 21 st century (Frenk et al., 2010). This includes new infections; behavioural and environmental risks; moving from curative to preventative care; achieving health equity within and in-between countries; and multidisciplinary and interdisciplinary efforts to find solutions to global problems such as climate change and urbanisation (Koplan et al., 2009), (Frenk et al., 2010. It is the scope of the problems (and not their location) that sets apart global health from public health (Frenk et al., 2010).
In a paper by Johnson et al. the authors discussed global health learning outcomes for medical students within the United Kingdom (Johnson et al., 2012). There are 6 key proposed learning outcomes such as global burden of disease, socioeconomic and environmental determinants of health, and health systems. The paper is one of the teaching resources given to students during their global health module.
At King's College London Medical School, final year medical students undertake a global health module and as part of their assessment, write a 2000 words essay prior to their elective placement. The global health teaching comprises of 2 components: a virtual component and face-to-face symposia. During their virtual element, students are provided with 9 webinars on global health as well as links to key sites and email support. For the symposia element, there is a focus on the rationale for including global health in core curriculum and guides for students completing the global health essay. There is also a focus on their up and coming elective.
Transformative learning is a learning theory proposed by Jack Mezirow (Mezirow, 1997). Since its inception, transformative learning has been researched and discussed as a theory within adult education, including medical education (Taylor, 2007). Transformative learning is about challenging established assumptions through critical reflections, this transformation of perspectives occurs from a disorienting dilemma through to critical reflection. Currently the identified components of transformative learning include: 'disorienting experience', 'emotional response', 'critical reflection', 'perspective change' and 'commitment to future action' (Sawatsky et al., 2018).
Although transformative learning is a work in progress, it has the potential to be a pedagogy that can be used to help address the challenges to health professionals in the 21 st Century (Van Schalkwyk et al., 2019).
More work is needed to study how transformative learning can be used in health professional education and how to assess its impact. It is also important to bear in mind the underlying philosophical position during any assessment when evaluating whether transformative learning took place (Tavares et al., 2019). This is important so that we are able to understand the underlying assumptions and examine justifications related to the philosophical positions (Tavares et al., 2019). Transformative learning is rooted in a constructivist epistemological position that emphasises critical engagement in learning and knowledge creation (Van Schalkwyk et al., 2019).
Within medical education, recently, there have been published papers on transformative learning and professional identity formation during international health electives (Sawatsky et al., 2018), as well as a scoping review looking at transformative learning as a pedagogy for the health professions (Van Schalkwyk et al., 2019). These papers contribute to the growing literature in this emerging area.
Relating to global health, Frenk et al. described the purpose of transformative learning is to 'produce enlightened change agents' (Frenk et al., 2010). It is with these works in mind that we approach our data analysis and discussion

Methods
Consent was through opt in and 90% of 420 students consented. All students' essays analysed obtained a pass mark. A random sample of essays (N=40) were anonymised and thematically analysed without regard to the grade. A lead researcher was overseeing the data collection process.
Nvivo 12 (QSR International) was used by two independent researchers to thematically analyse the essays to look for components of transformative learning. The data were analysed in 2019.
We followed the analytic framework used by Sawatsky et al. to look at the components of transformative learning: 'disorienting experience', 'emotional response', 'critical reflection', 'perspective change', and 'commitment to future action' (Sawatsky et al., 2018). In addition, we assessed whether the essays are coherent.
Ethical approval was obtained for this study (King's Ethical approval -Ref 5719).

Results/Analysis
In the academic year 2018-2019, there were 420 final year medical students who completed a global health module and a 2000 word essay at King's College London. We analysed 40 of these essays. The topics of these essays were chosen by the students and ranged from infectious disease to maternal obesity, sustainable development goals and social determinants of health. All the essays analysed were coherent to read.
The top 50 most mentioned words in the 40 sampled essays were put into a "word cloud", and as expected "global" and "health" featured strongest.  Table 1 lists the number of essays and the number of references for each of the 5 components of transformative learning. We will go through each of the transformative learning components in turn, outlining the general themes noted, along with quotations for each of the components. For these examples, the disorienting experience involved noticing something that differed from their expectations. The disorienting experiences could be categorised into different types of experiences as follows: practice-based, literature-based, identity-based and teacher-led.

Emotional response
Only a small minority of students demonstrated an emotional response to what they are writing -three essays (7.5%).
Writing about the results of a report regarding inequities in access to surgery, one student revealed that: 'The immense disparity in surgical care to me was overwhelming' This student also referred to the results of the report as "surprising" and "alarming", indicating that the emotional response co-occurred with a disorienting experience.
One student expressed "pride" at the global effort in tackling global health issues, and another found it "extremely concerning" that someone who has been diagnosed with a manageable condition such as diabetes suffer from long term debilitating changes to their health. Other emotional descriptors used by students included "shockingly" and "sadly".

Critical reflection
This component of transformative learning was by far the most common with 12 of the 40 essays (30%) demonstrating critical reflection. Students reflected on various aspects of global health including global burden of disease, socioeconomic and environmental factors of health, cultural competency and healthcare services.

'Developing awareness of the global burden of disease, understanding the social determinants of health (especially the impact of migration and the health challenges facing new arrivals in the UK) and fostering cultural competency are key elements of the global health approach in order to ensure quality healthcare for London's diverse population.'
Despite not having been on their elective, some students were able to reflect on how their 'home' (UK) healthcare situation compared with their intended elective placement and their linked preparation research.

Perspective change
Three of the 40 essays (7.5%) demonstrated perspective change. By reading around the topics, students' perspectives were shifted. Examples include changing an "entrenched idea" held about the best way of teaching and talking about disease around the globe, and factors leading to health in addition to healthcare provision: 'But provision of healthcare is not enough; careful consideration of the factors leading to health determinants go beyond geographical location and access to medical care.'

Commitment to future action
This was the second most common category after critical reflection. Eight of the 40 essays (20%) demonstrated a commitment to future action. Most of this is through the student's up and coming elective placement. Points that were raised in this component of transformative learning include further exploration of the socioeconomic and environmental factors on a healthcare system; drawing comparisons between 'home' and 'host' institutions; tackling inequalities in health; talking to local people regarding a policy implementation and offering a training session for the department on their upcoming elective.

'As I plan my elective in Obstetrics, I hope I will be able to use what I have learnt here and see each interaction with an obese woman as a chance to discuss lifestyle change and exercise...'
Students' intentions may change again when they find themselves in the new situation of the elective and under the guidance of their supervisors. This raises an interesting question about how intentions and commitments to action unfold and change shape across multiple learning interventions.

Discussion
This study used global health essays, written by final year medical students to identify if there is evidence that transformative learning took place. To our knowledge, this is the first study of its kind looking at essays written before elective placements/ international health electives.
The findings suggest that students were able to articulate and demonstrate global health concepts in their written essays. This maybe a reflection of the learning during their global health module prior to the writing of the essays.
In addition to raising global health topics, the essays provided a platform for students to link global health learning outcomes as previously published (Johnson et al., 2012) to the students' upcoming elective placements. Topics such as global burden of disease, socioeconomic and environmental determinants of health and health systems were raised by students. How much students understood about these topics is beyond the scope of this study, but the fact that these are in their scholarly essays suggests that students appreciated their importance within the theme of global health.
The essays acted as an assessment modality, and it was also an opportunity for students to enhance their learning and for transformative learning to take place, in some of the students. With a total of 40% of the essays demonstrating at least one component of transformative learning, this is an interesting finding. How many components of transformative learning are needed before one can say transformative learning has taken place? A similar question has been raised by Van Schalkwyk et al. in their recent paper -is movement through the components of transformative learning required in order for transformative learning to have taken place (Van Schalkwyk et al., 2019)? It could be argued that if there is evidence from the students of a disorienting experience, perspective change and critical reflection, then transformative learning has taken place.
Perhaps the most important finding is that the essays in this study elicited critical reflection in 30% of the students. Reflection is known to deepen professional values, have a positive effect on empathy and enhance engagement in the learning process (Winkel et al., 2017). For these students, enhanced empathy and engagement in learning may be good preparation for transformative learning to occur during the elective processes, but further research would be needed to evaluate this. Indeed, as part of their global health module, students are taught skills for reflection, underlying the importance of reflection in medical education per se and part of being a life-long learner as a practicing clinician.
In the literature, critical reflection has been linked to the quality improvement competencies (Wittich et al., 2010). In this regard, we can make a similar connection to say that critical reflection allows medical students to link to the global health learning outcomes as published by Johnson et al. (Johnson et al., 2012).
In terms of limitations and challenges, although the essays were good to excellent, only 10% had 3 transformative learning indicators. 10% in 40 essays is a small sample but increasing the sample size for analysis could provide more reliable findings.
In addition, post-elective essays may be more valuable to demonstrate transformative learning, but some pragmatic issues arise with this as shown in a previous study (Sawatsky et al., 2018). Emotional responses are perhaps more likely to occur after the students' elective experiences. Furthermore, research to explore whether engaging in transforming learning activities prior to elective strengthens transformative learning during the elective experience would be of interest.
It would be interesting to look at whether teaching students specifically about Transformative Learning itself can influence their ability to experience and demonstrate transformative learning in their essays. These could be areas of further work.
It will also be interesting to see if these findings could be replicated by other medical schools.

Conclusion
Some students showed evidence that transformative learning took place during the research and writing of global health essays. Global health essays provide an opportunity and have the potential for transformative learning to take place, as well as acting as an assessment modality and research opportunity for students prior to and in some cases without an elective placement experience.
COVID19 could potentially disrupt elective placements globally in the short to mid-term, so it is imperative that global health remains in curricula, even if it cannot be directly linked to electives. He has published peer-reviewed paper in medical education, with a focus on community-based medical education.Dr Wong has presented at national and international conferences on community-based medical education.

Ms Eleanor Bowen-Jones is a PhD Candidate in Global Health
Research at King's College London, funded by the Royal Society of Medicine. Her research interests include undergraduate medical electives, Global Health ethics, and multi-disciplinary approaches to medical and health professions' education and research. She has presented at national and international medical education conferences.