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

Shaun C Ewen, David J Paul and Gina L Bloom
Med J Aust 2012; 197 (1): 50-52. || doi: 10.5694/mja12.10219
Published online: 2 July 2012

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:

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.

Provenance: Not commissioned; externally peer reviewed.

  • Shaun C Ewen1
  • David J Paul2
  • Gina L Bloom3

  • 1 Melbourne School of Population Health, University of Melbourne, Melbourne, VIC.
  • 2 Centre for Aboriginal Medical and Dental Health, University of Western Australia, Perth, WA.
  • 3 Onemda VicHealth Koori Health Unit and Australian Health Workforce Institute, University of Melbourne, Melbourne, VIC.



Acknowledgement: This review was originally funded by the National Health and Medical Research Council (NHMRC) as part of the Educating for Equity project, under an International Collaborative Indigenous Health Research Partnership grant (ID 634586).

Competing interests:

No relevant disclosures.

  • 1. Australian Medical Council. Assessment and accreditation of medical schools: standards and procedures. 2010. (accessed May 2012).
  • 2. Australian Dental Council, Dental Council of New Zealand. Accreditation standards: education programs for dentists, 2010. (accessed May 2012).
  • 3. Nash R, Meiklejohn B, Sacre S. The Yapunyah project: embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum. Contemp Nurse 2006; 22: 296-316.
  • 4. Duke M, Ewen S. Social and emotional wellbeing training of psychiatrists in Victoria: preliminary communication. Australas Psychiatry 2009; 17 Suppl 1: S100-S103.
  • 5. Duke M, Ewen S. Implementation of Indigenous mental health training in Victoria. Australas Psychiatry 2009; 17: 228-232.
  • 6. Hampton R, McCann W. Developing a postgraduate program in Indigenous mental health and wellbeing at University of Southern Queensland. Australas Psychiatry 2007; 15: S75-S79.
  • 7. Pedersen A, Barlow FK. Theory to social action: a university-based strategy targeting prejudice against Aboriginal Australians. Aust Psychol 2008; 43: 148-159.
  • 8. Ranzijn R, McConnochie K, Day A, et al. Towards cultural competence: Australian Indigenous content in undergraduate psychology. Aust Psychol 2008; 43: 132-139.
  • 9. Sonn CC. Incorporating Indigenous and cross cultural issues into an undergraduate psychology course: experience at Curtin University of Technology. Aust Psychol 2000; 35: 143-149.
  • 10. Bazen JJ, Kruger E, Dyson K, Tennant M. An innovation in Australian dental education: rural, remote and Indigenous pre-graduation placements. Rural Remote Health [internet] 2007; 7: 703. (accessed Apr 2011).
  • 11. Bazen J, Paul D, Tennant M. An Aboriginal and Torres Strait Islander oral health curriculum framework: development experiences in Western Australia. Aust Dent J 2007; 52: 86-92.
  • 12. Andersen C. Indigenous footprints on health curriculum. Australian Journal of Indigenous Education 2009; 38 Suppl: 40-45.
  • 13. Anderson DeCoteau M, Lavallee B. Lessons learned and pathways forward: chronicling indigenous medical workforce development in Canada since 2004. Focus on Health Professional Education 2011; 12: 13-22.
  • 14. Broughton J. An oral health intervention for the Maori Indigenous population of New Zealand: Oranga niho Maori (Maori oral health) as a component of the undergraduate dental curriculum in New Zealand. Int Dent J 2010; 60 Suppl 2: 223-228.
  • 15. Carr SE, Paul D, Bazen J. Integrated undergraduate Aboriginal health curricula: validating a program evaluation survey tool. Focus on Health Professional Education 2011; 12: 34-40.
  • 16. 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.
  • 17. 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.
  • 18. Edwards C. The Indigenous content of Australian nutrition and dietetics degrees. Aborig Isl Health Work J 2005; 29: 11-14.
  • 19. Ewen S, Gough J. Evaluation of Indigenous child health teaching and learning: improving health outcomes? Focus on Health Professional Education 2007; 9: 23-32.
  • 20. Ewen SC, Collins ME, Schwarz JA, Flynn EM. Indigenous simulated patients: an initiative in “closing the gap” [letter]. Med J Aust 2009; 190: 536. <MJA full text>
  • 21. Ewen SC, Robertson K, Kamaka M, Pitama SG. Indigenous simulated patient programs. A three-nation comparison. Focus on Health Professional Education 2011; 13: 35-43.
  • 22. Fredericks B. Which way? Educating for nursing Aboriginal and Torres Strait Islander peoples. Contemp Nurse 2006; 23: 87-99.
  • 23. Hays R. One approach to improving Indigenous health care through medical education. Aust J Rural Health 2002; 10: 285-287.
  • 24. Horsburgh M, Lamdin R. Maori health issues explored in an interprofessional learning context. J Interprof Care 2004; 18: 279-287.
  • 25. Jarvis-Selinger S. Social accountability in action: university-community collaboration in the development of an interprofessional Aboriginal health elective. J Interprof Care 2008; 22: 61-72.
  • 26. Jones RE. Te Ara: a pathway to excellence in Indigenous health teaching and learning. Focus on Health Professional Education 2011; 13: 23-34.
  • 27. Jones R, Pitama S, Huria T, et al. Medical education to improve Maori health. N Z Med J 2010; 123: 113-122.
  • 28. Jong M. Learning about Indigenous health: immersion and living with elders in Northern Canada. Focus on Health Professional Education 2011; 13: 44-51.
  • 29. Kairuz T, Shaw J. Undergraduate inter-professional learning involving pharmacy, nursing and medical students: the Maori health week initiative. Pharm Educ 2005; 5: 255-259.
  • 30. Larson JP. Wase Wakpa: a community-university connection. Home Health Care Manag Pract 2005; 18: 53-56.
  • 31. Lower T. Indigenous content in the health promotion curricula. Aborig Isl Health Work J 2001; 25: 33-34.
  • 32. Mackean T, Mokak R, Carmichael A, et al. Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential. Med J Aust 2007; 186: 544-546. <MJA full text>
  • 33. Mazel O, Anderson I. Advancing Indigenous health through medical education. Focus on Health Professional Education 2011; 13: 1-12.
  • 34. Meyer L, Jackson Pulver LR, Fitzpatrick S, Haswell MR. Scenario planning in Indigenous health. Focus on Health Professional Education 2011; 13: 65-67.
  • 35. Mortley E. Efficacy of an Aboriginal Health Unit in an undergraduate nursing course. Aborig Isl Health Work J 2011; 35: 11-13.
  • 36. Paul D, Allen C, Edgill P. Turning the corner: assessment: a key strategy to engagement and understanding in Indigenous health. Focus on Health Professional Education 2011; 13: 52-64.
  • 37. Paul D, Carr S, Milroy H. Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum. Med J Aust 2006; 184: 522-525. <MJA full text>
  • 38. Ranzijn R, McConnochie K, Nolan W, et al. Teaching cultural competence in relation to Indigenous Australians: steps along a journey. InPsych 2007; 29: 10-11.
  • 39. Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care 2005; 43: 356-373.
  • 40. Gates M, Bradley KD. Measuring cross-cultural competence in medical education: a review of curricular effectiveness and attitudinal studies. Annual meeting of the American Educational Research Association; 2009 April 12-18; San Diego, Calif. (accessed Nov 2011).
  • 41. Gustafson DL, Reitmanova S. How are we “doing” cultural diversity? A look across English Canadian undergraduate medical school programmes. Med Teach 2010; 32: 816-823.
  • 42. Brach C, Fraser I. Can cultural competence reduce racial/ethnic health disparities? A review and conceptual model. Med Care Res Rev 2000; 57 Suppl 1: 181-217.
  • 43. Dharamsi S. Moving beyond the limits of cultural competency training. Med Educ 2011; 45: 764-766.
  • 44. Minniecon D, Kong K. Healthy futures: defining best practice in the recruitment and retention of Indigenous medical students. Canberra: Australian Indigenous Doctors’ Association, 2005.
  • 45. Taylor J. Confronting “culture” in medicine’s “culture of no culture”. Acad Med 2003; 78: 555-559.
  • 46. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923-1958.
  • 47. Stephens C, Porter J, Nettleton C, Willis R. Disappearing, displaced and undervalued: a call to action for Indigenous health worldwide. Lancet 2006; 367: 2019-2028.
  • 48. Betancourt JR. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med 2003; 78: 560-569.
  • 49. Betancourt JR, Green AR. Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Acad Med 2010; 85: 583-585.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.