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Year : 2017  |  Volume : 30  |  Issue : 1  |  Page : 64-67

Life in unexpected places: Employing visual thinking strategies in global health training

1 Health Sciences Centre, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
2 Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
3 Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada

Date of Web Publication13-Jul-2017

Correspondence Address:
Monica Kidd
Family Medicine Teaching Clinic, South Health Campus, 4448, Front Street SE, Calgary Alberta T3M 1M4
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.210511

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Background: The desire to make meaning out of images, metaphor, and other representations indicates higher-order cognitive skills that can be difficult to teach, especially in the complex and unfamiliar environments like those encountered in many global health experiences. Because reflecting on art can help develop medical students' imaginative and interpretive skills, we used visual thinking strategies (VTS) during an immersive 4-week global health elective for medical students to help them construct new understanding of the social determinants of health in a low-resource setting. We were aware of no previous formal efforts to use art in global health training. Methods: We assembled a group of eight medical students in front of a street mural in Kathmandu and used VTS methods to interpret the scene with respect to the social determinants of health. We recorded and transcribed the conversation and conducted a thematic analysis of student responses. Results: Students shared observations about the mural in a supportive, nonjudgmental fashion. Two main themes emerged from their observations: those of human-environment interactions (specifically community dynamics, subsistence land use, resources, and health) and entrapment/control, particularly relating to expectations of, and demands on, women in traditional farming communities. They used the images as well as their experience in Nepali communities to consolidate complex community health concepts. Discussion: VTS helped students articulate their deepening understanding of the social determinants of health in Nepal, suggesting that reflection on visual art can help learners apply, analyze, and evaluate complex concepts in global health. We demonstrate the relevance of drawing upon many aspects of cultural learning, regarding art as a kind of text that holds valuable information. These findings may help provide innovative opportunities for teaching and evaluating global health training in the future.

Keywords: Complexity, cultural competence, global health, humanities, Nepal

How to cite this article:
Allison J, Mulay S, Kidd M. Life in unexpected places: Employing visual thinking strategies in global health training. Educ Health 2017;30:64-7

How to cite this URL:
Allison J, Mulay S, Kidd M. Life in unexpected places: Employing visual thinking strategies in global health training. Educ Health [serial online] 2017 [cited 2023 Jun 6];30:64-7. Available from:

  Background Top

The desire to make meaning out of images, metaphor, and other representations is central not only to the arts and social sciences but also to the practice of medicine.[1],[2] Such meaning-making represents higher-order cognitive skills that can be challenging to teach and evaluate in any medical context,[3],[4] especially in the complex and unfamiliar environments encountered during global health experiences. Following Schaff et al.[5] and the premise that reflecting on art can help develop medical students' imaginative and interpretive skills, we used an encounter with street art in Kathmandu to explore the social determinants of health in Nepal, with a group of Canadian medical students.

The International Summer Institute in Global Health Training (InSIGHT) is a preclerkship elective for medical students at Memorial University of Newfoundland in St. John's, Canada. Its purpose is to explore and experience the social determinants of health in a low-income setting, specifically Nepal. The curriculum consists of 2 weeks of experiential learning in different community settings that include visits to an urban migrant settlement and a remote rural community as well as to several nongovernmental organizations and medical facilities in the Kathmandu valley. These experiences contextualize population health in Nepal and set the stage for a further 2 weeks seeing patients in a clinical setting in a major teaching hospital in Kathmandu. One of the key teaching and learning strategies in the InSIGHT program is frequent written and oral reflection that brings experiences into the transformative and creative realm of higher-order learning.

Intersecting visual thinking strategies and global health learning

Visual thinking strategies (VTS)[6] specifically, and visual art more generally, has been used as a part of humanities teaching in medical education to encourage a deeper engagement with visual cues to improve students' physical observation skills, foster empathy, and increase their tolerance for ambiguity.[5],[6],[7],[8],[9],[10],[11],[12],[13] Briefly, VTS involves asking participants three questions about a work of art: What's going on in this picture? What makes you say that and why? Moreover, what more can we find? By paraphrasing student comments neutrally, and linking student comments, facilitators invite participants to look carefully, to consider the views of others, and to appreciate multiple interpretations.[6] We were aware of no previous formal efforts to use art in global health training but recognized its potential for employing new kinds of knowledge production in an esthetically overwhelming cultural context. These processes are necessary to attain the critical consciousness and self-awareness necessary to attain what is often referred to as “cultural competence.”

Kathmandu street art – for and of the people, and subject to the elements – speaks to many of InSIGHT's curricular themes. Painting on walls has become an important form of public messaging in Nepal since the early 1990s, with political parties employing pictorial symbols as a means of gaining voter recognition. In an increasingly literate, urban space, philosophical, and political slogans have replaced the cryptic images of sun, cow, hammer, and sickle that had represented the numerous political parties and coalitions vying for power in a fluid and rapidly changing political landscape. In 2013, the Kolor Kathmandu project of the artist collective, Sattya Media, brought together artists from worldwide to creatively contest the use of public space for political messages by painting murals in the Kathmandu valley for each of Nepal's 75 districts.[14] Although some of the murals contained political messages, the collective's purpose was to depict the lives of ordinary Nepalis in each of the districts. The purpose of this study was to determine whether VTS might allow us to use street art as a novel text to challenge and deepen medical student's understanding of the social determinants of health.

  Methods Top

In July, 2014, the authors (who represent global health, community health, and family medicine) travelled with a group of eight 1st- and 2nd-year medical students from Memorial University of Newfoundland to Kathmandu to teach InSIGHT. The mural we chose for this exercise is by Canadian artist Danaé Brissonnet [with assistance from volunteers identified as Shweta, Nikhil, Prashant, and Shobha; [Figure 1]. It covers approximately 10 m × 3 m of a concrete wall in front of an average home, and represents hardship and change in the District of Doti, an area in the Himalayan foothills not dissimilar to Bhattedanda, a village we visited with our students in the district of South Lalitpur.
Figure 1: Image credit: Danaé Brissonnet, Doti, 2013. Oil on cement

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We placed our students in front of the mural and reminded them that there could be no wrong answers that everyone reads images in different ways. Then, we asked them the three VTS questions: What do you see? What makes you say that? Is there anything more? Given the context of our course, we added a fourth question: How does the image relate to what you now know about health in rural Nepal? Employing VTS pedagogy, we tried to be neutral about their comments and to encourage them to dig deeper into the meanings they ascribed to images. Specifically, we asked them to think about how their experiences thus far informed their read of the painting. Our conversations lasted approximately 20 min. We obtained our students' consent to record and transcribe the session; each author reads the transcript and hand coded for themes. We developed our thematic analysis based on consensus about key student observations and how they related these observations to the learning experience as it was unfolding to demonstrate the students' ability to see elements of the mural as symbolic of the themes around social determinants, such as gender inequality, social stratification, and environmental challenge.

  Results Top

Two main themes emerged from the students' observations. The First dealt with human-environment interactions, specifically community dynamics, subsistence land use, resources, and health.

“The tiger in the corner stood out to me because you see him carrying the fruits and vegetables in a basket, and he has a house on his back. It drew a parallel to Bhattedanda, where everyone grew their own vegetables and supported themselves.”

In our visit to the small community of Bhattedanda, we were confronted with the importance of food security and utilizing land wisely. From the multitude of vegetables in kitchen gardens, to community forestry management, to the use of biogas as a by-product of animal dung, the role of the ecosystem in health emerged during our visit to the community, and subsequently in the students' read of the mural.

“There's a lot of connection between the land and the people. There's a tree growing out of the woman's ear, and beside the fish is a picture of the people's homes. And the woman sitting in the spider web. It's very much like a deeper connection, like the earth and the people are one.”

“With the colours and the umbilical cord, one thing leads to another. [it's like] finding life in really unexpected places.”

Finding life in unexpected places meant finding a good life: A secure life, with basic needs met and a sense of continuity and future. This comment suggests that students recognized that life, even in the most rugged and remote locations, is supported by an ecosystem and network of determinants. More importantly perhaps, students could challenge their own notions of what constitutes quality and goodness in the absence of material goods, technology, and comfort. While not every student made individual comments on this theme, they all acknowledged that aspects of their experience in the rural community were represented by the images of agricultural life in the mural. This theme also appeared in four of the students' written reflections produced later that week.

The second theme that of entrapment/control spoke to a number of social conditions we learned about in the communities we visited. All eight students agreed that the images within the mural reflected some measure of being locked into one's fate. The image of a woman in a spider web elicited a general discussion around feeling trapped or experiencing social inequality.

“The spider web [contrasts] to the rest of it. I can't really place why. But [the woman] looks distressed in the spider web. I would say it's symbolic of her being trapped. And it also looks like those creatures are cutting parts of the web, so maybe it's implying that she's being released.”

“There's a scale on her head. In Western society, we would associate that with justice and equality. That may be something like gender equality: she's trapped.”

It was apparent from our experiences in Nepal that a stratified society continues to exist even though the caste system is no longer supported in law. As the students' comments suggest, they saw how the impact of caste, religion, gender, and socioeconomic status shapes the lives of people in both an urban migrant community and a rural village.

“Once someone was born in that situation, they just stay. That's something that I would get out of the spider web that I wouldn't have gotten before we went on the visit [to Bhattedanda].”

The multiple meanings and ambiguity around the web were an important part of the discussion, allowing us to build on the VTS value of respect, and to encourage the flow of possibility in the images. To underscore the challenges and rewards of pausing – as a clinician – to consider the complexity of an individual and his/her story, we let this indeterminacy hang: there is no right answer to the meaning of the web and the woman suspended within. Instead, the meaning each student assigned was constructed from the images they noticed, their knowledge of the context, and their experiences. Each answer begged another question.

  Discussion Top

Global health education has been widely acknowledged as having an influence on multiple dimensions that go beyond skill building and cultural competence. In a meta-analysis, Mutchnick et al.[15] identified eight ways in which students may benefit from international and cross-cultural experiential learning opportunities: increased cultural competence; deeper understanding of professional practice issues through comparative experience; more compassion toward patients; better communication skills; increased appreciation for and/or knowledge of public health; improved clinical skills; greater orientation toward public service; and increased awareness of resource use. Many global health programs also aim to foster a willingness among graduates to work with underserved populations or in less than ideal circumstances in communities that lack specialists, technology, and infrastructure.[16] Mutchnick et al.[15] conclude that global health training is an important means of developing socially engaged and accountable physicians who understand the social challenges in the populations they serve. It is this transformative learning potential in global health that we seek in our InSIGHT program.

This exercise was a first experiment to determine whether VTS might be useful in our global health teaching context; specifically, we wanted to find out whether students would engage with the exercise, and whether discussion of the images and metaphors contained in the mural would provide an alternate means of synthesizing their newfound understanding of the social determinants of health in Nepal. Thus, the scope of our study was small: Only eight students, only 20 min of discussion, and no formal reflective exercise after the experience with which to better assess their performance. Students referenced the mural and the images in their reflections later in the program. One student chose to write one reflection as a poem which highlighted many of the same themes of gender disparity, environment, and geographic difficulty discussed as we looked at the mural. However, limited our first foray was into this new pedagogy, we were impressed with the power of VTS to underscore adult learning principles [17] and help students to express ideas in a supportive small group environment about the connections between human health and the environment, and also how one's power in a society (in Nepal, a complex amalgam of gender, ethnicity, geography, and material resources) may influence one's health. These observations indicate that students were beginning to apply, analyze, and evaluate complex concepts in global health, all higher-level cognitive outcomes, which are often difficult to teach and evaluate.[18]

  Conclusion Top

We used VTS applied to street art in Nepal, to help junior medical students more fully explore new concepts and experiences in global health. Examining a mural depicting hardship and change in the Himalayan foothills allowed students to challenge their own notions of what constitutes a “good life,” and to explore how caste, religion, gender, and socioeconomic status shape people's health and well-being. While small in scale, we believe that these findings suggest the visual arts may provide innovative opportunities for teaching and evaluating global health training in the future.

Financial support and sponsorship

Memorial University Medical Graduate Society Wallace Ingram Award for 2012, valued at CAD 11,680.

Conflicts of interest

There are no conflicts of interest.

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