Introduction: Women in Haiti and throughout the Haitian Diaspora shoulder a disproportionate burden of cervical cancer morbidity and mortality. The widespread Human Papillomavirus (HPV) vaccination holds promise for helping to attenuate this disparity. However, previous research has not fully examined Haitian women's perceptions of, and barriers to, HPV vaccination, which is essential for informing future intervention. The current paper aims to fill this gap. Methods: As part of ongoing Community-Based Participatory Research (CBPR) efforts, we conducted a series of focus groups with Haitian immigrant women in Little Haiti, the predominantly Haitian neighborhood in Miami, Florida, U.S. Focus group questions assessed women's knowledge and beliefs about cervical cancer and HPV, their opinions of vaccines in general, their knowledge and perceptions of the HPV vaccine specifically and health communications preferences for cervical cancer prevention. Results: Among the participants who had heard of HPV, many held misconceptions about virus transmission and did not understand the role of HPV in the development of cervical cancer. Virtually all participants expressed support for vaccines in general as beneficial for health. Some women had heard of the HPV vaccine, primarily as the result of a contemporary popular media campaign promoting the Gardasil; vaccine. Physician recommendation was commonly mentioned as a reason for vaccination, in addition to having more than one sex partner. Women felt the HPV vaccine was less appropriate for adolescent girls who are presumed as not sexually active. Women indicated a strong preference to obtain health information through trusted sources, such as Haitian physicians, Haitian Community Health Workers, and especially Kreyol-language audiovisual media. Discussion: Study findings indicate a need for culturally and linguistically appropriate educational initiatives to promote awareness of HPV and its role in cervical cancer, the importance of vaccination against the virus, explicitly differentiating HPV from HIV and providing specific information about vaccine safety. Conclusion: In the U.S., there is a substantial lack of educational information available in Haitian Kreyol about HPV and cervical cancer. This gap results in missed opportunities to promote disease prevention through vaccination and regular screening. Addressing such gaps is essential for achieving health equity among Haitian immigrant women and other, similarly underserved women, who are disproportionately burdened by cervical cancer.

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Background: Hepatitis C virus (HCV) infection is a major public health threat throughout the world because of its ability to lead to cirrhosis, hepatocellular carcinoma and need for liver transplant. Findings from studies have illustrated that levels of knowledge and awareness are low among those populations most affected by hepatitis C. The purpose of this descriptive pilot study was to assess the educational needs of potential hepatitis C patients at a Veterans Administration (VA) medical center. Few studies have identified the educational strategies preferred among patients who are diagnosed with hepatitis C. Methods: Potential hepatitis C patients in this study are defined as those individuals who had laboratory tests indicating abnormal liver enzymes and liver function tests. A survey 'Assessing Educational Needs of Potential Hepatitis C Patients' included 13 questions relating to the educational needs of this population. Results: A total of 152 patients completed the survey over a period of six months. The participants from the study did not agree that there was adequate educational material available to them in the hepatitis C clinic (71%). Out of the several educational delivery methods listed, presentations given by healthcare professionals to a large group of people were most popular at 36.2%. Participants (61%) would be interested in joining a support group and 56% felt comfortable receiving advice from health care professionals via a computer. The topic that participants would most like to learn about was living with hepatitis C. Conclusion: Assessing educational needs of potential hepatitis C patients provides a starting point in the discussion of how healthcare professionals can best deliver education. It is important to note that hepatitis C patients worldwide have a high degree of heterogeneity based upon their differing comorbid conditions, which would warrant specialized educational programs with the utilization of a variety of educational strategies.

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Context: With medical training focused on medical knowledge and skills, the nurturing of humanistic care can suffer. Objectives: We designed and conducted an outpatient rheumatology patient-partner exercise that integrates the assessment of student compassionate care into an outpatient clinical skills training exercise. Methods: Eleven third-year medical students were videotaped performing a medical history on a patient volunteer. Students, the preceptor and a fourth-year medical student independently observed the videotape, tagged segments demonstrating observed or missed compassionate care opportunities and completed a compassionate care questionnaire. Students also participated in a focus group. Ten patients completed a comparable questionnaire and provided feedback on student encounters. Findings: Students recognized and reflected on opportunities for compassionate care. The preceptor's feedback was reinforced. Students' ratings of their demonstrations of compassionate care were lower after reviewing videotapes, and were also lower than preceptor ratings. Patients were satisfied with the exercise and highlighted student professionalism. Conclusions: The exercise proved to be an effective format for promoting student reflection on and self-assessment of compassionate care. It demonstrated that nurturing compassionate care can be integrated into an outpatient clinical skills exercise.

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Context: Although most health education programs assess students' professionalism, there is little clarity within the health education literature on the definition of professionalism. This makes assessment of students' professionalism a potentially flawed activity. This literature review clarifies professionalism by bringing together diverging definitions from across a number of health disciplines and discusses the complexities and limitations of these definitions. Methods: A search was conducted within the medical and health science education literature to identify articles that discussed professionalism and its assessment. Theoretical, qualitative and empirical research were included in the review. Findings: The literature variably defines professionalism as upholding professional values, as demonstrating professional attitudes or demonstrating professional behaviours. Each of these perspectives influences how professionalism is to be assessed, with each perspective having its own limitations. The behavioural perspective is simple to assess, but it has been criticised for being too superficial. The values perspective has the potential to develop professionals who are motivated by philanthropic values, but values can be difficult to identify and assess. Attitudes are complex in their structure, but they are less superficial than behaviours and can be assessed with attitudinal scales. Conclusion: Health professions educators should ideally assess all three perspectives of professionalism, however, this may not be realistic given the already laden curricula and the demands on educators. Educators may decide to only assess one perspective and given its advantages, the attitudes perspective may be a useful starting point.

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Introduction: Sub-Saharan Africa (SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin. Methods: Final year medical students attending nine medical schools in SSA were surveyed - students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained. Results: Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top careerrelated factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom. Discussion: The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.

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Context: SMILE is a Simple, Mental health, Initiative in Learning and Education. SMILE was a pilot project introduced into an undergraduate clinical nursing program, Southern Cross University, Australia 2010. The program aimed to improve the knowledge and skills of third-year nursing students participating in their first clinical placement in mental healthcare. Methods: Complementary to the clinical nursing program and the university curriculum, SMILE provided further training and support for student learning in mental healthcare. The SMILE project was a structured 15-day education program that covered the following topics: suicide prevention; psychosis; drugs and alcohol education; mental state exam; families and carers in mental health; and the Mental Health Act. The education sessions were one hour in duration. The educational material and resources were created from current research, literature and health service policy. A problem-based learning approach was used to support this education project. The dynamic factor related to SMILE was that it was based 'in the field.' SMILE enabled the students to bridge a theorypractice gap and expand upon their current knowledge base as well as participate in ward activity. Twenty students attending their first clinical placement in mental healthcare participated in SMILE and were asked to complete a pre- and post- evaluation questionnaire before starting and upon completion of the 15-day project. Results: The students participating in SMILE reported a greater understanding of mental healthcare issues and expressed a developing knowledge base and improved practical skill level. Conclusion: SMILE was a positive initiative that provided valuable feedback and opportunity to improve on clinical education in mental healthcare.

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Context: A good understanding of the learning styles of students is necessary for optimizing the quality of the learning process. There are few studies in Turkey on the subject of the learning characteristics of medical students. Objectives: The aim of this study was to define the learning patterns of Turkish medical students based on the Turkish version of Vermunt's Inventory of Learning Styles (ILS). Methods: The Turkish version of the ILS was developed and administered to 532 medical students. Learning patterns were investigated using factor analysis. Findings: Internal consistencies of scales ranged from 0.43 to 0.80. The Turkish version of the ILS identified four learning styles among medical students. In comparing the pre-clinical and clinical phases of medical students related to mental models of learning, statistically significant differences (p<.01) were found between the two groups for the learning characteristics: lack of regulation; certificate; self-test and ambivalent orientation; intake of knowledge; and use of knowledge. Conclusion: The Turkish version of the ILS can be used to identify learning styles of medical students. Our findings indicate an intermediate position for our students on a teacher-regulated to student-regulated learning continuum. A variety of teaching methods and learning activities should be provided in medical schools in order to address the range of learning styles.

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Introduction: In India, there has been little effort to teach medical students about public health research. Few medical institutions in India and nearby Nepal formally offer exposure to field surveys or projects to medical undergraduates as a part of their training in community medicine. Little is known about the effect of such activity on students or how they apply what they learn. We implemented a systematic, hands-on experience in the public health research process with medical undergraduates in Puducherry, India to evaluate its effect on students. Material and Methods: Two groups, each with 30 third-semester (second year) medical undergraduates, participated in a 15-day, two and one-half hours per day course on the public health research process. At the end of course, a retrospective post-then-pre self-assessment of students' skills was obtained. One year later, we resurveyed students with open-ended questions to assess their impressions of what they had gained from learning about the field survey process. Results: Out of the 60 students, 55 (91.6%) provided complete responses for analysis. The mean post-exposure Likert scores of students' self-perceived skills and knowledge were significantly higher than their retrospective assessments of themselves prior to the course in areas such as being aware of the public health research process, their skills in interviewing and communicating with local villagers, and ability to collect, enter via computer and present gathered information (p<0.005). Six categories of common responses, all positive, emerged from the open-ended feedback: 1) ability to apply learning to research work, 2) communication skills, 3) awareness about local epidemiology of injury ,4) awareness of local first-aid practices and health care seeking behavior, 5) awareness of survey techniques, and 6) anticipated application of this learning in the future and its effect on the student. Conclusions: Overall, the initial implementation of a program exposing medical students to the community survey research process was well received. Early exposure of medical undergraduates to the survey research process appears to help them be better clinicians, who are able to understand and use field level data.

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Introduction: DISCERN is an instrument designed to help patients assess the reliability of written information on treatment choices. Originally created in English, there is no validated Spanish version of this instrument. This study seeks to validate the Spanish translation of the DISCERN instrument used as a primary measure on a multicenter study aimed to assess the reliability of web-based information on treatment choices for attention deficit/hyperactivity disorder (ADHD). Methods: We used a modified version of a method for validating translated instruments in which the original source-language version is formally compared with the back-translated source-language version. Each item was ranked in terms of comparability of language, similarity of interpretability, and degree of understandability. Responses used Likert scales ranging from 1 to 7, where 1 indicates the best interpretability, language and understandability, and 7 indicates the worst. Assessments were performed by 20 raters fluent in the source language. Results: The Spanish translation of DISCERN, based on ratings of comparability, interpretability and degree of understandability (mean score (SD): 1.8 (1.1), 1.4 (0.9) and 1.6 (1.1), respectively), was considered extremely comparable. All items received a score of less than three, therefore no further revision of the translation was needed. Conclusion: The validation process showed that the quality of DISCERN translation was high, validating the comparable language of the tool translated on assessing written information on treatment choices for ADHD.

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Introduction: Visual arts have been used to facilitate the teaching of the United States Accreditation Council for Graduate Medical Education (ACGME) competencies used in some countries. Some medical students may not appreciate the usefulness of incorporating arts in medical education. Therefore, arts programs that can interest medical students are necessary. We initiated and evaluated a visual arts program at the Changhua Christian Hospital in Changhua, Taiwan, with an aim to give the students a short review of visual arts and to interest them in the incorporation of arts in medicine. Methods: A total of 110 students in clerkship or internship participated in a visual arts program with emphasis on medicine-related visual arts. Content analysis of the data from the notes made by the instructor from direct observation of students' descriptions during discussions and the written feedback from students at the end of the program was used to evaluate the effect of the program. Anonymous questionnaires were also used for self-assessment of students. Results: Qualitative analysis of the data revealed that the course was interesting to students. Themes emerged including its helpfulness to students in interpreting paintings, enhanced empathy, increased cultural awareness, enhanced observational skills, better team work, listening and communication skills and reduced stress. Ratings on the questionnaire showed similar results. Moreover, students had an increase in their confidence and desire to interpret paintings. Conclusion: The structured visual arts program, with emphasis on medicine-related visual arts and other humanities subjects, was able to attract the attention of medical students. It might be helpful to improve the required skills of ACGME competencies, but further studies are needed to support these conclusions.

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Introduction: Communicating bad news to patients and families is an essential skill for physicians but can be difficult for interns. Very little is known about skills in this area for interns in developing countries. Method: Two focus groups, consisting of a total of 12 interns were conducted in the Seth G.S. Medical College and KEM Hospital in Mumbai, India. The grounded theory approach was used to identify common themes and concepts, which related to: (1) barriers in communicating bad news, (2) interns' confidence in communicating bad news, (3) interns' perceptions about their need for such training and (4) interns' suggested methods for training. Results: Interns described barriers in time constraints, language, their personal fears, patients' illiteracy, crowded wards with no privacy and lack of training. All interns lacked confidence in breaking news of death, but seven were confident in breaking bad news about chronic diseases or cancers. Subjects reported they had received very little classroom teaching or formal instruction in this area, though they had had opportunities to observe a few instances of breaking bad news. They expressed need for increased focus on communication skills curriculum in the form of case discussions, workshops and small group teaching, in addition to clinical observation. Conclusions: Interns in our school in Mumbai reported inadequate training and low comfort and skill in communicating bad news and expressed need for focused training.

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Context: The College of Medicine at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) is running a PBL-based curriculum. A progress test was used to evaluate components of the basic medical and clinical sciences curriculum. Objective: To evaluate the performance of students at different levels of the college of medicine curriculum through USMLE-based test that focused on basic medical and clinical sciences topics. Methods: The USMLE-based basic medical and clinical sciences progress test has been conducted since 2007. It covers nine topics, including: anatomy; physiology; histology; epidemiology; biochemistry; behavioral sciences, pathology, pharmacology and immunology/microbiology. Here we analyzed results of three consecutive years of all students in years 1-4. Findings: There was a good correlation between progress test results and students' GPA. Progress test results in the clinical topics were better than basic medical sciences. In basic medical sciences, results of pharmacology, biochemistry, behavioral sciences and histology gave lower results than the other disciplines. Conclusions: Results of our progress test proved to be a useful indicator for both basic medical sciences and clinical sciences curriculum. Results are being utilized to help in modifying our curriculum.

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Background: Community-based participatory research (CBPR) emphasizes collaborative efforts among communities and academics where all members are equitable contributors. Capacity building through training in research methodology is a potentially important outcome for CBPR partnerships. Objectives: To describe the logistics and lessons learned from building community research capacity for focus group moderation in the context of a CBPR partnership. Methods: After orientation to CBPR principles, members of a US suburban community underwent twelve hours of interactive learning in focus group moderation by a national focus group expert. An additional eight-hour workshop promoted advanced proficiency and built on identified strengths and weaknesses. Ten focus groups were conducted at an adult education center addressing a health concern previously identified by the center's largely immigrant and refugee population. Program evaluation was achieved through multiple observations by community and academic-based observers. Results: Twenty-seven community and academic members were recruited through established relationships for training in focus group moderation, note-taking, and report compilation. Focus group training led to increased trust among community and research partners while empowering individual community members and increasing research capacity for CBPR. Conclusions: Community members were trained in focus group moderation and successfully applied these skills to a CBPR project addressing a health concern in the community. This approach of equipping community members with skills in a qualitative research method promoted capacity building within a socio-culturally diverse community, while strengthening community-academic partnership. In this setting, capacity building efforts may help to ensure the success and sustainability for continued health interventions through CBPR.

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Background: In the last decades there has been a sharp rise in the elderly population throughout the world. The unique needs of the elderly require a multidisciplinary and comprehensive medical approach. None of the 50 medical schools in Pakistan teach geriatrics in their undergraduate or postgraduate training. This paper discusses the development and implementation of the first geriatric curriculum in a medical school of Pakistan and its effect on knowledge and attitudes of third-year medical students. Methods: The curriculum was designed through collaboration and approval of various academic departments at the Aga Khan University in Karachi Pakistan. After a review of existing geriatric curricula at other institutions, a problem-based, inter-disciplinary spiral curriculum was designed. Strategy of student and course evaluation was planned and incorporated in the curricular program. No extra resources or funds were used. A component of the new curriculum was assessed by evaluating pre- and post- course knowledge, and seeking feedback from participating third-year students. Results: A significant improvement in mean scores for summed overall knowledge in geriatrics (pre-test mean 4.7 vs. post-test mean 6.4, p value of <0.001; out of a maximum possible of 9 was noted. Breakdown of knowledge mean scores into component areas of knowledge showed a significant increase in understanding in aging demographics (pretest 0.7 vs. post-test 1.7, p value of <0.001), geriatric history taking (pretest 0.64 vs. post-test 0.88, p 0.001) and geriatric assessments (pre- test 1.4 vs. post- test 1.7, p value 0.01). A strong majority (87%) of the students felt that the overall course objectives were achieved. All students were satisfied with the quality of teaching, 90% rating it good or higher. Conclusion: An important advance in medical education was achieved via integration of a low cost, spiral geriatrics curriculum in a medical university of Pakistan. We found that introduction of the geriatric curriculum improved the knowledge of third-year medical students. This was our school's initial step towards building professional capacity in response to a rising elderly population.

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Context: Experts suggest that distance learning continuing medical education (CME) is only effective when there is the opportunity for two-way discussion and reflection. The value of on-line mentoring has been mainly studied in the West. Objectives: We examined the benefits and practical implications of providing mentors for distance learning CME in a low technology setting. Methods: We conducted a randomized controlled trial with qualitative and quantitative analysis of the impact of mentoring on completion of CME and quality of reflective learning. Results: Twenty-six of 64 doctors completed all four CME modules. Non-completers were interviewed by telephone. Odds ratio analysis suggested that mentored doctors were three times more likely to complete their CME; however, this did not reach statistical significance (p=0.07, 95% CI 0.89-10.57). Being in rural practice (p=0.05) and younger in age (p=0.005) were significantly associated with completion of CME. Mentored doctors seemed to show a higher quality of reflection on learning. Contact between mentors and mentees was difficult. Both mentors and mentees felt that optimal use of the system was not made. Discussion: Despite mentors' perceptions that they had little impact, mentored doctors did appear to be more likely to complete CME. Work is needed to increase the quality of interpersonal and educational interaction between mentors and mentees.

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Introduction: Medical education is a continuously evolving field. Training institutes and programs should have a process in place to gather continuous feedback and then make appropriate modifications in order to provide education and training effectively. Our study aimed to assess the effect of a quality improvement cycle approach in using various educational interventions within a residency. Effects were measured on the key educational outcomes of residents' medical knowledge, skills and professional attitudes using results of postgraduate examination with both written and clinical skills components. Methodology: A number of educational interventions were implemented which included changes in work hours with increased time for self-study, new educational activities including a Residents' Hour, a Residents' Slide Session, Grand Rounds and Journal Clubs, Clinico-pathological conferences, and a two- week postgraduate course for senior residents. Newer and improved assessment tools were also implemented, including an annual in-training mock exam based on the format of the postgraduate examination. Pass rates in postgraduate examinations (Fellow of College of Physicians and Surgeons exam and Member of Royal College of Physicians exam) were compared before and after the interventions to assess the effectiveness of the interventions. Results: The first group of residents after introduction of the educational interventions completed residency training in 2001. Postgraduate exam pass rates (sometimes after two or more attempts) were 59.2% (42 of 71 graduates) before 2001and 86.4% (38 of 44 graduates after 2001 (p=0.002). The number of candidates passing the examinations in either their first or second attempts before 2001 was 17 of 42 (40.5%), which increased to 33 of 38 (86.8%) after 2001 (p=< 0.001). Conclusions: Our study describes a number of interventions that were successful in bringing about an improvement in the performance of our residents. These can serve as a guide for postgraduate training programs, particularly those of Internal Medicine, in implementing strategies to strengthen training and enhance the performance of trainees.

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Context: Negative role modeling is a plague medical educators fight once students enter the clinical arena. The literature is replete on the fact that students routinely encounter faculty who display attitudes and behaviors inconsistent with the values taught throughout the medical curriculum, particularly in the preclinical years. Approach: Using a back and forth between the text of a third-year student's reflective essay and two of her faculty's observations on her negative encounters with several clinical faculty, the authors propose 'teaching for fearlessness.' Discussion: Using Papadimos and Murray's use of 'fearless speech' derived from Foucault's thinking on parrhesia, the authors build a case that students should be encouraged to expose and challenge inequities on behalf of their patients, themselves and the profession at large. Conclusions: Medical educators should model and provide students with opportunities to develop and use 'fearless speech' as a way to reshape the culture of medical education and patient care.

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Introduction: In 2006, a Postgraduate Diploma in Eye Care (PGDEC) for mid-level health personnel was initiated in Papua New Guinea, in partnership with The Fred Hollows Foundation New Zealand, the local government and Divine Word University. In the absence of national accreditation and with limited resources, an interim evaluation was needed. Methods: We adapted the World Federation for Medical Education (WFME) standards to use in a self-audit to evaluate nine areas and 38 subareas of programme structure, processes and implementation. We developed a rating system: each area and subarea was scored for partial or complete attainment of basic or quality development levels. Ratings were referenced with supporting documents. Data were gathered internally, through document census and meetings between stakeholders. Findings: A qualitative and quantitative portrait emerged: all nine programme areas completely attained at least basic level and two completely attained the quality development level. Twenty-six (68%) subareas completely attained the quality development level. Key successes included the administration of the PGDEC, synergies between the partnership's stakeholders and its relationship with the public health system. Discussion and Conclusions: This self-audit adapted from WFME standards provided a simple, yet systematic and largely objective evaluation. It proved beneficial to further develop the programme, highlighting strengths and areas for improvement.

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