PART 1: SPECIAL SECTION

 

Self-identity discrepancy theory: exploring returning South African Cuban-trained medical students' sense of belonging

 

 

B. M. Donda^I; V. Singaram^II; R. Hift^III

^IClinical and Professional Practice University of KwaZulu-Natal, Durban, South Africa; https://orcid.org/0000-0001-7520-3732
^IIClinical and Professional Practice University of KwaZulu-Natal, Durban, South Africa; https://orcid.org/0000-0002-6974-7423
^IIIClinical and Professional Practice University of KwaZulu-Natal, Durban, South Africa; https://orcid.org/0000-0003-3580-1513

 

 

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ABSTRACT

BACKGROUND: The Nelson Mandela-Fidel Castro Collaboration programme (NMFCMC) between South Africa and Cuba was established in 1996. South African students, undergo five years of medical training in Cuba and finish the final eighteen months of training in South Africa. These students experience academic difficulties on their return
METHODS: All twelve NMFCMC students enrolled at the University of KwaZulu-Natal in 2015 participated in this study. Data were elicited using focus group interviews, narrative interviews, found photovoice and the Collage Life Story Elicitation Technique
RESULTS: Challenges faced by participants resulted in identity discrepancy, which in turn promoted unfavourable attitudes, affect, psychological and physical behaviours towards participants' belongingness
CONCLUSION: Returning NMFCMC students experienced difficulties in assimilation due to identity discrepancies and frustrated sense of belonging. Focusing on reinforcing positive aspects of identity, and interpersonal relationships through moderating the tendency of local teachers and students to emphasise the "otherness" of the NMFCMC student is crucial

Keywords: medical education, discrepancy theory, consequences of identity incongruence, sense of belonging, Nelson Mandela Fidel Castro Medical Collaboration Programme, South Africa

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INTRODUCTION

Return of sojourners from overseas exploration gives a fallacy of simply going back home to the familiar; where one belongs. Usually sojourners are oblivious to the fact that identities can be contested as their worldview might have been modified by overseas experiences. Similarly, the home ground may have changed due to socioeconomic influences that the sojourner may not even be aware of. Therefore, sense of self and space can promote unbelonging instead of belonging. Return of students who have studied abroad can be even more complex as educational practice is culturally embedded (Hu 2002; Jordan 1985; Correa et al. 2008; Makonye 2020; Ebaeguin 2015). Despite such complications international medical education partnerships are fast becoming popular (Alsulami 2021; Chattu et al. 2020). Issues of student return in such programmes are indeed problematic even though they continue to receive little attention.

Studying abroad is associated with a range of academic, cultural, social, emotional and psychological consequences (Brunsting, Zachry, and Takeuchi 2018; Han, Pistole, and Caldwell 2017; Lowinger et al. 2016). Differences in teaching and evaluation style, in addition to broader cultural differences between the country of origin and the host country, may encourage a display of aspects of cultural shock encountered on exposure to a different academic and cultural environment (Alsulami 2021; Mesidor and Sly 2016). Students may experience frustration, anger, sadness, loneliness confusion, anxiety and depression (Jin and Wang 2018; Alsulami 2021; Mesidor and Sly 2016). Feelings of alienation and marginalisation may heighten psychosomatic symptoms (Sullivan and Kashubeck-West 2015). These responses may be exacerbated where and when the host environment is unwelcoming. For an example, increased rates of anxiety and depression were seen in East Asian international students who reported discriminatory experiences (Wei et al. 2015). Poor academic performance may be exacerbated where teachers have a low expectation of the visiting student (Mesidor and Sly 2016).

Students in culturally compatible international programmes with congruent pedagogic practices may excel academically. However, Lindley, McCall, and Abu-Arab (2013) found that international medical students were challenged by issues of context and culture which included differences in approaches to learning, language, communication and relationships in both the learning and the social contexts. These may arise from educational factors such as differences in the learning and teaching environment, unfamiliarity with the health care system in the host country, and the legal and political framework in which a jointly administered training programme is offered (D. G. Waterval et al. 2016; D. Waterval et al. 2018). Indeed, it is known that medical training is stressful even in one's home environment (Rehman and Baluja 2021; Shankar et al. 2018). These stresses can be magnified when studying abroad and upon return.

In this study, we described the challenges reported by a group of South African students who entered the University of KwaZulu-Natal (UKZN) for a final 18 months of medical training following five years of medical studies in Cuba. The students were enrolled in a programme of medical training shared between the two countries in terms of a bilateral agreement known as the Nelson Mandela Fidel Castro Medical Collaboration (NMFCMC). Students selected for this program are recruited predominantly from rural and less socially advantaged districts of South Africa. They complete the first five years of the six-year Cuban medical curriculum in Cuba, following which they return to South Africa for a final 18-month period of training in preparation for practice in South Africa. South African medical schools have interpreted their training mandate such that they expect the returning NMFCMC students to demonstrate knowledge and skills equivalent to that of locally trained students. The students do not however graduate with a South African degree, they are required to sit for the final Cuban national medical examination and if successful graduate with a Cuban University degree. The NMFCMC students have experienced considerable academic difficulties in meeting the requirements of the South African final examinations (Sui et al. 2019; Zungu, Mathu, and Scheepers 2019; Lungelow 2011; Motala and Van Wyk 2019; Phasha 2021; Donda, Hift, and Singaram 2016).

We suggest that the challenges experienced by a sample of NMFCMC students on their return to South Africa, can be viewed not just as pedagogic issues. Instead, we postulate that challenges arise from difficulties in assimilation as a consequence of the divergent identities resulting from the incongruence of the professional socialisation expected of the Cuban medical student and that of the South African-trained student. Thus, this study analyses the narratives of our participants for evidence of identity incongruence, described as emotional and psychological distress. In addition, we analysed how such distresses influenced their sense of belonging. Our study is not a causal study; thus, we interpret students' stories and draw associations between concepts. In analysing the narratives of our participants, we base our analysis on Higgins theory of identity incongruence, E. T. Higgins (1987) which aptly described the situation encountered by the returning NMFCMC students.

 

METHODS

Participants

We studied all twelve NMFCMC students who returned to South Africa in 2015 and registered at the University of KwaZulu-Natal for their further training. All were ethnic Africans drawn from similar disadvantaged rural backgrounds and final year students in the NMFCMC programme. At the time of the study, they were in their final year of studies and had spent a minimum of six months in the University. They are referred to by pseudonyms as follows: Nonhlanhla (female), Khaya, Jabulani, Mluleki and Perfect (males). In this article we use the term "participants" to refer to those students who participated in our interviews, and "students" when we refer to the NMFCMC students more generally.

Ethics

All participants provided written, informed consent. The study was approved by the Human Social Science Ethics Committee of the University of KwaZulu-Natal (Reference HSS: 1808/015) and the University Registrar.

Data collection

We undertook a qualitative study using a combination of convenience sampling (Dôrnyei and Griffee 2010) as the participants were easily accessible and purpose sampling (Given 2008) as participants were selected because they had rich information on the phenomenon under study. All participants attended the focus group interviews. Five participants volunteered for individual interviews based on a narrative enquiry approach (Connelly and Clandinin 2006; Holstein and Gubrium 2012). All interviews were conducted in English, though participants were invited to use isiZulu at any stage should they wish to do so.

Focus group interviews

All participants participated in two "focus group interviews" Krueger (2014) based on the challenges they faced as they assimilated into South Africa. The focus group interviews lasted about 3 hours per session. The aim of the focus group interviews was to elicit collective views of the participants. Data saturation was reached at the second interview as there were no new themes emerging from the interview.

Narrative interview

As suggested by Jovchelovitch (2000), a drawing was used as a prompt for the narrative interview. The prompt was framed by Dewey's understanding of "miseducative" learning experience (Dewey 1937). Thus, each participant was asked to draw their worst experience as a newcomer. The researcher then asked each participant how their worst experience influenced how they perceived the challenges that they faced as they assimilate into South Africa. The researcher listened, took notes and only asked questions for clarity.

Photovoice

Participants were initially requested to take five photographs of spaces in which they had faced challenges the most as they assimilate into South Africa. None produced such photographs due to being overwhelmed during ward rounds. Then, participants were asked to source the five photographs from the internet, hence "found photovoice" (Rose 2006).

Collage Life Story Elicitation Technique

Participants were asked to design a collage using a modified format of the Collage Life Story Elicitation Technique (CLET) (Van Schalkwyk 2010). Participants were asked to choose phrases and photos representing how they managed the challenges they faced as they assimilate into South Africa. Unlike, in CLET the collages themselves were not analysed. Indeed, data from the CLET were not intended for this article. However, as the participants were telling stories of how they managed challenges, crucial data regarding the difficulties of assimilating into South Africa were identified. Such data have been included in this study.

Data analysis

Data were analysed in two tiers: configuration of data from found photovoice, CLET and narrative interview into each participant storied narrative and analysis of all five participant storied narratives together with data elicited from the focus group interviews. The first tier involved Polkinghorne's idea of "narrative analysis" which is centred around "emplottment" of each participant storied narrative (Polkinghorne 1995). During emplottment each participant's stories elicited from all three individual interviews were chronologically arranged focusing exclusively on the challenges that they faced during assimilation in South Africa to construct a single plot. Each participant's stories that were outside the plot were left out. Hence, the five storied narratives together with the focus group interviews were used as primary data. Images produced or selected by participants served only to facilitate the telling of their stories, and were not in themselves used as primary data for analysis. The second phase of analysis, involved analysing the five storied narratives collectively referred to as "analysis of the narratives" Polkinghorne (1995) together with the data elicited from the focus group interviews. Higgins self-discrepancy theory E. T. Higgins (1987) was used to analyse primary data into codes, categories, and themes. Quotes and images that best captured participants' stories were identified.

Discrepancies in identity are central to Higgins' theory of self-discrepancy (E.T. Higgins 1987) (Figure 1). Higgins conceptualizes the self as having three dimensions: actual, ought and ideal. The actual self is concerned with the self-concept (How I believe I am), the ought self relates to obligations (How I should be), and the ideal self reflects wishes (How I would like to be). Higgins suggests that the actual self relates to self-concept and ought and actual selves act as self-guides. Critically, however, the self is not only defined by the individual but is equally influenced by the perceptions of significant people in the lives of individuals - the "looking-glass self' (Cooley 2017).

Higgins postulates relationships between incongruence in identity and affect, including fear, anxiety, lack of confidence, frustration and demoralization, resentment anger and depression. Thus, Actual own/Ought own incongruence (How I see myself versus How I should be) may be seen as violation of the individual' s obligations, predisposing to a sense of unworthiness and self-blame. Similarly, Actual own/Ought other incongruence (How I see myself versus How others think I should be) may be seen as a violation of the obligations set for one by others, resulting in fear, anxiety, apprehension, resentment and social anxiety. Actual own/Ideal own incongruence (How I see myself versus How I would like to be) may be viewed as a failure to realise one's aspirations, resulting in frustration, demoralization and depression. Actual own/Ideal other incongruence (How I see myself versus how others would like me to be) is likely to result in loss of self-esteem, loss of face and loss of social esteem. The acute emotional and behavioural consequences of such discrepancies were termed "identity crises" by Erikson (1994), a term which though trivialized in popular usage, remains apt. Firstly, based on Higgins theory of self-discrepancy, we analyse the narratives and experiences of being an NMFCMC student in a South African medical school as associated with the potential for identity incongruity at numerous levels and its potential to frustrate their sense of belonging (Donda et al. 2016).

 

RESULTS AND DISCUSSION

Though international students commonly struggle with feelings of isolation and marginalisation while abroad Sullivan and Kashubeck-West (2015), a sense of dislocation emerged strongly from the narratives of our participants even though they are essentially "home". A wide range of emotional and psychological responses emerged in the narratives of our participants. Yet, even as our participants described the emotional consequences of the challenges they faced in assimilation, the predominant tone of the interviews was one of positivity, leading to an overall impression of remarkable resilience (Figure 2). We believe however, that in order to understand experiences of our participants appropriately, this resilience should be borne in mind even as we discuss the narratives of our participants.

We found that, the circumstances surrounding the return of the NMFCMC students are such as to ensure that identity incongruence is both inevitable and, with the benefit of hindsight, predictable (Figure 3). The South African student enters the programme with a nascent ideal self-identity, which in our NMFCMC students frequently takes the form of a powerful commitment to the upliftment of their rural home communities. During the course of six years in Cuba, the student develops a strong personal and professional socialisation as a Cuban resident and novice Cuban medical practitioner (A), taking on the aspirations of both and therefore developing a modified Ideal own identity. In parallel, they undergo the formal educational program (B). Cuban professors, by their personal and pedagogic expectations, set the Ought other agenda. The student internalises these, forming an Ought sef-identity. As they strive to meet the Ought self expectations, so they become progressively more competent as novice Cuban medical practitioners. With increasing competence, they satisfy both their own and their teachers' expectations thus bringing the Actual own identity into congruence with the Actual other, Ought other and Ought own expectations, thus developing a congruent identity (C).

Meanwhile, South African practitioners and locally-trained students have developed a different set of Ought and Ideal expectations, in response to the professional socialisation and educational models of that country (D).

As soon as the NMFCMC students enter a South African medical school, they find incongruence in these Ought and Ideal identities (E). Since they and locally trained students' study towards different Ought outcomes, their performance is no longer in line with expectations, producing a performance gap and leading to serious Actual own/Actual other incongruence (F). In order to satisfy their South African teachers, they are forced to dismantle the stable identity they experienced in Cuba and to adjust their Ought and Ideal expectations to match those inherent in the South African paradigm (G). This results in a prolonged period of identity incongruence with all the consequences that will be described below that include: a disturbed concept of self, reduced self-esteem, loss of agency, frustration, depression, potential demotivation, lack of social esteem, social anxiety, lack of trust and lack of confidence.

Actual own/Actual other and actual own /ideal other

Higgins delineated between actual own/ actual other and the actual own/ ideal other discrepancies. According to Higgins, the actual own and actual other discrepancy refers to contradiction between who you think you are and who others think you are (E.T. Higgins 1987).

Such identity congruency may lead to a distabilised self-concept. The actual own and ideal own discrepancy refers to failure to fulfil one desires and can lead to lowered self-esteem, frustration and depression. However, our participants linked the two discrepancies since; they both reflect issues around disturbance of a stable self-concept, which may result in low self-esteem, feelings of frustration and powerlessness.

Dissonance of the self, frustration and powerlessness:

The most basic incongruities relate to Actual own/Actual other incongruence. We observed such incongruence in two main areas in our participants. They perceived themselves as being seen as foreigners in their own country and as incompetent students:

"People tend not to recognize you as a South African. You are recognized as a foreigner in your own country. They make you feel as if you are not a South African." (Khaya).

Participants made frequent reference to the potential for demotivation, though the interviews suggest that this was more of an expression of frustration, rather than a reflection of actual loss of motivation.

"But, it's a bit unfair that in Cuba we were called South Africans but in South Africa we are South Africans, but we are called Cubans. So, that thing actually it demotivates you" (Focus group).

Frustration was frequently accompanied by a sense of impotence and loss of agency: "You have to swallow a better pill. You cannot win the debate." (Khaya).

Although we did not study it directly, it is our impression that our NMFCMC students, having been successful in completing the first five years of the Cuban curriculum, and had brought with them a generally positive sense of competence and confidence. Being seen as incompetent rather than competent students that they were confident that they are made them feel othered and stigmatised.

"As soon as you say you are a Cuban [-trained student], there is this thing that you don't know anything." (Jabulani).

A prominent consequence of the discrepancy in Actual own/Ideal own identity is frustration.

"... I was unable to pick up a murmur and everyone will go up there and say 'Ok there is a murmur of course' ... I will go there and will not hear a thing ... So, it was challenging and very frustrating" (Focus group).

Loss of confidence and self-esteem

Self-esteem is a consequence of congruence between the Actual and the ideal self. Loss of confidence is a common consequence after repeated experiences of failure to meet the expectations of others (Earle 2009; Earle, Siegrist, and Gutscher 2010). Such experiences result in discrepancies between Actual/own and Actual/ ideal identity.

"Ah ... being doubtful of yourself all the way." (Perfect).

"I think that we show that we lack confidence. When we look at the consultant for signs that we are doing the right thing it just shows that we are not sure." (Focus group).

Lack of confidence may potentiate subsequent poor performance since low self-efficacy has been associated with inaccurate conceptions of the difficulty of the task, impaired planning and increased stress (Bandura 1982).

Anger and depression: Actual /ought other and Actual /ideal own discrepancy

Anger and depression are believed to be closely related (Busch 2009; Daniels and Holtfreter 2019), although the relationship is complex (Ng et al. 2019; Zimmer-Gembeck et al. 2016). Berkowitz has suggested that depressive feelings may result in anger and that the "depressed mood in itself produces angry feelings ..." (Berkowitz 1990; 2014). The primary cause of anger is frustration (Busch, Rudden, and Shapiro 2004; Busch 2009; Dollard et al. 1939). Anger may be internalised leading to lower self-esteem. Our participants were frequently angered and felt undermined and bullied when they fail to meet the expectations of local teachers and students, thus being confronted with Actual own/Ought other identity discrepancy, leading in turn to Actual own/Ideal own discrepancy.

"When people say things about something that has given you so much ... you get angry and depresssed at the same time. I get really angry" (Khaya).

"[Another consultant] wavele wangiphoxa nje [embarrased me out of the blue]. You get angry and frustrated" (Mluleki).

Even thought there were reports of anger and depression, none of our participants had reported substance-abuse, suicidal ideation or consultation with a psychologist. In our experience at the University of KwaZulu-Natal, such problems have been uncommon.

Loss of trust: Actual own/ ought other discrepancy

The dual role of teachers as subjective advisers and objective assessors could lead to misperceptions on the part of students. An observer might read the sequence of events from the consultant's point of view as a sympathetic interaction. However, in the course of teaching followed by an (appropriately) objective appraisal in the assessment, the shift from positive assistance to negative assessment was perceived by the participant as a breach of trust:

"My first block went well my consult was very understanding. However, she didn't give me a fair end of block mark. I had the lowest mark." (Nonhlanhla).

When a participant had complained to locally-trained students that an examination was unfair, they had responded sympathetically. Yet the view of his NMFCMC colleagues was that the sympathy was not genuine. "They only pretended [to agree with you] because you were saying so." (Focus group).

Fear and anxiety

Both fear and anxiety may be viewed as a response to a threat, to the extent that they may be viewed as overlapping. Fear is considered "a normal reaction to a real or imagined threat". Anxiety is viewed as a more complex emotion which is less well characterised than fear (Tovote, Fadok, and Luthi 2015). Higgins regards Actual own/Ought other discrepancy as an important predictor of fear, anxiety and apprehension, which may negatively affect social functioning, including a sense of threat, resentment and social anxiety (E. T. Higgins 1987). Individuals with high self-esteem place value on self-accountability, and frequently develop extreme anxiety in response to Actual/Ought identity discrepancy (Marcussen 2006). Although fear and anxiety may be differentiated as described above, the word fear is frequently used in common speech in a sense where anxiety might be more appropriately descriptive. There were numerous references to fear, expressed in different contexts see Figures 4 and 5.

 

 

 

 

"I think the first thing that comes to my mind, it was fear, that's the first thing that we would think." (Perfect).

Fear of failure

"When I was doing internal medicine, fear of failure drove me. My roommate [an NMFCMC student] repeated internal medicine the whole year." (Nonhlanhla).

"... you have fear that you may not pass. Statistics as well as past students told me that there were difficult blocks and that most students struggled." (Mluleki).

Given the NMFCMC students' record of poor performance in local examinations over many years, fear of failure in the South African examinations was appropriate. Sustained fear is associated with greater anxiety and unstable self-esteem (Martin and Marsh 2003; Sagar, Busch, and Jowett 2010).

The ultimate fear: Exclusion from the programme

"Something I worked for so long, cherished for the rest of my life, I can't fail." (Jabulani).

Many of the participants were strongly driven to succeed in their chosen career: indeed, this was a powerful component of resilience. Conversely, Markus and colleagues emphasise the feared self: the person the individual wishes not to become but fears becoming (Markus and Nurius 1986; Oyserman and Markus 1990) as being motivational. They argue that recognition of a feared self-motivates the individual to act in a manner such as to ensure that the feared qualities never materialize (Carver, Lawrence, and Scheier 1999). In this case, the feared self is the student exclusion from the programme, aspirations dashed, and potentially humiliated before family and community.

Scholars have described the unidimensional identity, one in which a particular aspect of identity become so important that self-esteem is almost entirely dependent upon its integrity. Studies of professional footballers who return from first-world countries to their home countries suggest that any disruption of the subject's identity as a sporting superstar leads to anxiety, anger, humiliation, and a diminished sense of self. Such a unidimensional identity tends to be common among the NMFCMC students, where being a doctor and sometimes the first doctor to come from and return to serve my community is frequently critical to their identity.

"Looking back at the influence of the community, very few of us from my matric class have made something out of themselves. They got it a name: Kwafelubala [The place where people die for nothing]. I want to rise above this. This cannot be me. I would like to make a difference. I don't judge myself by the things I have accumulated but by the number of people I have helped.

Odokotela omntakabani [Doctors come from reputable families]. My family was not well off, but I came from there" (Jabulani).

Anxiety

Anxiety, often expressed in the language of fear, was a frequently recurring theme among our participants.

"... because it was the first time, I was taking bloods ... I'd be sweating because it was the first time [to present a patient at the bedside to peers and teachers] ..." (Focus group).

"... my consultant was very understanding ... she gave me advice instead not to panic" (Nonhlanhla).

Anxiety may hinder performance. It may result in hypervigilance and faulty assessment of the environmental signals, leading to unrealistic exaggeration of the threat facing the individual (Lohr, Olatunji, and Sawchuk 2007; Seligman, Maier, and Solomon 1971). Much of the anxiety among our participants arises from the precedence set by earlier cohorts of students, who perpetuated stories about negative experiences. Such stories encouraged fear of hypothetical events such as rigged failure, rejection and ignominious exclusion from the programme. The effect of such anecdotes was to exacerbate anxiety, bring about an exaggerated perception of threat and reduce the ability to see the challenges in perspective.

"We were given heads up never to mention we were Cuban. You only waited for the day you are marked as a Cuban." (Focus group).

"Before coming here, I had a fear of rejection from students and academics." (Khaya).

Actual own/ ought other discrepancy

Resentment

Participants repeatedly expressed or implied resentment at what they saw as discriminatory or unfair treatment.

"I mention something out loud and won't be correct, the next person says exactly the same thing I said but they're local [so] they get recognition, yabo [you see] or clinically what I do must be double checked, overseen, etc., where probably for the next local not really, so the treatment does differ" (Focus group).

"I feel that when we look at the consultant in the eyes for confirmation, they feel we lack confidence, but when it's a local student they will assist." (Focus group).

Our participants frequently reported experiences, which they perceived as unfair: "Consultants grill you unfairly." (Focus group).

Self -identity incongruance and sense of belonging

In this section of the article, we present evidence of ways in which self-identity incongruence affects sense of belonging (Table 1). We noted that there was a negative correlation between self-identity discrepancies and sense of belonging. Consequences of self-discrepancy expressed as psychological and emotional distress affected sense of belonging indirectly and directly.

Indirect influences of self-discrepancy on sense of belonging

By encouraging certain attitudes (low self-esteem and low self-confidence), behaviors (passing, covering and physical hiding) and affect (resentment, fear) Self-identity discrepancies affected sense of belonging indirectly.

Attitudinal: Low self-esteem, and low self-confidence

Higgins asserts that when there is a discrepancy between who one thinks he is (actual own) and who others think he is (actual, other) there is bound to be distabilisation of the self-concept and by extension low self-esteem (E. T. Higgins 1987). The NMFCMC students join South African institutions on their final eighteen months of medical training, which sets them apart from the rest of the mainstream locally trained students from the onset. Being a newcomer when other groups have thoroughly settled reduces a sense of belonging (Goodenow 1993). Further, Researchers argue that demographically dissimilar groups struggle to find appropriate biases upon which to form favourable identities which in turn reduces group identification (Chattopadhyay, George, and Lawrence 2004) and organizational attachment (Kim et al. 2019). Gasiorek and Van de Poel (2014) asked a group of NMFCMC students at the University of Stellenbosch to complete a graphic task modelled on the method of Schubert and Otten (2002), designed to determine how they perceived the relationships between themselves and relevant groups in terms of distance. The results confirm that students identified strongly with Cubans and Cuban doctors and saw themselves as Spanish rather than English speakers. Cuban citizens, South African doctors trained in Cuba and Cuban doctors were seen as distant from their South African equivalents.

Our participants expressed that their self-concept destabilised as they were made to feel like they were not South Africans. Self - concept or self-identity "is a collection of beliefs about oneself". Whereas, self-esteem is an attitude towards oneself (Leary and MacDonald 2003) which depend on ones' perceptions of the level of one's worthiness of others' respect and support (Jindal-Snape and Miller 2009). Self-concept is seen as a description of the self and self-esteem as an evaluation of the self (Jindal-Snape and Miller 2008). Therefore, self-esteem or global reflection of how individual feel about themselves is crucial for mental wellbeing (Niwa, Way, and Hughes 2014). Areas of the self-concept that are most relevant for self-esteem are competencies and interpersonal relationships (Harter 1999) which were both not appropriately established in the case of NMFCMC students. Leary (2021) suggests that self-esteem reflects the degree of acceptance by the group. Our participants reported numerous instances of not being accepted or rather perceptions of not being welcomed. Low self-esteem derived from questionable competency can be associated with both depression and anxiety (Watson, Suls, and Haig 2002). Our participants expressed that they were homogenised and labelled struggling students based on their different skills set they brought from Cuba.

Further, self-esteem is influenced by clarity Campbell (1990) and confidence (Baumgardner 1990). Our participants expressed a lack of clarity regarding their professional identities as medical students trained and graduated by Cuban institutions for practice in South Africa. In addition, our participants reported a lack of confidence based on the divergence of South African and Cuban professional identities, roles and medical protocols and practice. Hence, such experiences negatively affected their self-concept, self-esteem, and self-confidence and in turn, their sense of belonging suffered.

Affective: Resentment, frustration, loss of trust and fear

Emotions are linked to belongingness as they usually represent reactions to changes that threaten one's relationships (Leary 2021). For instance, resentment, anger, grief, guilt and embarrassment, are common responses to relationship threat and other belongingness issues (Baumeister and Robson 2021). Higgins assert frustration is a consequence of who one believes one is (actual own) and others perception of who they wish one could be (ideal other). Fear, resentment, loss of trust as consequences of who one thinks he is (actual own) and who others think one ought to be (ought own) linked to social anxiety as discussed earlier (E.T. Higgins 1987).

The presence of trust implies a belief on the part of the individual that the other individual is able or prepared to compromise in such a way that the understanding of the personal point of view or the other individual expectation can be modified. As stated by Earle:

"Trust is social and relational; The basis for trust is a judgment of similarity between one person and another, that the person to be trusted would act as the trusting person would. The resilience of trust is due to its nonspecific, shared-values basis, ... When trust is strong, potentially damaging information can be construed in benign or even positive ways." (Earle 2009).

Thus, trust has an element of attachment and engagement both crucial to sense of belongingness. Where there is no trust often apprehension ensures and may result in social anxiety and its effect on belonging. Our participants were inconsiderate of the fact that exams are objective. Examinations are therefore not representations of the personality of the lecturer but an authentic reflection of the quality of knowledge and skill demonstrated and examined.

Behavioural: Passing, covering and physical hiding

Higgins did not discuss identity management strategies and physical hiding as a means to ameliorate negative evaluation, however our participants mentioned and at times even recommend such responses. All our participant students, believed it was appropriate to deny their identity as NMFCMC students, and to pass themselves off as locally-trained students based on the deeply engraved preconceptions created from the anecdotes of senior NMFCMC students. Senior NMFCMC anecdotes were about stereotyping and alienation of NMFCMC students by lecturers and locally-trained students. Though in a different context, in a study that explored students' sense of belonging in Orthopedics, Gerull and colleagues found that students' sense of belonging was significantly driven by stereotype preconceptions that orthopedic surgery was reserved for white athletic males even before doing the rotation (Gerull et al. 2021).

Social identity theory holds that people attempt to maintain social identities which are both positive and distinct (Tajfel et al. 1979). Individuals who belong to groups subjected to discrimination will often attempt to hide their identity to avoid stigma. Such individuals use identity-management strategies such as passing and covering to conceal their identities. In passing, individuals belonging to a stigmatised group mask or deny their membership of a specific group, and take care in how they speak and behave to support this deception (Goffman 1963; Newheiser and Barreto 2014). In covering, individuals modulate behaviour and statements likely to reveal their true identity in an effort to belong to the mainstream (P. Higgins 2021; Ghosh 2018; Yoshino 2001). Passing increases the need for situational vigilance and self-regulation, depletes cognitive resources, creates a continual state of dissonance (DeJordy 2008; Frable, Blackstone, and Scherbaum 1990), and results in distress and anxiety (Pachankis 2007).

Even though one student alluded to physically hiding behind other students, it remained important to be noted. Physical hiding is a means of evading negative evaluation perceived to be shameful that one might have been subjected to before and can easily be an expression of social anxiety as will be discussed in detail later in this article. Indeed, according to Higgins shame can be brought about by a discrepancy between who one thinks one is (actual own) be and who others think one should be (ought other) discrepancy. According to Tangney et al. (1992) susceptibility to shame correlates with "anger arousal, suspiciousness, resentment, irritability, a tendency to blame others for negative events, and indirect (but not direct) expressions of hostility". Both identity management strategies and physical hiding do not involve assertion of the individual's self-concept and self-esteem thus has a negative effect to an individual's sense of belonging.

Direct influences of self discrepancy to sense of belonging

Direct influences of identity discrepancy were noted in instances where it exerted psychological influences like social anxiety and lack of social esteem.

Psychological: Social anxiety and lack of social esteem

Our participants reported having fear of being ridiculed, which expressed their fear of negative evaluation. E. T. Higgins (1987) suggested that how others think you should be or wish that you can be created an actual own / ought other and actual own / ideal other discrepancy which my result in social anxiety and loss of social esteem respectively. Indeed, social Anxiety is characterised by fears of negative evaluation (Sareen et al. 2005) which encourages avoidance rather than engagement. Repeated failure or criticism may result in a vicious cycle of poor performance, negative responses from peers and teachers, loss of confidence, and a sense of persecution (Aydin 2013; Rapee and Heimberg 1997; Weeks, Heimberg, and Rodebaugh 2008; Weeks et al. 2008; Wells, Clark, and Ahmad 1998). For our participants, negative evaluations provided by lecturers during rotations potentiated loss of face in the eyes of locally-trained peers and lecturers themselves. This commonly results in fear of criticism, social interaction anxiety, and avoidance behaviour, not only towards the classroom and ward setting with which the criticism was associated. Further, it may promote isolation and presence of a sense of otherness as the individual withdraws into their own space E. T. Higgins (1987) referred to as "loss of social affection" (Johns and Peters 2012). Negative fear of evaluation promotes interpretation bias as such individuals are prone to interpret normal situations as threatening (Stopa and Clark 2000). In most instances, objective evaluations and feedback given by lecturers were seen as prejudiced. Negative interpretation bias can decrease social activity and exacerbating social isolation (Kimbrel 2008). Moreover, social isolation is connected to anxiety, anger, depression and guilt (MacDonald and Leary 2005). Thus, fear of negative evaluation is associated with greater feelings of thwarted belongingness, which makes it an appropriate mechanism to explain variations of belongingness. People who fear being judged negatively will avoid the situations where social performance may lead to rejection, seeking less-challenging contexts instead (Rapee and Heimberg 1997).

 

LIMITATIONS OF THE STUDY

Our intention in this study of twelve NMFCMC students was to better understand the effects of challenges students experienced during assimilation in South Africa on their self-identities and sense of belonging. The multiple data-gathering approaches used in the study allowed triangulation, reducing biases and strengthening validity. We used the narrative enquiry approach and participatory methods to allow the participants to lead the discussion thus making their voices audible. We did not intend to generalise the findings however, studies of similar nature had similar findings see (Lungelow 2011; Phasha 2021; Sui et al. 2019; Motala and Van Wyk 2019).

 

CONCLUSION

We have shown that the problems experienced by NMFCMC students returning to South Africa transcend the academic alone. Challenges experienced by the students arise from difficulties they encounter in assimilating into South African medical education and medical practice. Lindley et al. (2013) have suggested that international students returning home are often unclear as to whether they are visitors or actual inhabitants. It is clear that our NMFCMC students are similarly conflicted. The identity incongruence, which follows the difference in how the students see themselves and how they are viewed by teachers and locally trained students results in significant distress, which negatively affected their sense of belonging. Higgins described the relationship between various forms of incongruent identity and particular emotional responses. We have described some of these above. However, it is usually impossible to separate one set of circumstances or one emotion from another. Alternatively, do we believe that the identity perspective offers the best insight into complex emotional states under all circumstances? We do however believe that it has been useful in aiding understanding of how the distress initially arises and progresses to affect sense of belonging.

We have discussed ways in which self-identity discrepancies influenced participants' sense of belonging directly and indirectly. Direct consequences were exerted on the psychological domain resulting in social anxiety and loss of social esteem, which have negative effects on attachment and engagement. Further, self-discrepancies influenced participants' attitude, affect and behaviour, which frustrated sense of belonging.

The simplest way to avoid Actual own/Actual other identity incongruence is to hide one's identity and avoid placing oneself in situation where the incongruence is likely to be made obvious. This encouraged passing and covering which in turn made students less likely to develop a sense of belonging, or to take active, public steps to improve their personal and communal situations, for example by reporting discrimination or agitating for a change in learning conditions. Though Higgins himself did not comment upon issues such as passing and the feared self, we have found them to be highly pertinent to the identity of the NMFCMC students. The "feared self Carver et al. (1999) was a powerful motivator of participant performance, particularly when coupled with unidimensional identity. The price paid however was a high level of anxiety and fear. Identity discrepancy, whether directly or indirectly, hindered learning and integration into the academic and social community at the University level.

Issues of socialisation and identity have until now not been considered in any formal manner. At the fundamental level, this requires greater efforts to modify South Africa's health system to bring it into closer alignment with that of Cuba. A drive to a more equitably delivered, community-responsive and decentralised form of healthcare is indeed the expressed intention of the South African government, and is the subject of legislation currently before Parliament (Parliament of the Republic of South Africa 2018). Focusing on reinforcing positive aspects of identity, and interpersonal relationships through moderating the tendency of local teachers and students to emphasise the "otherness" of the NMFCMC student is crucial.

 

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