J Community Health DOI 10.1007/s10900-012-9547-y
ORIGINAL PAPER
Student Objectives and Learning Experiences in a Global Health Elective David Holmes • Luis E. Zayas • Alex Koyfman
Springer Science+Business Media, LLC 2012
Abstract International health electives offer unique experiences for medical students to develop clinical skills and cultural competencies in unique and diverse environments. Medical students have been increasingly pursuing these learning opportunities despite the challenges. However, their goals in pursuing these opportunities and the relation between their learning objectives and actual experiences have not been studied adequately. It is important to assess these programs based on student objectives and whether those objectives are met. Thirtyseven medical students from five cohorts at a US medical school completed pre-post questionnaires regarding their global health elective objectives and learning experiences. The questionnaires included mostly open-ended questions and a Likert-scale rating of their overall experience. Qualitative thematic analysis involved inductive coding and followed a content-driven immersion-crystallization approach. Quantitative program evaluation measures yielded descriptive statistics. Five general objectives and four types of learning experiences were identified. Student objectives were: (1) to observe the practice and organization of health care in another country; (2) improve medical/ D. Holmes (&) Department of Family Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Farber Hall #202, 3435 Main St., Buffalo, NY 14214, USA e-mail:
[email protected] L. E. Zayas School of Social Work, College of Public Programs, Arizona State University, Phoenix, AZ, USA A. Koyfman Department of Emergency Medicine, Brigham & Women’s Hospital and Massachusetts General Hospital, Boston, MA, USA
surgical skills; (3) improve language skills; (4) learn about another culture; and (5) deepen knowledge of infectious diseases. All of their objectives were achieved. Moreover, one learning theme, ‘‘self-reflection and personal growth,’’ was not a student objective. Quantitative assessment showed that most students had a favorable elective experience. Program challenges were also identified. Students in a global health elective were able to fulfill self-identified learning objectives, while also gaining other unexpected yet important lessons. Students’ learning objectives also should be considered in evaluating learning experiences in international health electives. Keywords Medical education International health electives Oversees medical studies
Introduction Globalization requires that future physicians understand and experience health issues in an international context. In response, medical schools and residency programs in the US have been offering formal clinical electives in foreign countries [1–4]. According to the AAMC Graduate Questionnaire that medical students complete just before graduation, 31% of students graduating from US medical schools in 2010 participated in an international health elective during their medical training [5], compared with only 6% of students graduating in 1984 [6]. A survey of 96 US allopathic medical schools found that 95% of the schools had international opportunities for students to participate in, and 87% offered international clinical electives [1]. The experience provides a wealth of knowledge and skills that enhance medical training. A literature review conducted by Jeffrey et al. [7] indicated that the
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majority of studies reviewed found that students who participated in international health electives reported greater self-confidence in history-taking and performing physical exams than students who did not complete electives overseas. Also, several of the studies indicated that students who engaged in international health electives increased their knowledge of tropical disease and immigrant health [7]. Besides developing medical knowledge, there are indications that international health electives support student interest in primary care and/or health disparities issues. For example, Haq et al. [8] found that 70% of global health elective participants (59 medical students and one resident at various medical schools) planned primary care careers. Smith and Weaver [9] found that after returning from an international elective in Nicaragua, students had an increased interest in volunteerism and in working with underserved communities in the US and abroad. Other researchers have reported increased respect for clinical judgment, recognition of the importance of public health education, and greater cultural sensitivity as result of international electives [10, 11]. One study comparing an international and a domestic community medicine clerkship found that while the percentage of students planning to work in underserved areas beforehand was lower in the international group compared to the domestic group (72.8 vs. 80.6%) and declined in both groups 2 years after the clerkship, the percentage of students still planning to do so was much higher in the international group (23.1%) than in the domestic group (5.6%) [12]. A literature review concluded that international health electives were associated with career choices in underserved or primary care settings [13]. These electives had positive effects on clinical skills, knowledge of tropical medicine, and attitudes such as appreciation of public health and cross-cultural communication [2, 13]. While the value international health programs has been established, little attention has been given to how learning experiences meet students’ objectives. What do students hope to get out of such experiences that they could not get at their medical schools? Are students achieving their objectives for participating in global health electives? Unlike other studies which focus on learning outcomes, this study assesses the learning objectives of medical students engaged in a global health elective program at the University at Buffalo’s (UB) medical school, and whether or not their objectives were achieved. The program assessed in this study is sponsored by the UB Department of Family Medicine, which assists students in finding international health placements. It was established in the early 1980s, when medical students prompted a Family Medicine faculty member to start an international health education program for students [10]. Student interest
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and faculty conviction that core primary care skills would be improved by experience in settings without advanced medical technology or specialist networks led to the program’s establishment. Initially, rotations were set up for students in Africa. Since then the program has grown and students now engage in global health electives throughout the world. Students are responsible for all the arrangements and expenses. For the elective to be approved, an on-site physician must be present and responsible for supervising and grading the students. Electives may be taken during any four-week module of fourth year. The main study questions are: what are the learning objectives and perceived learning experiences and challenges that students have in a global health elective? Are their objectives being met by their learning experiences?
Methods The program was evaluated using pre- and post-elective questionnaires that included a mixture of closed- and openended questions. Padgett [14] notes that ‘‘quantitative evaluations are good at establishing what works, but qualitative evaluations help to understand how a program succeeds or fails.’’ Both questionnaires were self-administered to five program cohorts totaling 43 students participating in the program from academic years 2001–2006. This evaluation is limited to 37 students for whom complete data were available. Pre-elective questionnaires asked students to provide information about the sponsor organization and to describe their educational objectives for their elective. Post-elective questionnaires asked students to describe what they learned from their experiences, strengths of the program, and challenges that they encountered. It also asked students to offer reflections on their experience and to rate their overall experience using a five-point Likert scale. The program director and staff developed the questionnaires to determine student objectives and learning outcomes. The UB’s Institutional Review Board declared that the study had exempt status. The students’ handwritten responses to the open-ended questions were entered into a word-processing file for data management and text analysis, and quantitative data were entered into an Excel database for analysis. Residency match lists also were obtained from the Office of Medical Education. Data were de-identified and analyzed in aggregate. Three analysts reviewed the open-ended data following a content-driven immersion-crystallization approach, which consists of a systematic iterative process of interpretation and categorization of text involving ‘‘repeated delving into and experiencing of the data’’ to identify patterns of significance and connections [15]. A medical anthropologist experienced in qualitative data
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analyses developed the analytical plan and trained and supervised the two other analysts, a family physician and a medical student, in this inductive process. Open-ended responses were analyzed by question per pre/post instruments. Student objectives, learning experiences, and program challenges were analyzed separately to identify meaningful and significant descriptions. Then, the analysts compared their findings and debated their interpretations in order to develop inductively coding categories through consensus [16]. Lastly, themes pertaining to the students’ learning objectives and experiences were developed from major single codes as well as from related codes to establish the main findings. Main program challenges were itemized. Quantitative measures yielded descriptive statistics and supplemented qualitative findings. To enhance the trustworthiness of the qualitative analysis one analyst performed a negative case analysis check by reviewing the data set in search of evidence contrary to the findings [17].
Results Students participated in three types of programs: (a) purely clinical experience, (b) research and clinical experience, and (c) language training (Spanish) and clinical experience. Most students participated in both inpatient and outpatient care. The students included 12 men (32%) and 25 women (68%) who traveled mostly to Latin American countries (Table 1). The majority of the students (54%) participated in the elective sometime between their residency Match Day (mid-March) and graduation (early May), while the remainder did so before Match Day. Almost two-thirds Table 1 Location of global health electives Region Latin America
Asia Europe
Africa
Countries
Number of students
Students per region
Costa Rica
9
23
Ecuador
5
Peru
4
Mexico
2
Cuba
1
Dominican Republic
1
El Salvador
1
India
7
7 4
England
2
Ireland
1
Switzerland Congo
1 1
Lesotho
1
Mozambique
1
3
Table 2 Students’ residency matches Residency
# students (%)*
Family medicine
10 (26)
Internal medicine
7 (18)
Pediatrics
5 (13)
Obstetrics-gynecology
3 (8)
Emergency medicine
5 (13)
Medicine/Pediatrics
2 (5)
General surgery
2 (5)
Ophthalmology
2 (5)
Otolaryngology
1 (3)
Transitional
1 (3)
Undecided
1 (3)
* Number of students entering the specialty divided by the total # of students (37). Percentages do not add up to 100% due to rounding
(62%) of the students in the sample were accepted into primary care residencies (Table 2). Students’ assessment of the value of their elective showed that the majority had a favorable experience. Of 32 students who responded to this question (five did not respond), the average rating was 4.6 on a 5 point Likert scale (5 being the highest rating). Out of 31 students responding (six did not respond), 27 (87%) stated that they would recommend the experience to others. Qualitative data, moreover, offered more descriptive evaluation of the students’ elective experience. Qualitative findings from pre-questionnaire data are summarized under ‘student objectives’ and those from post-questionnaire data are summarized under ‘learning experiences’ and ‘program challenges’. Given their learning experiences while considering stated program challenges, the students’ learning objectives appear to have been met. Student Objectives The students’ elective objectives, as stated in the prequestionnaires, were categorized under five major themes. These themes were developed from several statements that revolved around a particular objective, and each are exemplified here by reference to one illustrative or representative quote. One thematic objective that emerged is (1) To observe the daily practice and organization of health care in another country. For example, one student hoped ‘‘to develop an appreciation and ability to participate in health care in a developing country.’’ Another one is (2) To improve medical skills (patient history and physical exam) and surgical skills. Hence, as one student noted: ‘‘To master diagnostic skills without the aid of cutting-edge technology.’’ A third objective that came up is (3) To improve language skills. One student wanted ‘‘to improve
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my rudimentary knowledge of medical Spanish so that I may be a more effective communicator with Spanish speaking patients.’’ A fourth one is (4) To learn about another culture. One student, for example, wished to ‘‘learn more about Costa Rican culture.’’ And the fifth objective is (5) To deepen knowledge of infectious diseases. An example derives from a student who wanted ‘‘to better understand treatment and care issues related to patients with HIV and AIDS.’’ A common thread regarding these thematic objectives is that all the students wanted to use their international experience to improve the way they care for their patients. They hoped to accomplish this by attaining a better understanding of a different language and culture than the ones they are familiar with, by improving their clinical skills (i.e., history taking, physical exam and care procedures) in less than ideal conditions, and by increasing their knowledge of infectious disease in the context of globalization of health care. Learning Experiences Analysis of post-questionnaire qualitative data yielded a series of learning experiences categorized under four major learning themes: (1) development of medical knowledge and skills in an international context; (2) awareness of health status and health care in other countries; (3) cultural influences on health care; and (4) self-reflection and personal growth. Learning theme #1 meets student objectives #2 (increased clinical skills) and #5 (knowledge of infectious diseases); learning theme #2 achieves objective #1 (observe health care in another country); and learning theme #3 meets objectives #3 (learn another language) and #4 (learn about another culture). However, learning theme #4 has no corresponding objective and was unexpected. Learning themes and examples of learning experiences are summarized and linked to their respective learning objective in Table 3. Following is a narrative of the learning themes. Development of Medical Knowledge and Skills in an International Context The majority of students reported an increase in skill development and medical knowledge. Students stated they became less reliant on diagnostic tests and put a stronger emphasis on history-taking and physical examination. As one student mentioned, ‘‘I learned to rely on clinical findings instead of ordering labs or radiology films.’’ Students observed, treated, and performed various procedures. ‘‘I learned the dosing of antibiotics and analgesics, and had the opportunity to suture after several machete injuries,’’ reported one student. Another stated, ‘‘I was able to work
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on my suturing, pleural taps and knee injections.’’ Students encountered an array of infectious diseases they had learned about but not seen in their traditional medical school setting. One student ‘‘…saw several diseases…never encountered in US—congenital rubella, xeroderma pigmentosum, very late stages of rheumatic heart disease…’’ Another one stated, ‘‘I learned more about TB and leprosy…I learned and saw greater oncology pathology.’’ Furthermore, one student observed how ‘‘diagnoses were made more often by clinical symptoms and less often used diagnostic tests.’’ Awareness of Health Status and Health Care in Foreign Country Students learned about how health care is organized and delivered in another country. For example, one student observed that the ‘‘health care system in Costa Rica is free, but with many flaws, [such as] long waits and poor MD compensation. On the other hand, doctors were usually very well respected with little or no fear of litigation.’’ Another student mentioned, ‘‘we also learned about the local health care system…Even medical treatment of common infirmities was different due to practical considerations.’’ Students became more aware of the importance of preventive medicine, public health, and careful utilization of resources. One student learned how ‘‘poverty and lack of resources impacts public health and individual care,’’ while another wrote, ‘‘I learned how a country with few economic resources has an infant mortality rate comparable to nearly every developed country.’’ Another student also noted, ‘‘I learned very cost effective uses of laboratory tests and scans… [and] about the different medications used in India.’’ Cultural Influences on Health Care Many students learned about local cultural norms and how they affected health care in foreign countries. For example, one student described learning about ‘‘…longstanding cultural beliefs about certain medical problems and how to integrate these beliefs into my medical knowledge.’’ Another ‘‘learned about…local home remedies.’’ Another student wrote, ‘‘talking with the local doctors…helped me to learn more about…local attitudes toward health.’’ Another was able to observe ‘‘…the workings of a highly cooperative social structure’’ in the community and how that could influence seeking health care. In addition, students learned about language and cross-cultural communication in health care. For example, one student declared, ‘‘[I] vastly improved my Spanish. I now feel very confident interviewing a patient in Spanish, going through a physical exam, and giving recommendations in Spanish…’’ Another
J Community Health Table 3 Thematic student objectives and learning experiences Objectives
Learning experiences
1: Observe health care in another country
2: Awareness of health status and health care in foreign country: Clinical content: high incidence of preventable diseases; late stage presentation How health care is organized and delivered Hospital cultures: patient-doctor relationship; physician practice style Lack of diagnostic tests Addressing needs of underserved areas in global context Effects of lack of education on health
2. Increase clinical skills 5: Increase knowledge of infectious diseases
1: Medical knowledge and skill development Importance of history-taking and physical exam Diagnoses based on clinical symptoms Increased flexibility to work in less than ideal settings Cost-conscious care/resource utilization Diverse array of tropical and infectious diseases that are studied but not seen in US Procedures: suturing, surgical, triage, pelvic exam
3: Increase language skills 4: Learn about another culture
3: Cultural influences on health care How health beliefs affect health care delivery Sick roles and daily survival Food choices and differences Collectivist notions of social support Language: medical Spanish/working with translators Culturally sensitive health care communications Ethnomedical treatments: dosing, medications, home remedies
No objectives identified in this category
4: Self-reflection and personal growth Cultural humility versus ethnocentrism Human rights: social and economic Patient advocacy Clarity about future career role Self-confidence in a medical setting Self-awareness of privilege
student noted, ‘‘I learned how to work with a translator to communicate with patients… [and] learned some basic medical words in Marathi…’’ Lastly, in learning ‘‘…how to approach discussions about birth control in Latino culture’’ another student appeared to gain skills in culturally sensitive communication. Self-Reflection and Personal Growth The electives also provided students with role models and opportunities for self-reflection and personal growth. For example, one student mentioned that her preceptor was ‘‘…a role model as a person and as a physician. She is active politically and socially to help protect her patients’ right to health care.’’ Another student resolved to ‘‘…aspire to incorporate medical missions into my future practice…’’ Another student reflected on the impact of interactions: ‘‘it
was interesting to interact with interns and medical students from other countries and compare our experiences.’’ Furthermore, one student contemplated on the experience as follows: ‘‘the hard work in simply living that these people endure without complaint fostered in me great respect and…some shame for any time I felt life was ‘hard’ for me. I believe this sort of perspective would truly benefit every American and help remind us to always ‘count our blessings.’’’ Program Challenges Although most students highly rated their elective experience, some reported several types of challenges. Language was by far the most commonly reported challenge (12 of the 37 students reported so). As one student noted, ‘‘the language was a barrier at times because I was not
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fluent in the local dialect.’’ The next most commonly reported challenges were the political situation (4 students) and finding housing (4 students). Some of the political problems involved, according to one student, were ‘‘…dealing with government, police or judicial corruption.’’ In terms of housing, one student conceded, ‘‘…hav[ing] to find housing on your own, but housing is usually very cheap.’’ Only three students said cultural adjustment issues were a problem. Three students complained about the largely observational (vs. hands-on) nature of the clinical experience. And one thought the elective experience was ‘‘tedious.’’ No students reported concerns about safety.
Discussion International travel and immigration has emphasized the global interdependence of health [18]. The US continues to become more culturally diverse with growing populations that embrace distinct health beliefs and practices, while travel facilitates the movement of diseases. Hence, future physicians need greater knowledge and understanding of global health. They must be able to adjust their clinical approach to the needs of diverse populations instead of following a ‘one-size fits all’ conventional treatment plan. Physicians also must be proficient in developing trusting, cross-cultural doctor-patient relationships. This and other research suggest that global health electives can be helpful in training medical students to become better physicians [7, 11, 13, 19]. Houpt et al. [20] addressed the question of what constitutes global health and what should American and Canadian medical students know about it. Through their research they concluded that in order for students to achieve global health competency, medical school curricula should include the following three domains: (1) global burden of disease, (2) traveler’s medicine, and (3) immigrant health. By engaging in global health electives the students in this study developed competencies in these domains. They learned about infectious and other types of diseases. Through their own experience of traveling and in meeting with the course director for guidance before the trip and debriefing after the trip, they learned about the preparations and cautions overseas. Also, by immersing themselves in a different culture, students learn valuable lessons about sensitivity and cross-cultural communication [7, 8, 11, 13, 19, 21]. In evaluating pre- and post-questionnaires, it appears that all student objectives were achieved, as indicated by the first three learning themes—developing knowledge and skills in tropical medicine (meets objectives #2 and #5), awareness of health status and health care in a foreign
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country (meets objective #1), and appreciation of cultural influences on health care (meets objectives #3 and #4). In addition, students appeared to achieve a degree of personal growth reflecting on their unique experiences, which was not a stated objective. Unlike other learning themes, this was an unanticipated albeit welcome benefit. Some students described developing a better understanding of their own privilege and a sense of advocacy for patients. The experience may inspire students in regaining the idealism for medicine and the compassion for patients that many tend to have at the beginning of medical school and that is sometimes replaced with cynicism during their clinical training years [9]. Moreover, a majority of students in our sample (62%) were accepted into primary care residencies. Research has found that a higher number of students who participate in global health electives go into primary care residencies [7, 13, 21, 22]. While appropriate for in-school program evaluation, this study has some limitations regarding its wider application. It involves a small sample of students at one medical school; hence, its findings may not be generalizable or transferable to other programs. There were no comparison or control groups. Also, the results were based on student self-reports, and a few students completed most but not all the questionnaire items. On the other hand, the strengths of the study are that it evaluated the learning experiences of five student cohorts in over a dozen different countries, that it considered the students’ personal objectives before they embarked on the elective, and that it included quantitative and qualitative program evaluation measures. This study supports and contributes to the relatively modest literature on the educational value of international health electives, which are offered by most medical schools in the US. The study is unique for it assesses the students’ personal objectives prior to the elective and examines the students’ learning experiences qualitatively to determine their type and extent and whether or not the objectives were achieved. Students wanted to learn about the practice and organization of health care in another country; to improve their clinical skills; to learn other languages and about other cultures; and to advance their knowledge of infectious diseases. The findings show that the students’ objectives were achieved and that the program was successful. Important educational outcomes identified in this study, such as medical knowledge and skill development, knowledge about different health care systems, languages, and cultures, and personal growth are consistent with findings from other studies [7, 13]. However, one learning experience regarding self-reflection and personal growth which was not a stated student objective was an unanticipated outcome. Challenges voiced by the students are important to consider. Some challenges may be necessary for learning
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and should not be eliminated. For instance, working through cultural and language barriers may be necessary to foster cultural humility and competence. However, other challenges may not facilitate learning and should be avoided, if possible. For instance, students may be better served by programs with hands-on clinical experience rather than observational ones. Few studies have addressed challenges that students encounter in participating in global health electives. One study identified ‘‘financial, language and organizational burdens’’ that can hinder student participation [23], and another noted student concerns over international conflicts or epidemics [24]. It is important for medical school programs to consider and offer advice regarding these and other challenges that students may encounter. It is also important to conduct formal student evaluations of their global health electives in order to maximize the students’ learning opportunities by helping to guide and prepare future participants. Considering their learning objectives and preparation for the elective may be useful as a starting point.
Conclusions Students in this study who completed global health electives achieved their common objectives. Moreover, they experienced personal growth, which was not one of their objectives. These students developed knowledge, skills and attitudes in areas important in all medical fields, especially as patient diversity and the globalization of health care continue to increase. Despite some challenges, they had positive educational experiences that appeared to better prepare them for practice in a more interconnected and diverse health care environment. Thus medical schools should expand their global health education programs and encourage more students to engage in experiential learning opportunities abroad. In doing so, students’ learning objectives also should be considered in evaluating their learning experiences. Acknowledgments This study was supported in part by grant 1 D56 HP00171-02 from the Health Resources and Services Administration (Washington, DC) to Dr. Koyfman. The authors would like to thank Dr. Kim Griswold, Dr. Richard Pretorius, Dr. Ray Bissonette, and Mr. Andrew Danzo for their assistance in reviewing this article and Ms. Karen Devlin for her assistance in the preparation of the manuscript.
References 1. McKinley, D. W., Williams, S. R., Norcini, J. J., & Anderson, M. B. (2008). International exchange programs and U.S. medical schools. Academic Medicine, 83(10), S53–S57.
2. Drain, P. K., Primack, A., Hunt, D. D., Fawzi, W. W., Holmes, K. K., & Gardner, P. (2007). Global health in medical education: A call for more training and opportunities. Academic Medicine, 82(3), 226–230. 3. Bateman, C., Baker, T., Hoornenborg, E., & Ericsson, U. (2001). Bringing global issues to medical teaching. Lancet, 358, 1539–1542. 4. Edwards, R., Rowson, M., & Piachaud, J. (2001). Teaching international health issues to medical students. Medical Education, 35(8), 807–808. 5. Association of American Medical Colleges. (2010). 2010 Medical school graduation questionnaire all schools report. Washington, DC: Association of American Medical Colleges. 6. Association of American Medical Colleges. (1984). 1984 Medical school graduation questionnaire all schools report. Washington, DC: Association of American Medical Colleges. 7. Jeffrey, J., Dumont, R. A., Kim, G. Y., & Kuo, T. (2011). Effects of international health electives on medical student learning and career choice: Results of a systematic literature review. Family Medicine, 43(1), 21–28. 8. Haq, C., Rothenberg, D., Gjerde, C., et al. (2000). New world views: Preparing physicians in training for global health work. Family Medicine, 32(8), 566–572. 9. Smith, J. K., & Weaver, D. B. (2006). Capturing medical students’ idealism. Annals of Family Medicine, 4(1), S32–S37. 10. Bissonette, R., & Route, C. (1994). The educational effect of clinical rotations in nonindustrialized countries. Family Medicine, 26(4), 226–231. 11. Mutchnick, I. S., Moyer, C. A., & Stern, D. T. (2003). Expanding the boundaries of medical education: Evidence for cross-cultural exchanges. Academic Medicine, 78(10), S1–S5. 12. Chiller, T. M., De Mieri, P., & Cohen, I. (1995). International health training. The Tulane experience. Infectious Disease Clinics of North America, 9(2), 439–443. 13. Thompson, M., Huntington, M., Hunt, D., Pinsky, L., & Brodie, J. (2003). Educational effects of international health electives on U.S. and Canadian medical students and residents: A literature review. Academic Medicine, 78(3), 342–347. 14. Padgett, D. K. (2008). Qualitative methods in social work research. Thousand Oaks, CA: Sage Publications. 15. Borkan, J. (1999). Doing qualitative research (pp. 179–194). Thousand Oaks, CA: Sage Publications. 16. Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation, 27(2), 237–246. 17. Kuzel, A. J., & Like, R. C. (1991). Primary care research: Traditional and innovative approaches (pp. 138–158). Newbury Park CA: Sage Publications. 18. Mazur, L., & Sechler, S. (1997). Global interdependence and the need for social stewardship. New York: Rockefeller Brothers Fund. 19. Godkin, M., & Savageau, J. (2001). The effect of a global multiculturalism track on cultural competence of preclinical medical students. Family Medicine, 33(3), 178–186. 20. Houpt, E. R., Pearson, R. D., & Hall, T. L. (2007). Three domains of competency in global health education for all medical students. Academic Medicine, 82(3), 222–225. 21. Godkin, M., & Savageau, J. (2003). The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Family Medicine, 35(3), 273–278. 22. Ramsey, A. H., Haq, C., Gjerde, C., & Rothenberg, D. (2004). Career influence of an international health experience during medical school. Family Medicine, 36(6), 412–416. 23. Vora, N., Chang, M., Pandya, H., Hasham, A., & Lazarus, C. (2010). A student-initiated and student-facilitated international
123
J Community Health health elective for preclinical medical students. Medical Education Online, 15, 4896. doi:10.3402/meo.v15i0.4896. 24. Imperato, P. J. (2004). A third world international health elective for U.S. medical students: The 25-year experience of the State
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University of New York, Downstate Medical Center. Journal of Community Health, 29(5), 337–373.
