Analysis reflective reports
Contact information was available for 39 students, who were all invited to share their reflective reports (Fig. 1). A total of 33 students gave permission to analyze their reports (85%). Reports on the tropical medicine internship, public health internship and the combination internship were all taken into account. The period in which the IHEs took place was from July 2017 to February 2019. Internships took place in the following countries: Ghana, Indonesia, Malawi, Mozambique, Nepal, Nicaragua, Uganda, Surinam, Tanzania, Zambia and South Africa.
Inclusion of reflective reports
Deductive analysis of provided 20 categories of possible learning outcomes relevant to an IHE. Table 1 summarizes these categories, including illustrative quotes taken from the reflective reports. 6 related to the cultural development, 6 to the employability/career, and 9 to the personal development domain. The possible learning outcomes covered most, but not all 14 global health (GH) competencies as described earlier [18]. Some learning outcomes related to more than one domain, which we further explored in the interviews. Experiences that are related to the global health competencies and were mentioned by most students were: an understanding of travel medicine, skills to better interface with different populations, cultures and healthcare systems, appreciate contrasts between healthcare delivery systems and expectations and understand healthcare disparities between countries ( Table 1). Four GH competencies were not mentioned in the reports: humanism costs of global environmental change, evolving global governance issues and scientific and societal consequences of global change. Seven possible learning outcomes had not previously been described and were included as new learning outcomes: training of (new) practical skills, career perspective, (learning) to set personal boundaries, gaining confidence in own (medical) actions, creativity in problem solving, reflecting on own behavior (at home and/or during elective), developing cultural awareness. These competencies had been mentioned as both learning outcomes prior to the elective and more developed competencies afterwards.
Analysis of individual interviews
To further investigate and refine the 20 possible learning outcomes found in the analysis of student reports, 46 students were invited to participate in the semi-structured interviews. 39 student respondents, of whom 21 were willing to participate (46%). Because of the distance, 2 students were unable to meet the interviewer and were excluded. A total of 19 interviews were conducted. The average age of students during their IHE was 24.6 years and three male and sixteen female students were interviewed. Electives took place in Ghana, Malawi, Nepal, Rwanda, Uganda, Sierra Leone, Surinam and South Africa. Within this group, 15 students went on a tropical medicine IHE, 1 on a public health IHE and 3 on a combined IHE.
Using the interviews, the 20 possible learning outcomes were further refined, resulting in 9 clearly formulated learning outcomes which will be described below. The outcomes are ordered by domain: cultural development (C); employability/career (M); and personal development (P). Some of the learning outcomes relate to more than one domain.
Developing intercultural competence (C,P)
Students get acquainted with a new culture and learn how to work in this different cultural setting as well as how to approach people/patients in an appropriate manner (also called intercultural communication). Students learn to solve a problem, taking into account all parties involved and their sometimes different interests, while respecting local norms and values. Furthermore, students learn to be open to a new culture and/or different professional habits and, in the meantime, they learn how to work with these differences in mind. Students experience a different way of life and a different culture in the host nation and institution. On the other hand, the students reflected that they had developed a new, different view of their own culture, behavior and (work) attitudes in Dutch society.
Developing appreciation for differences in healthcare delivery systems (C,M)
Students get to know the organization of the host nations’ healthcare system and gain an understanding of differences in healthcare systems. They learn to appreciate the influence of culture, religion, health literacy of the population and economics on both a healthcare system and the way patients and their environment cope with illness. They learn to work within a health care system with a different culture, manners and professional habits.
Understanding international health (M)
Students are introduced to (infectious) diseases which are rare in sending countries but common in host countries and learn why the treatment of these diseases has proven to be so difficult. Additionally, they are confronted with diseases that are more familiar to them but present at a much more advanced stage. They gain knowledge on how to diagnose and treat these diseases by focusing on differences in diagnostics and treatments.
Understanding the global burden of disease (M)
Students gain insight into common diseases of the region and differences in prevalence of diseases between the host and the sending country. They learn to put the treatment choices into perspective and appreciate differences in treatment driven by a knowledge gap and/or low resources. Students learn about prevention programs and the impact of illness on the patients and their environment.
Developing a career perspective (M)
Students’ experiences abroad either confirm or discourage their aspirations for working abroad. Some students become more certain of their choice of medical specialty or their wish to be involved in healthcare projects in low income countries.
Developing clinical skills (M, P)
Because of limited access to diagnostic tests, students need to further develop their clinical skills needed for history taking and physical examination. Students feel that recognition of symptoms of disease and clinical reasoning are more deeply trained. They learn to cope with different circumstances and to come up with practical solutions, for example, they train practical skills such as performing physical examinations or assisting in the operating theater. In addition, students work on professional communication skills as well as communicating in a different language inside and outside of the hospital and/or learn to communicate through an interpreter or using nonverbal communication skills.
Becoming cost conscious (M,P)
Students experience greater awareness of the costs of healthcare and learn to be more pragmatic because of a limited amount of resources. Students develop a greater appreciation for the prevalence of health insurance and the influence of the economic welfare of a country on its healthcare system. Students gain more appreciation for the sending country’s healthcare system and all its possibilities. However, they also develop a more critical view on the consumption of diagnostic means and/or medications by medical doctors in the sending country. Students learn to cope with differences in the availability of treatment options and the sometimes unfortunate effects.
Developing social responsibility (P)
Students develop increased awareness of others around them and gain drive to improve a situation without self-promotion. It reminds them of their motivations to become a medical doctor. Furthermore, they understand that developmental aid only has a limited effect when it is for a short period of time and question how much impact their presence truly has on the host country/hospital. They become able to weigh the ethical dilemmas associated with their stay abroad such as the benefits of their presence for the local population/the hospital versus the local investment in their training.
Self-actualization (P)
As a result of the (large) differences between the circumstances in their host and sending country, students experience how to handle working outside of their comfort zone. This can increase their self-confidence regarding their own actions. At the same time, students learn to recognize and guard their own boundaries and how to indicate that they do not feel competent enough to perform a certain task. Because of interactions with people inside and outside the hospital, students learn more about their own behavior and attitudes as they get the opportunity to reflect and talk about it with the local population. Differences in cultural background, religion, attitudes and beliefs of the host country as well as political conflicts or economic status play an essential role in this new understanding.
Importantly, the participants often mentioned the importance of the local context and how it facilitated their development towards a specific learning outcome. For example, in countries where students were more familiar with the language, such as Surinam or South Africa, they were more able to communicate and work independently. This facilitated the development of medicine-related learning objectives such as developing practical skills and gaining an understanding of international health. In countries such as Nepal or Uganda, where students suffered more from a language barrier, students felt they learned more in terms of personal and cultural development because they were forced to focus more on non-verbal communication and context to understand what was happening. Furthermore, students participating in a tropical medicine IHE or a combination internship IHE more often described development towards medicine-related learning outcomes, whereas the students who participated in the public health internship felt that cultural competencies had been further developed during the elective. Students also stressed the importance of learning objectives within the domain of personal development, which is unique to an IHE. Important aspects within this development domain were gaining more self-confidence, learning to put things into perspective, developing greater appreciation for the conditions in the sending country and learning to care more for the people around them and gaining awareness of the differences in lifestyle and living situations around the world.
In the interviews, students also mentioned non-educational motivations for choosing an IHE at a specific location, for example, the desire to experience life abroad for an extended period of time (more than a vacation), having lived abroad before or having enjoyed a previous visit to the country/a LMIC and having the desire to return.