Analysis reflective reports
Contact information was available for 39 students, all of whom were 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 Combined Internship were considered. The period in which the IHEs took place was from July 2017 to February 2019. The internships took place in the following countries: Ghana, Indonesia, Malawi, Mozambique, Nepal, Nicaragua, Uganda, Suriname, Tanzania, Zambia and South Africa.
Inclusion of reflective reports
Deductive analysis of the provided 20 categories of possible IHE-related learning outcomes. Table 1 summarizes these categories, including illustrative quotes taken from the reflective reports. 6 related to cultural development, 6 to employability/career and 9 to the area of personal development. Possible learning outcomes cover most, but not all, of the 14 Global Health (GH) competencies as described earlier [18]. Some learning outcomes related to more than one area, which we explored further in the interviews. Experiences related to global health competencies and mentioned by most students were: understanding travel medicine, skills to better interact with different populations, cultures and health systems, appreciating contrasts between health care delivery systems and expectations, and understanding of health care disparities between countries (Table 1). Four GH competencies were not mentioned in the reports: humanism, cost of global environmental change, emerging issues of global governance, and scientific and societal implications of global change. Seven possible learning outcomes were not previously described and were included as new learning outcomes: learning (new) practical skills, career prospects, (learning) to set personal boundaries, gaining confidence in one’s (medical) actions, creativity in solving problems, reflecting on one’s own behavior (at home and/or during an elective), developing cultural awareness. These competencies were mentioned both as learning outcomes before the electives and as more developed competencies afterward.
Analysis of individual interviews
To further explore and refine the 20 possible learning outcomes found in the analysis of student reports, 46 students were invited to participate in semi-structured interviews. 39 students responded, of which 21 were willing to participate (46%). Due to 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 the IHE was 24.6 years, and three males and sixteen females were interviewed. Electives are held in Ghana, Malawi, Nepal, Rwanda, Uganda, Sierra Leone, Suriname and South Africa. Within this cohort, 15 students transferred to the Tropical Medicine IHE, 1 to the Public Health IHE and 3 to the Combined IHE.
Using the interviews, the 20 possible learning outcomes were further refined, resulting in 9 clearly articulated learning outcomes, which will be described below. The results are arranged by domain: cultural development (C); employability/career suitability (M); and personal development (P). Some of the learning outcomes relate to more than one area.
Developing Intercultural Competence (C,P)
Students are introduced to a new culture and learn how to work in this different cultural environment as well as how to approach people/patients appropriately (also called intercultural communication). Students learn to solve a problem by taking into account all parties involved and their sometimes divergent interests, while respecting local norms and values. In addition, students learn to open up to a new culture and/or different professional habits and, in the meantime, learn how to work with these differences. Students experience a different way of life and a different culture in the host nation and institution. Conversely, the students reflected that they had developed a new, different view of their own culture, behavior and (work) attitudes in Dutch society.
Developing an Assessment of Disparities in Health Care Delivery Systems (C,M)
Students become familiar with the organization of the host nation’s health system and understand the differences in health systems. They learn to appreciate the influence of culture, religion, population health literacy, and economics on both the health care system and the way patients and their environments cope with illness. They learn to work in a health care system with a different culture, manners and professional habits.
Understanding International Health (M)
Students learn about (infectious) diseases that are rare in the sending country but common in the receiving country, and learn why treating these diseases has proven so difficult. In addition, they face diseases that are more familiar to them, but are at a much more advanced stage. They gain knowledge on how to diagnose and treat these diseases, focusing on the differences in diagnosis and treatment.
Understanding the Global Burden of Disease (M)
Students gain insight into common diseases in the region and differences in disease prevalence between host and sending countries. They learn to put treatment choices into perspective and appreciate treatment differences driven by knowledge gaps and/or low resources. Students learn about prevention programs and the impact of disease on patients and their environment.
Career Prospect Development (M)
Students’ experiences abroad either confirm or discourage their aspirations to work abroad. Some students become more confident in their choice of medical specialty or their desire to participate in health projects in low-income countries.
Developing Clinical Skills (M,P)
Due to limited access to diagnostic tests, students must further develop their clinical skills necessary for history taking and physical examination. Students felt that disease symptom recognition and clinical reasoning were more thoroughly trained. They learn to deal with different circumstances and come up with practical solutions, for example, they practice practical skills such as performing a physical examination or assisting in the operating room. In addition, students work on professional communication skills as well as communicating in a different language inside and outside the hospital and/or learn to communicate through an interpreter or using non-verbal communication skills.
Cost Awareness (M,P)
Students become more aware of health care costs and learn to be more pragmatic with limited resources. Students develop a better understanding of the distribution of health insurance and the impact of a country’s economic well-being on its health system. Students gain a greater appreciation of the sending country’s healthcare system and all its capabilities. However, they also develop a more critical view of the consumption of diagnostic tools and/or drugs by doctors in the sending country. Students learned to cope with differences in the availability of treatment options and sometimes adverse effects.
Development of social responsibility (P)
Students develop a greater awareness of others around them and gain a drive to improve the situation without self-promotion. It reminds them of their motivations for becoming a doctor. Furthermore, they understand that development aid has only a limited effect when it is for a short period of time and they doubt how much impact their presence has on the host country/hospital. They become able to weigh the ethical dilemmas associated with their time abroad, such as the benefits of their presence to the local population/hospital versus the local investment in their training.
Self Update (P)
As a result of the (large) differences between the circumstances in the receiving and sending countries, students experience how to deal with work outside their comfort zone. This can increase their self-esteem regarding their own actionc. At the same time, students learn to recognize and guard their own boundaries and how to show that they do not feel competent enough to complete a certain task. By interacting with people inside and outside the hospital, students learn more about their own behavior and attitudes as they get the chance to reflect and talk about it with the local population. Differences in the cultural background, religion, attitudes and beliefs of the host country, as well as political conflicts or economic status play a significant role in this new understanding.
Importantly, participants often mentioned the importance of the local context and how it facilitated their development towards a particular learning outcome. For example, in countries where students were more familiar with the language, such as Suriname or South Africa, they were better able to communicate and work independently. This facilitated the development of medical-related learning objectives, such as developing practical skills and gaining an understanding of international health. In countries like Nepal or Uganda, where students suffer more from a language barrier, students feel they have learned more in terms of personal and cultural development because they have been forced to focus more on non-verbal communication and context to understand what is going on . In addition, students participating in a tropical medicine IHE or a combined IHE internship more often described development toward medicine-related learning outcomes, while a student participating in a public health internship felt that cultural competencies were further developed during of the elective course. Students also emphasized the importance of learning goals in the field of personal development, which are unique to VUI. Important aspects within this area of development were gaining more self-confidence, learning to put things in perspective, developing a better appreciation of conditions in the sending country and learning to care more for those around them and gaining awareness of differences in lifestyle and living. situations around the world.
In the interviews, students also mentioned non-educational reasons for choosing VEI in a particular location, for example wanting 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/ SNSD and desire to return.