What is global health?

Broadly defined, global health is an “area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” The global health paradigm acknowledges health as a human right and recognizes that health disparities exist worldwide. Within this paradigm, health care workers are challenged to participate in the care of these vulnerable populations locally and abroad.

Historically, global health has been directly associated with country-specific economic and political influences. Over time, global health research has increased global awareness of health inequities in developed and developing countries, with a focus on addressing infectious disease, maternal and child mortality, and immunization programs for communicable diseases. More recently, with increased access to knowledge and technology globally, a framework for improved health equity may be possible. Unfortunately, there is often still an unequal distribution of resources across populations in a given country.

Funding for global health tends to be heavily focused on a number of disease-specific interventions (e.g., human immunodeficiency virus [HIV]/acquired immunodeficiency syndrome [AIDS], tuberculosis, malaria). Less funding is typically allocated for the development of health system infrastructure (e.g., health education, health care providers). Decisions regarding financial allocations are often dictated by the politics and preferences of donor countries, where the focus of funding may not be on the provision of equitable health care. In addition to domestic and foreign government agencies, there are several large international nongovernmental organizations (NGOs), such as the World Health Organization or World Bank, who are engaged in global health work and research. There are also a variety of NGOs working in global health research, with a focus ranging from science to advocacy and policy development.

Many prelicensure health professions engage in educational activities outside of a program’s home country. In PA education, up to 40% of programs have offered elective ICRs. Global health educational activities may include didactic, service learning opportunities and supervised clinical experiences in international settings, as well as distinct global health tracks within curricula. Although institutional goals and objectives for learning abroad may vary, engagement in global health often requires students to consider health disparities as they affect population health and a variety of illnesses. Students engaged in global health educational activities may begin to gain awareness and understanding of their role as health care providers within the context of the global community. In these settings, students may interact with a variety of health profession students, including but not limited to medical, nursing, public health, and physical and occupational therapy students. Working collaboratively, students participating in these educational activities have the potential to help improve community health, particularly among communities and in countries with disadvantaged populations or low health service resources. Students may encounter individuals from a variety of global health entities and organizations while abroad, such as global health researchers, volunteers or employees with NGOs, or students from global health educational programs.

Although global health is most often focused on population health needs and health equality in developing countries, it also incorporates those same health initiatives locally. Broadly recognizing public health issues and population needs allows for the application of potential solutions anywhere there are health inequities. This may allow urban, rural, underserved, developed and underdeveloped countries, immigrant and migrant populations to be recognized within the framework of global health. By accounting for the scope of problems, rather than the location in which it occurs, clinicians learn to recognize and address health disparities in their own community.

Is an international clinical rotation right for me?

PA programs that offer international experiences may do so because it aligns with their program or university mission, vision, and goals, which may include:

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  Integrating a global perspective into education

  
  
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  Partnering with international entities

  
  
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  Incorporating a service-oriented focus

  
  
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  Engaging with diverse and underserved populations/communities

  
  
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  Improving the health and wellness of diverse communities

  
  
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  Reducing health disparities

  
  
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  Providing students with opportunities to learn in global settings

Programs may offer ICRs to provide their students with a unique opportunity to acquire knowledge, skills, and attributes that may be more difficult to achieve on a domestic rotation. First, ICRs may increase students’ cultural competency through exposure to unique population-related health care problems (e.g., disease management, health promotion, and disease prevention educational strategies). Second, ICRs may increase students’ awareness of how culture, economics, and politics influence individual and public health outcomes. Third, PA programs may hope to better inform students interested in global health and international work or service of the differences that exist outside of their home country through exposure to other health care systems, practices, and policies. Fourth, some programs may want students to increase their working knowledge of assessing and managing conditions not endemic to their home country. Finally, many programs may be motivated to offer ICRs based on the interest and demand of prospective students who would like to have an international clinical experience ( Fig. 34.1 ).

Salus University physician assistant student Viviana DiStefano evaluates a young boy in Zacapa, Guatemala while participating in an international clinical experience.

An international clinical experience may encompass either an ICR or a service-learning (SL) opportunity. An ICR is typically a credit-bearing clinical phase course involving supervised clinical experiences that take place outside of one’s home country. An ICR most commonly fulfills the requirements of an elective clinical rotation, with delineated instructional activities, learning outcomes, and assessments that contribute to a course grade. An SL experience “integrates meaningful community-engaged service with instruction and reflection to enrich the learning experience, teach civic responsibility, and strengthen communities.” If the SL experience is a component of a course, it will have delineated instructional activities and outcomes.

It is important to differentiate between an ICR and SL opportunity as both can occur outside of one’s home country, and one type of experience may be more or less appropriate for an individual student given their goals, expectations, and preferences. Both types of experiences offer an opportunity to increase the development of cultural competence as students are exposed to health conditions and disease states that may be unique to a particular patient population. Students may be required to practice medicine with limited resources and learn about nontraditional medical treatments because both culture and economics affect patient care. Although both of these international experiences often occur in locations with underserved populations or low resource settings, ICRs are more likely than SLs to occur in developed countries.

There are several differences between an ICR and SL opportunity to be considered when determining which type of experience is a “good fit” for a student. Students should first consider their motivations to engage in an international clinical experience, as these reflections will likely affect their decision making as to whether an ICR or SL experience is most appropriate for them.

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  Are you interested in exploring what working among underserved and multicultural populations may be like?

  
  
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  Would you like to compare the health system or health professions education in your home country with that of another country?

  
  
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  Do you hope to broaden your medical knowledge, reinforce your physical examination skills, and strengthen your diagnostic abilities?

  
  
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  Are you interested in managing conditions less common than those seen in your home country?

If so, an ICR may be an excellent way for you to accomplish these goals.

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  Do you see your future self volunteering time and resources to support community needs either at home or abroad?

  
  
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  Do you want to serve the needs of a particular community, perhaps one that is underserved or an at-risk population?

If so, an SL trip may be a great introduction to understanding ways in which you can contribute and support the needs of others.

Students should also consider how much time they want to commit to an international clinical experience. An ICR is an elective clinical course and typically requires a longer-term commitment (e.g., 4 to 6 weeks) for completion. An SL experience tends to occur over a shorter period (e.g., 1 or 2 weeks), may or may not be part of a course, and therefore may or may not be credit-bearing, depending on the institution. Some PA programs offer one or two elective clinical rotations; therefore students considering an ICR should reflect on whether or not they would want to use one or all of their electives for this purpose. Depending on personal motivation for engagement in an international experience, students may decide a shorter SL trip that does not use a clinical elective rotation meets their goals.

Another factor to consider is the student’s comfort level with traveling independently. It is common for only one, or sometimes two, student(s) to complete an ICR in a given location at a time, whereas SL experiences are frequently completed with a group comprised of interdisciplinary students, faculty, and qualified clinicians. If a student has not traveled much on their own or would prefer to travel as part of a group, an SL experience may be more appropriate than an ICR.

Other international clinical learning and practice opportunities

For qualified PA graduates, international clinical experiences may increase awareness and interest in clinical work outside of their home country. Although an ICR may not be a student’s only opportunity to have an international clinical experience in their career, it is a particularly unique opportunity to commit several weeks to community immersion and supervised clinical experiences during their formative professional education. There are a variety of volunteer medical mission organizations that coordinate regular trips in which clinicians may participate. PA programs that engage in these types of trips often encourage alumni participation as well. These may be opportunities for those interested in providing community-focused service to remain involved with these patient populations. For those qualified PAs interested in working outside of their home country, there may be opportunities in countries where the profession is newly developed or developing. In the United States there are also many organizations that function outside of U.S. borders that offer potential employment opportunities (e.g., U.S. military bases, embassies, etc.).

Decision making through reflection and information gathering

For the purposes of this chapter, the focus of decision making pertains to international clinical experiences that occur in the setting of an ICR, although some of the framework may apply to other international clinical experiences, such as SLs. Students should engage in ongoing reflection and information gathering to make an informed decision of whether or not to participate in an ICR. Reflection is an ongoing process that commences when the student first considers an ICR and continues until a decision is made. This section describes a framework to facilitate decision making, with an emphasis on the interplay between reflection and information gathering. This process draws from individual effort as well as sources outside the individual. For example, a student may attend an ICR information session to learn about the course then reflect on their level of interest; if the student remains interested, they may review additional course materials, speak to a prior student participant, or discuss the opportunity with the ICR faculty coordinator. The outcomes of reflection and information gathered should be both advisory and cautionary to students as they determine whether or not an ICR is a good fit for them and as part of their entire education.

Reflection

Students should reflect on their potential participation in an ICR by making sufficient time for reflection, gathering sufficient information, answering key questions, and discussing their ICR decision making with others. The role of reflection as an educational method for ICR preparation, participation, and post-travel activities are discussed in a later section. The student should dedicate sufficient time for reflection over a several week period as information is gathered and multiple factors are considered. Students should be cautious about rushing their decision because of near deadlines and avoid procrastinating the decision process. Students should gather sufficient information from credible sources (e.g., course materials, country information) and key informants (e.g., course coordinator, prior participants) to reflect on. Students should specifically reflect on their interests, expected learning activities and outcomes, anticipated challenges, and how learning experiences will impact their future practice. Students should also reflect on an ICR in the context of their entire education; the alignment of interests with clinical site and countries; and logistical matters such as cost, time away, and the time required for predeparture training and post-travel activities. Students should also consider personal factors, including relationships, finances, physical and mental health, and preferences with respect to risk aversion and external resources (e.g., housing, transportation, amenities). See Box 34.1 for the list of reflection questions to facilitate decision making.

The following student characteristics can increase the likelihood of a successful ICR: flexibility, reliability, problem-solving abilities, self-motivation, independence, positive attitude, cultural sensitivity, effective communication, and organization skills. Students should honestly consider if they possess these attributes as they self-select to participate in an ICR. In addition to individual reflection, students should consider how discussion with trusted individuals can facilitate their reflection and decision-making processes. For example, students may consider discussing the content of their reflections with family, friends, classmates, their faculty advisor, the course coordinator, and prior participants. Students may also have targeted questions for certain individuals. For example, the student may want to talk to the course coordinator about the clinical learning experience and engagement with preceptors, whereas the student should talk to a family member about being out of the country for a significant amount of time or the personal implications of expenses.

Information gathering

Students should gather sufficient accurate information about the ICR course and clinical site from credible sources and key informants to guide the decision-making process and the aforementioned reflection. Additionally, the information should help students elucidate the potential benefits and possible challenges of the ICR. See Table 34.1 for a list of commonly recognized benefits and challenges of ICR.

Table 34.1

Benefits and Challenges of ICRs

Potential Benefits	Possible Challenges
■ Unique medical learning experience ■ Cultural/diversity experience ■ Professional and personal growth ■ Patient care experience in settings with unique and/or diverse resources ■ Comparative health systems ■ Guidance for future international work/service ■ Sharing experience with others ■ Ambassadors of the PA program and PA profession	■ Physical safety ■ Physical/mental illness ■ Immunization(s) ■ Financial expense ■ Time away from relations ■ One less domestic rotation ■ Experiences may be more observational ■ Time and effort for additional preparation ■ Cancellation of rotation because of unexpected events ■ Variable resources and comforts (e.g., housing, transportation amenities)

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