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METHOD/MODEL PRESENTATION

Enhancements to an International Service-Learning Model: Integration of Program Alumni and Global Stakeholder Feedback

Hayward, Lorna M. PT, EdD, MPH; Li, Li PT, DPT; Venere, Kenneth PT, DPT; Pallais, Andrea PT, DPT

Author Information
Journal of Physical Therapy Education: Volume 29 - Issue 2 - p 43-53
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Abstract

BACKGROUND AND PURPOSE

The United States (US) continues to diversify with 37% of the population currently comprised of minority groups and with census projections for growth in minority residents to 57% by 2060.1 Increased diversity in the US population and the globalization of “health risks and opportunities” requires alignment of our health profession's education system with 21st century practice needs.2(p1926) Educators of health care practitioner students, including those in nursing,3,4 occupational therapy,4–6 medicine,1,4,7 and physical therapy4,6,8–12 realize cultural competence and collaboration are essential 21st century skills required for providing quality patient care. Research supports the need for cultural competence in patient-provider interactions to prevent a compromise in care due to different ethnic or cultural (cross-cultural) backgrounds.2,7,13,14 Providers, including physical therapists (PT), without the aptitude for working in crosscultural situations may experience communication breakdown with either patients or family members, which could impede the management of the diseases or conditions characteristic of a population.14 Effective care incorporates the patient's values, family structure, and culture.2,8,9,13

One strategy for promoting cultural competence and for increasing a student's global perspective is through study abroad (SA) experiences. The growing trend in SA is supported by statistics documenting a tripling of the number of US college students studying abroad since 1993, with campuses reporting over 273,000 participants in 2011.15 During 2011, 14,522 health professions students studied abroad, representing an increase in participation of 14% from 2010.15 Professional leaders in physical therapy support inclusion of global educational opportunities to facilitate cultural competence development in PT students.16 Essential documents such as the Professionalism in Physical Therapy Core Values17 contain culturally competent patient care outcomes. In addition, A Normative Model of Physical Therapist Professional Education delineates practice expectations targeting individual and cultural differences.18 For the purposes of this work, cultural competence is defined as “acceptance and respect for difference, continuing self-assessment regarding culture, vigilance towards the dynamics of differences, ongoing expansion of cultural knowledge and resources, and adaptations to services.”19(p13)

PT educators have responded to the need for promoting cultural competence in students educated in the US.4,8–12,20–26 Two burgeoning approaches are either through international service-learning (ISL) or international clinical education (ICE) opportunities.11 Authors of a study conducted in 201220 reported on the scope of international programs in physical therapy where, of 201 US schools (110 responded), 40.9% (45) offered ICE. In addition, 54% (21 of 39) of programs with ICE also provided additional short-term international exposure.

Service-learning has been defined as an experiential learning pedagogy in which students participate in activities that incorporate response to community needs, collaboration, meaningful service, reflection, and institutional commitment.27–29 ISL is a service opportunity that “occur[s] outside of the country where a physical therapy educational program is located.”11(p73) Service-learning (SL), whether domestic or international, and ICE have benefits for physical therapy students, including increased cultural competence,4,12,21,22,24,25 appreciation of professionalism and the Core Values,12,21,24,30 and improved collaboration among peers.3,12,25 Contact with people from diverse cultures is an effective strategy for promoting cultural competence, as students are situated within authentic situations that foster selfawareness of personal beliefs and opportunities to administer patient care.8,22,31

The physical therapy literature is replete with articles documenting the development and implementation of ISL programs.4,8–12,20–26 In addition, a plethora of research has examined the immediate student learning benefits.4,8–12,20–26 Limited research has explored ISL from either the perspective of the global partner or the long-term impact on program alumni.23,32 Developing and maintaining a successful ISL program requires collaboration between an educational setting and a global partner32,33 and includes a process of evaluation and enhancement.23 A need exists for research that explores the long-term benefits and detractors of ISL for stakeholders at the international location. Including stakeholder input in the evaluation process is integral to the success and sustainment of a global partnership because “[it] focuses on the relationships between academic and community partners, with principles of co-learning, mutual benefit, and long term commitment.”34(p312) Stakeholder feedback and formal reflection on the partnership empowers the global partner which strengthens and sustains a relationship.35 The purpose of this method/model was to modify an existing ISL approach12,24 by including the perspectives of the global partner and the longitudinal perspective of 5 years of program alumni.

METHOD/MODEL DESCRIPTION AND EVALUATION

Educational Setting

The educational context is a large urban institution whose philosophy incorporates practical, experience-based learning. Central to the philosophy is cooperative education (co-op), in which a student alternates periods of classroom study with full-time employment related to career or personal interests. The Doctor of Physical Therapy (DPT) curriculum is a 6-year professional level program with 80–100 students matriculating annually. Students complete two 6-month co-op terms, 1 in the third year and 1 in the fourth year, during which they are employed fulltime as PT aides. Students also participate in a short-term SL opportunity within the local community in their third year. Sixthyear students engage in a 3-phase, 32-week (8-week/12-week/12-week) clinical education component. The ISL project is an extra experiential opportunity occurring in the fifth year for a cohort of 15 PT students prior to clinical education. Participants in the ISL project are selected by 1 author (LH) and are based on applicant-expressed interest for traveling abroad, working with children, and possession of Spanish language skills. Lodging is limited at the ISL site to 17 volunteers, restricting the number of individuals to 15 students and 2 leaders.

International Service-Learning Setting

The ISL settings are 2 For His Children (FHC) orphanages located in Quito and Latacunga, Ecuador.36 For His Children was chosen for the ISL experience because approximately 35% of the 50 child residents have moderate to severe special needs and would benefit from weekly or daily physical therapy. Typical diagnoses include cerebral palsy, Down syndrome, sensory integration disorders, prematurity, and developmental delay. The faculty leader (LH) has a strong relationship with FHC and has traveled there 7 times with PT students since 2014.

At the FHC Quito site, 24 children range in age from 0 to 8 years and live in 2 separate buildings: Infant House (ages 0–2) and Toddler House (ages 2–8). In Latacunga, 28 children live in 1 building and range in age from 0–20 years. Tias, or “aunties,” are paid employees who provide basic care including feeding, bathing, and supervision of the children in 24-hour shifts. Additional personnel include a psychologist, part-time speech language pathologist, and part-time PT.

Participants

Alumni of the ISL program (n = 70) were recruited for study participation via email. The alumni represented 5 years of ISL program participants (Table 1). Purposive sampling is a qualitative sampling strategy in which subjects are deliberately chosen by the researcher using defined criteria. Subjects are chosen to “provide important information” about a topic of study with a goal of achieving a good representation.37(p71) A purposive sampling strategy37 was used to choose 6 key FHC staff. Criteria for selection included that they had worked with the PT ISL teams, were a mixture of clinical and administrative staff, and represented the interests of both FHC locations. The Office of Institutional Compliance classified the project as exempt because it was conducted in an established educational setting and examined the impact of an instructional technique.

Table 1
Table 1:
Participant Demographics

Educational Intervention

The educational intervention relied on an established ISL model, previously described in detail, which incorporated academic study about Ecuador and pediatric physical therapy, a 9-day ISL experience in Ecuador, and multiple opportunities for reflection.12,24 The educational objective was to promote cultural competence, professional identity, and Core Values development. The model was integrated into a required 2-semester capstone course, “Physical Therapy Project I and II,” designed for fifth-year PT students. Each year, the trip leader (LH) conducts a needs assessment with the host site. Then, under direction and supervision of the leader, the students spend the fall semester researching the culture of Ecuador, disorders affecting the children, and devising targeted interventions. While in country, a typical day could entail that the students assist with infant feeding, therapeutic exercise, perform hippo- or aquatic-therapy, observe a physical therapy evaluation, or instruct the Tias in home programs.

OUTCOMES

Instruments/Methods Used to Assess the Model

Outcome data were collected by the authors from alumni and the global partner regarding their perspectives about the existing ISL model using both quantitative and qualitative methods.

Quantitative-Alumni Survey. An online survey was developed by LH to query program alumni about their perception of the longterm impact of the Ecuador ISL experience. The survey contained 18 questions, of which 8 related to demographics. Ten questions explored the impact of the ISL experience on student career path, clinical specialty, culture/foreign language interest, Core Values, pro-bono work, professional development, and interaction with the faculty leader (Appendix 1). The 10 questions were informed by previous work of the author,12,24 APTA core documents,17,18 and reflected the ISL model's objectives of promoting cultural competence,12,16,21,24,30 professional identity, and a professional relationship between peers and faculty.3,12,25,38,39 The survey was pilot tested with 7 PT students who were non-ISL participants, placed on Google DocsTM and distributed using the FacebookTM social media messaging feature to program alumni (n = 70) who represented 5 years of PT student participants (2008–2012). To incentivize yield, alumni who completed the survey were entered into a raffle for a $100 gift card. Of the 70 alumni contacted, 61 completed the survey for a return rate of 87.1% (Table 2).

Table 2
Table 2:
Program Alumni Survey Return Rate (n = 61)

Qualitative Data-Global Partner Interviews. Six 1-on-1, semi-structured interviews were conducted with key stakeholders to gain their perceptions of the partnership benefits, drawbacks, and suggestions for improvement (Appendix 2). Two interviews were conducted in English by LH. Four interviews were conducted in Spanish by a student (AP) on the 2013 ISL team who was a native Spanish speaker.

Alumni

Descriptive statistics were compiled from the alumni survey and demographic information can be found in Table 3. Ninety percent (n = 59) of alumni ranked the Ecuador ISL within the top 10% of their most meaningful college experiences. Students perceived that the ISL experience impacted their interest in culture, with 46% (n = 30) learning more about Ecuador, 55% (n = 36) Latin culture, and 65% (n = 42) an additional culture. Seventy-four percent (n = 45) expressed an interest in learning a foreign language and 58% (n = 26) continued to study a language with increased commitment. Other survey questions concerned student perception of the impact of the Ecuador ISL on professional development. Thirtyfive respondents (62%) perceived that the Ecuador ISL influenced them to provide pro bono services. Regarding career choice, 69% (n = 45) highlighted the Ecuador ISL in a resume/cover letter, 80% (n = 52) discussed it in a job interview, 32% (n = 21) applied for a job serving Latinos, and 11% (n = 7) selected pediatrics. Sixty-five percent (n = 42) had more frequent contact with the faculty trip leader compared to other faculty members, with 45% (n = 29) indicating that they would contact that faculty for a recommendation via email and 40% (n = 26) suggesting they would request a reference via email. Finally, 89% (n = 54) of alumni perceived that participation in the Ecuador ISL program increased their appreciation for the Core Values (Table 4).

Table 3
Table 3:
Program Alumni (2008–2012) Survey Demographics (n = 61)a
Table 4
Table 4:
Alumni Survey Responsesa

Global Partner-Qualitative

Global partner interviews were collected and analyzed using qualitative research techniques.40 Interviews lasted 1 hour and were then audiotaped and transcribed verbatim into English by a paid professional transcriptionist who was fluent in English and Spanish. All authors independently read the interview transcripts numerous times to gain an overall understanding of participant thinking and responses. The authors then met several times to discuss the responses and emerging ideas within the data. The authors used a process of content analysis to categorize and identify principle patterns that emerged from the data.40 During content analysis, the raw data were organized into patterns using codes developed by the authors that grouped data with similar meaning. Subsequently, the resulting patterns were collapsed into major categories that best summarized the data at a higher level.40,41 Discussion and consideration by the authors led to a preliminary identification of 5 core themes from the interviews, into which most categories and patterns fit. Throughout the data collection and analysis, several strategies were used to ensure rigor and enhance trustworthiness. Triangulation was a strategy used to maintain consistency and trustworthiness of the data.37,42 Having multiple researchers participate in the study served as investigator triangulation.42 The semi-structured nature of the interviews enabled researchers to clarify comments and questions that arose during an interview or focus group. The structure of the coding and analysis process also served as an additional strategy to ensure rigor. Five themes emerged from the global partner data: (1) understanding physical therapy; (2) partnership elements; (3) knowledge and supplies; (4) challenges; and (5) goals for the future.

Understanding Physical Therapy. One major theme concerned the role of physical therapy. The FHC staff articulated that by observing the ISL team, they learned about physical therapy and understood how to incorporate it into the children's treatment plans.

Every year we learn new things about how physical therapy can be adapted and adjusted in so many ways to fit with the abilities and lifestyle of the child. I enjoy watching the interaction between the Ecuadorian PT and the students. There is so much going on in physical therapy! We are always learning new techniques and treatment plans. It shows us that we all need to continue to exchange ideas and learn from each other. [FHC Interview MV]

Over the years, by working alongside the students that are here, and seeing, I am learning more about what physical therapy is and how it can be incorporated. [FHC Interview JS]

Another perceived benefit was appreciation for the value of physical therapy rendered by the ISL team. It provided FHC with a language for sharing details about a child's development with potential adoptive families.

The value of physical therapy is seeing how it impacts the child's ability for adoption and then being able to share specific details with potential adoptive families to let them know what a child's capable of doing. The physical therapy your group's provided has given us ideas about where the child stands in relationship to the average child at their age and then targeting different areas we can work on. [FHC Interview JS]

Partnership Elements. The FHC staff identified elements for an effective partnership: meeting the service site needs, continuity of leadership, advance planning, interaction with the local community, mutual respect, and cultural sensitivity. According to FHC, we are meeting their rehabilitation needs.

FHC views this partnership as very effective and the interaction with the physical therapy team improves the quality of care we give to the children. Thanks to the visits and interaction with the physical therapy team with our professional staff, Tias, children, other workers, and volunteers, we are more confident in the type of care we give the children with special needs. We are encouraged and very appreciative of this relationship. [FHC Interview MV]

For us, it's very important to keep this alliance…it's very important what you do, and we are open, open to any suggestions or work that can be done to coordinate together to benefit children. So we're very grateful for the time and the love you bring when you come here. [FHC Interview VR]

Another key element was having a consistent ISL team leader and a plan in place for rehabilitation work a priori. The FHC staff values the consistency of the leader because many of the children are constant residents. Pre-trip planning is appreciated because the ISL team is more efficient while in Ecuador.

The continuity of a team coming down every year, with the same leader…it's a face and a name that they [the staff] know and a connection that they have. [FHC Interview JS]

You have a plan before you come, and that's unique. We don't have any other group like that which comes down and already knows what they are going to do and how they are working with the kids. So the relationship with FHC excellent, you have a contact person who is consistent and persistent about emailing regarding specific questions to be answered which is very positive. [FHC Interview JS]

The stakeholder valued the ISL team's ability to reach out to the Ecuadorian community.

Being capable of connecting with Pan de Vida or going to the dump ministry and helping those people such as giving an assessment to Oscar's child, your reaching out beyond the bubble of FHC to other people in the community is important for our partnership. [FHC Interview JS]

Displaying sensitivity to cultural norms was another partnership element identified by the FHC staff as valuable.

We think differently, there are different cultures and we have to open to understanding them and you being to explain yourself, as well. The students come with an attitude of giving and also receiving and that's important. Between cultures we have to give and receive as well. We learn a lot when different people share their way of thinking and handling things. [FHC Interview JC]

Mutual respect and reciprocal communication contributed to building trust between the organizations. Including the stakeholder perspective in the partnership assessment was appreciated by the FHC staff.

It is valuable that you are doing this [interviewing the staff] because that shows concern for the partnership…it is not often that a team will come to us and say, “what is the impact of our being here and are we making a difference, is this beneficial for the kids?” Our partnership, the donations you brought, and giving us the tools to better the children's lives and help us find families is so important. [FHC Interview JS]

I appreciate the way that your physical therapy program involves the FHC PT in the partnership, on an equal basis, rather than a paternalistic relationship. The students are open to learning different methods from the FHC's PT. This builds a relationship of trust between the 2 organizations. [FHC Interview MV]

Knowledge and Supplies. The FHC staff noted that the donations the team brings down annually such as orthotics and other physical therapy supplies are critical because they help the Ecuadorian PT do his job more effectively.

You're able to help us with different donations and things that we couldn't normally get here or that would be expensive and then showing us how to use those [items] appropriately. [FHC Interview JS]

In talking with the PT, there are some very innovative things, such as the splints, the supplies that you bring. These things you provide to the children are a tremendous help. [FHC Interview VR]

The FHC PT noted that the reciprocal knowledge sharing with the ISL team supports his ability to solve problems and the new information shared improves the efficiency of his job.

I need the support of people like you, because you understand how to handle kids and can help me resolve many problems, bringing orthotics and information about new treatments available. Your program has helped me do my job more efficiently. [FHC Interview JC]

Challenges. Several partnership challenges were articulated which concerned issues related to cultural barriers between the North American and Ecuadorian way of doing things.

I think sometimes there's this feeling again of just in general, here's this group of North Americans coming in and showing us what they do and it's all these new ideas going on and we have our own [Ecuadorian] way of doing things. [FHC Interview JS]

Not all ideas can get accomplished because of my country's perspective on health care. You guys can provide us with an idea, but sometimes in Ecuador you cannot do that. Therefore, we try to do the best possible with what we receive and the advice we receive. [FHC Interview JC]

Another challenge mentioned is that sometimes the FHC caretakers or Tias overuse a new technique on children who may not require that treatment.

Sometimes the Tias have misunderstood things and have used methods for kids that might not need that certain thing [PT technique]…they were not prepped well enough. [FHC Interview JS]

A lack of fluency in Spanish by all team members was identified as a concern by the caretakers. However, the students were able to use other strategies to interact with the children.

The only problem is the language, because the staff does not speak English and only some students are Spanish speakers. But, I see charisma, good communication with children, even in their language [English]. The students are cheerful, smiling, polite, courteous, no problem. [FHC Interview GS]

Goals for the Future. Three areas were identified by the global partner as areas for improvement: (1) increased pre-trip communication, (2) more time with the children, and (3) a system for feedback from more FHC staff.

We could improve on the pre-trip communication, set up a scheduled meeting, once every few months, through Skype, or phone, or email to keep the dialogue moving about new kids that come in because they change, even though the children with special needs are a constant. [FHC Interview VR]

Yes, to have more time with the students and the kids because I believe we spent too little time with them. I have other cases of children we didn't even have the opportunity to see. [FHC Interview JC]

We are so happy about the evaluation of the partnership that is being done, it would be great if in the future more of the FHC staff could participate… [FHC Interview MV]

DISCUSSION

The purpose of this method/model was to evaluate an existing ISL approach12,24 by incorporating the perspective of 5 years of program alumni and feedback from the global partner.

Alumni Perspective

Survey responses demonstrated alumni perception of continued development of cultural competence that they attributed to their participation in the Ecuador ISL. The alumni perceived that the ISL facilitated their interest to learn more about Ecuador, Latin America, or another culture. Travel to and work in Ecuador also influenced alumni desire to either learn a new foreign language or continue to study a language with increased commitment. For our alumni, learning about Ecuador, traveling abroad, and providing physical therapy appeared to be a catalyst for understanding the elements comprising culture and its impact on health.43 Research maintains that cultural competence is a long-term and continuous process.31,44

Ninety percent of alumni indicated that the ISL experience was meaningful and ranked it among their most significant college events. The Ecuador ISL was important enough for alumni to highlight in a resume, cover letter, or discuss in a job interview. Of interest is that the ISL experience influenced their professional relationship with the faculty leader. Alumni noted they had more frequent contact with, were more inclined to request a letter of recommendation, or a reference from the trip leader via email. The faculty role abroad extends beyond the traditional duties for a teacher and may involve administrative and leadership skills not typically used in the classroom such as management of homesickness. However, the increased contact may strengthen the relationship between faculty and students. Research supports the notion that building rapport with students pre-travel results in stronger student-faculty working relationships that extend to the academic environment upon returning to the home institution.38 Through leading ISL programs, faculty leaders gain opportunities to talk informally with students and develop an appreciation for their view on education, physical therapy, and the world, which can strengthen the bond.39

The alumni perceived that the ISL experience increased their appreciation for the Core Values once they became a PT. International collaboration through educational programs has enormous potential for developing a community of globally engaged students. The value of compassion can be awakened through viewing the predicament of a population without access to needed physical therapy services or parents who can advocate for their access to good medical care. With 62% percent of our alumni currently providing pro bono services, it appears that the alumni demonstrated a transfer of skills into their interaction with socioeconomically disadvantaged people locally. Research underscores the influence of ISL on medical and health professions students’ desire to work with poor and ethnic minorities, volunteerism, and global health.22,45

Global Partner Perspective

Through our interviews with the FHC key staff, we identified 6 optimal elements of the partnership and 3 areas requiring attention (Table 5). These elements provided critical information to the Ecuador ISL trip leader regarding plans for enhancing the model. One major positive element was that the Ecuador ISL partnership is a long-term relationship that over time has increased the FHC staff's understanding of the role and scope of physical therapy. The staff recognized the benefits of physical therapy and how it can provide a benchmark for describing a child's developmental milestones. This information is useful for FHC staff when communicating with potential adoptive parents about interventions that may be required.

Table 5
Table 5:
Positive Partnership Factors, Needs Addressed, Drawbacks, and Plans for Enhancement

Another benefit concerned the identification of the elements that contribute to a successful partnership. One significant element was the existence of a well-structured intervention plan that meets the rehabilitation needs of children. Each year, the trip leader conducts a needs assessment with the FHC staff and uses the information to guide PT student research about the children's diagnoses and development of targeted interventions. The needs assessment, combined with the continuity of the leadership, is valuable for pre-trip strategic preparation and ensures that the ISL team has a basic rehabilitation plan in place prior to travel. The addition of assessment by the FHC staff at the conclusion of the trip provides invaluable suggestions for modification to future trips. Another benefit of the needs assessment is that most often the equipment and other therapeutic donations brought to ISL site are truly required, put to use, and assist the local PT in doing his job more efficiently.

Interaction with the local community was also desired by the global partner. Each year the ISL team has worked at a local soup kitchen, served a meal to residents living at a landfill, or provided an exercise program to elders. While mainly focused on the provision of physical therapy services, it is imperative for ISL teams to be flexible and willing to interact with the local community. Immersion within the local culture is an important strategy for exhibiting sensitivity to community-based needs and for building an authentic relationship. Involving the FHC staff in the evaluation process supported the existence of a genuine and reciprocal relationship, increased trust, and sustained the desire for continuing the partnership.23 Developing and maintaining a successful ISL program requires excellent and consistent collaboration between an academic and global partner.23,30

Global health training experiences in medicine and the health professions are beneficial for students and academic institutions, but are sometimes problematic for the global partner.46 Problems include “ethics, burdens on the host, impact on patients, the community, and local trainees; unbalanced relationships among institutions and trainees; and concerns related to sustainability and optimal resource utilization.”46(p1179) One strategy for managing this concern is to include the global partner in the evaluation to accurately identify needs that may change from year to year.32 Three challenges were identified by the FHC staff: (1) cultural barriers, (2) language fluency, and (3) treatment carryover. While not a major problem, cultural differences were identified by the FHC staff related to the differences between how medical care is delivered in Ecuador compared to the US. A related challenge was that the majority of the ISL team was not fluent in Spanish, which made communication with the Tias difficult. A final concern was the desire for frequent communication prior to the team's arrival to target interventions.

Based on feedback from the FHC staff, future plans for interaction with the site centered on augmented communication. One suggestion provided by FHC was to have quarterly Skype© meetings for advancing preparation of the ISL team to better tailor interventions to the children. In addition, each year the trip leader provides the FHC director with detailed documentation of the treatment and education rendered. The trip leader will continue with this activity because it conveyed what was accomplished therapeutically, is appreciated by the FHC staff, and can inform future trips.

The academic site proposed to bring the Ecuadorian PT to the US for additional training to promote sustainability of the new techniques introduced by the ISL team. This was accomplished in the fall of 2013 when the PT traveled to the US for a week of academic and clinical training. Regarding cultural barriers, more instruction prior to travel may increase respect for divergent diagnostic and treatment paradigms and facilitate the students’ development of cultural competence. The conundrum of inadequate language skills is challenging. One strategy is to continue to include team members that are native Spanish speakers and to encourage other students to develop basic language skills through coursework. A final recommendation was to devise a mechanism for gathering feedback from a wider representation of FHC staff. To do this, we created a survey (in Spanish) that was distributed in 2014 to the Tias who interact with the team.

These planned improvements are geared towards constructing a targeted and wellstructured ISL program. Periodic clarification of goals, expectations, responsibilities, and encouragement of reciprocal communication are key elements for maintaining long-term ISL partnerships that are mutually beneficial.32,46

Limitations

The current research has several limitations. One main limitation is that the survey was not administered to a contrasting nonparticipant group in the ISL program. As a result, it may be difficult to determine if the results related to professional development were solely due to the ISL experience. Also, the term “underserved” was not defined on the survey, which could have resulted in a different interpretation of the meaning of the word by the respondents. In addition, ISL model was implemented at a single university who visited 1 international service site, which limits the generalizability of the results to other physical therapy programs and ISL experiences.

Another limitation is related to selection bias, in that students who choose to participate in ISL experiences may be different from their peers. It is hard to control for participant professional or life experiences prior to ISL, which may also influence their desire for cultural literacy, global exposure, and/or working with clients who are without access to needed medical care. An additional limitation was that interviews with the global partner were conducted by a native Spanishspeaking student (AP) from the 2013 ISL team, potentially influencing how the interviewees responded. A final limitation is that the long-term perspective of alumni was gathered through survey data and qualitative comments that may not be standardized across other ISL programs.

CONCLUSION

The globalization of health care in the US has resulted in a growth of ISL models for PT students. One approach for promoting cultural competence and for increasing a student's global perspective is through ISL. Cultural competence is important because it can prevent a compromise in care due to different ethnic or cultural (cross-cultural) backgrounds during patient-provider interactions. Recognition that cultural competence is a continuous process is critical for its development.

While most research in physical therapy documents the development and implementation of ISL programs, research is indicated that evaluates both the perceived long-term impact for program alumni and the benefits and drawbacks for global partners. This current project has attempted to address this need by evaluating an ISL model from these 2 perspectives. The results suggest that developing and maintaining a successful ISL program requires a well-structured plan for interaction, excellent and continuous communication, reciprocal benefits, and continuity of team leadership.

Long-term follow-up of program alumni uncovered their perception of the impact of ISL on cultural competence, professional development, and appreciation for the Core Values. However, to ensure that US students are equipped for travel and working in country, faculty leaders are encouraged to prepare students before travel about Ecuadorian culture and health care practices. It is also important to stress that while in country, US students understand the importance of integrating local health care beliefs and practices into ISL programs to truly collaborate with the international partner. Studies that incorporate the perspective of the global partner or long-term impact of ISL on program alumni are limited, supporting the need for future research to uncover the elements that work to create successful and sustained partnerships between academic and global settings.23,32,46

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Appendix 1. Ecuador Study Abroad Alumni Survey

Figure
Figure

Appendix 2. Global Partner Interview Questions

Figure
Figure
Keywords:

Global education; Educational assessment; International service-learning

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