International Experiences in Physical Therapist Education: A Descriptive Study

Abstract

International service and learning are growing phenomena in physical therapist education (PTE) and programs are developing new opportunities in all corners of the world. With this growth comes risks of duplicative efforts and harmful consequences.

Purpose. 

This study is seeking to describe: 1) the proportion of US-based PTE programs sponsoring international experiences; 2) the number of physical therapist students participating in these activities annually; 3) the location of these programs; and 4) whether outcomes are formally collected.

Methods. 

A 36-item survey was distributed to the American Physical Therapy Association's list of 243 accredited programs. A total of 109 programs responded (44.9%).

Results. 

Seventy-three percent of respondent programs reported offering international experiences in 60 different countries during one academic year. It is estimated that 2,316 students participated in these experiences. Most international experiences were offered in low- and middle-income countries, with 24 different experiences being hosted in Guatemala alone. Student outcomes were collected for nearly all experiences, whereas host community outcomes were collected by less than 20% of programs.

Discussion and Conclusion. 

This study confirms a growing trend of physical therapist students traveling the world. The high concentration of experiences in specific countries, regions, and low-resourced communities magnifies the importance of working alongside community and academic partners to share ideas and resources. Although the collection of student outcomes is critically important to academic programs, the collection of community outcomes should be considered equally, if not more important in assessing the potential benefit of international experiences.

INTRODUCTION

International experiences in physical therapist education (PTE) encompass a vast array of service and learning opportunities. Many align with the American Physical Therapy Association's (APTA) core value of “social responsibility”¹ while others fulfill academic requirements established by the Commission on Accreditation in Physical Therapy Education.² These experiences can be classified into one of the four categories: clinical education, broadening experiences, service, and service learning (Appendix A, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A87). Briefly, clinical education is structured clinical learning for the purpose of acquiring clinical skills.³ Broadening experiences emphasize student learning not experienced in classroom or clinical settings.⁴ Service focuses on volunteer work typically in or with underserved communities or populations.⁵ Service learning combines both volunteer service with formal learning objectives.⁶

Many students are looking for opportunities to learn about and serve in communities all around the world and are seeking programs that offer these experiences.^7-11 Students who participate in international experiences embrace these opportunities as a means of fulfilling their academic requirements and accommodating their adventurous and altruistic spirit.⁹ In addition, there is evidence to suggest that international experiences promote many positive skills, including empathy, interpersonal communication, and understanding of social determinants of health.^10,12-16 As a result, a growing number of PTE programs are sponsoring international experiences.⁹

Similar trends exist in medical schools and residencies across the United States.^14,17-19 Studies show that 58% of pediatric residencies²⁰ and 57% of internal medicine residencies²¹ offer international experiences and over one-third of medical students participate in an international experience during medical school.^22,23 Unlike the medical education literature, few studies in PTE have looked at the prevalence or geography of international experiences. The first published report regarding the prevalence of “community-based learning” was published in 2004.²⁴ Seventy-seven percent of US-based PTE programs sponsored volunteer opportunities, service learning, and/or pro bono services; however, the analyses did not differentiate between domestic and international experiences. A 2009 report specifically explored international volunteer and service-learning experiences offered by PTE programs in the United States and Canada. Over a 10-year span (1996–2006), 29.5% of the respondent programs from the United States provided international service-learning opportunities, 23.2% sponsored other international volunteer opportunities, and 43.2% offered both. This particular study was the first to map the location of these experiences and found that students had traveled to 38 countries, islands, or regions. The Caribbean, Central America, and Mexico were among the most prevalent locations for these experiences.²⁵

In 2012, Pechak published findings of a survey study that investigated the current use, location and duration of international clinical education in US-based PTE programs. Of the 110 respondent programs, 40.9% offered international clinical education opportunities. These experiences occurred in primarily high-income countries (eg, Australia, Canada, United Kingdom, Sweden). This study was unique in that it was the first to provide insight into the prevalence of student participation. Approximately half of the respondent programs reported that between 1 and 5 students had participated in an international clinical education experience, whereas 13% of respondent programs reported that more than 20 students had an international clinical experience.²⁶

All 3 studies attempted to determine the future growth potential of these experiences. Village et al reported that as many as 53% of the respondent programs expressed interest in implementing new programs in the future, whereas the other 2 studies found that 15–19% of the respondent programs were interested in integrating international clinical education and international service learning into their curriculum within 2 years. As a result of these findings, authors of these studies urged the physical therapy profession to study the potential benefit of these activities and establish best practices.

With rapid growth in program development comes a risk of programs working in silos. This lack of accountability, combined with limited research and vague practice standards related to international experiences, poses increased risk of duplicative efforts and harmful consequences, especially in low-resourced communities.^8,27 Most studies investigating the impact of these experiences have focused on student outcomes.^28-38 Whether PTE programs are evaluating the impact of international experiences on community or institutional outcomes is not well-known.³⁹

Leaders within the physical therapy profession acknowledge the risks associated with international experiences and recognize the importance of monitoring outcomes and having an interactive tool that provides real-time information about domestic and international experiences provided by PTE programs (oral communication with Ira Gorman, PT, PhD, February 21, 2018, New Orleans, LA). Such information would enhance program collaboration and accountability, improve program quality (for students and the communities served), and inform resource allocation.

The purpose of this study was to identify and characterize international experiences provided by US-based PTE programs. Specifically, this study is seeking to describe: 1) the proportion of US-based PTE programs sponsoring international experiences; 2) the number of physical therapist students participating in these activities annually; 3) the location of these programs; and 4) whether outcomes are formally collected for participating students, institutions, and/or the host community.

METHODS

Participants

All program chairs (or representatives) of accredited, US-based PTE programs listed on the APTA web site were invited to participate (n = 243).

Design and Instrumentation

This cross-sectional study leveraged a 36-item survey developed by our research team (Appendix B, Supplemental Digital Content 2, https://links.lww.com/JOPTE/A88). Survey items investigating the prevalence of PTE programs were adopted from previous studies^24-26 and modified to yield a comprehensive analysis of international experiences, describe student participation, and document the collection of outcome measures.

In defining “international experiences,” a comprehensive literature search was performed to identify commonly used definitions that encompass all international service and learning-type activities. The final definitions were presented to and approved by the executive committee of APTA's Global Health Special Interest Group (GHSIG) for use in the current study. The resulting instrument was reviewed for content validity by 6 physical therapists with expertise in Global Health. Minor revisions were incorporated into the survey to enhance item clarity. The final instrument was pilot tested by 10 physical therapists to establish time requirements and determine ease of use. Once again, minor revisions were made based on participant feedback. Exempt status was received for this study through the Northwestern University Institutional Review Board (#STU00207718). Completion of all or a portion of the survey implied consent to participate in the study.

The survey was divided into 7 sections. Section 1 introduced the survey and provided operational definitions for each of the 4 experiences. Section 2 solicited information pertaining to program demographics, class size, and promotion of activities during the 2017–2018 academic year. Sections 3 through 7 inquired about each of the 4 international experiences (international clinical education, broadening experience, international service, and international service learning). Completion of sections 3 through 7 was conditional on selecting one of these four experiences. Participants who did not select any of the 4 experiences followed a skip pattern that led them to the end of the survey.

Sections 3 through 6 leveraged the same 7 questions to investigate each of the 4 international experiences being studied: 1) whether the experience was offered; 2) number of student participants; 3) year of student (i.e., first-, second-, or third-year students); 4) location of experience; 5) whether outcome measures were routinely collected; 6) what measures, if any, were used; and 7) subject of outcome measures. Finally, section 7 sought permission to list the location, institutional affiliation, and institutional contact of the experience in a publicly available database to be developed and managed by the Health Policy and Administration (HPA) section of APTA.

Procedures

Survey links were emailed to 243 program directors of accredited, US-based PTE programs in October 2018. These individuals and their corresponding email addresses were obtained through official listings of APTA's accredited programs.^40,41 Directors who felt that another faculty member could more accurately complete the survey were encouraged to forward the survey link to their representative. Four subsequent emails were sent over the course of 12 weeks to those individuals who had not yet completed the survey.

Survey data were entered into an Excel spreadsheet (v.16.29.1), and frequencies for nominal and categorical data were calculated. Location of international opportunities were tabulated and categorized by geographical region/country and income level per the World Bank.^42,43

RESULTS

Physical Therapist Education Program Characteristics and Participation

One hundred twenty-five surveys were returned, with 109 complete and unique surveys included in the final analysis for an overall response rate of 45%. Of the respondents included for study, 55% represented public institutions and 45% represented private institutions. Of the programs offering international experiences, 40% represented public institutions and 60% represented private institutions.

Of the 109 participating programs, 73% reported offering at least one of the four international experiences within their curriculum during the 2017–2018 academic year. International clinical education and international service learning were the most prevalent experiences, with 39% and 38% programs offering these experiences, respectively. Thirty percent offered broadening experiences, and 13% offered international service. The percentage of private and public institutions participating in these individual activities remained similar to the overall participation response of 60% private and 40% public.

Student Participation

Per respondent report, 16,120 students were enrolled in participating physical therapist education programs and 2,316 students in total participated in global health experiences (GHEs) during the 2017–2018 academic year, yielding a participation rate of 14% (assuming one GHE per student). When studying participation rates for each experience, 35% (693) of the students to whom international service was offered participated, 28% (1,024) participated in international service learning, 15% (394) in broadening experiences, and 7% (204) in international clinical education (Table 1).

Table 1. - Characteristics of Global Health Experiences

	Clinical Education	Broadening Experiences	Service Learning	Service
Students eligible	2,774	2,637	3,626	1958
Students participated	204	394	1,024	693
Schools that offered—public	16	14	16	4
Schools that offered—private	26	19	25	6
No. of countries	28	32	24	10

Geography

One hundred ninety-four international experiences were reported across 60 countries and 6 continents. Fifty-five percent of the countries were classified per the World Bank as low- or middle-income countries (LMICs).^42,43 Thirty-seven percent of countries were located in Latin America or the Caribbean, whereas 28% were located in Europe or Central Asia. Sub-Saharan Africa represented 18%, East Asia and the Pacific represented 10% of the countries while South Asia and the Middle East and North Africa represented 3% individually, and North America 1%. Guatemala was the most prevalent international site hosting 24 different experiences followed by Italy (20), Haiti (13), Belize and Peru (12 each), and Mexico and Nicaragua (8 each). See Table 2 for countries visited.

Table 2. - Countries Visited (No. of Individual Program Experiences in Country

	Broadening Experience	Clinical Education	Service Learning	Service
Latin America and Caribbean, n = 22 countries	Guatemala (8)	Belize (8)	Guatemala (12)	Guatemala (2)
	Peru (7)	Haiti (4)	Mexico (6)	Brazil (1)
	Haiti (4)	Peru (4)	Nicaragua (5)	Dominican Republic (1)
	Costa Rica (2)	Guatemala (2)	Haiti (5)	El Salvador (1)
	Dominican Republic (2)	Mexico (2)	Belize (4)	Nicaragua (1)
	Jamaica (2)	Nicaragua (2)	Costa Rica (3)	Panama (1)
	Panama (2)	Barbados (1)	Ecuador (2)	Peru (1)
	Honduras (1)	Chile (1)	Antigua (1)	Puerto Rico (1)
	St. Lucia (1)	Costa Rica (1)	Dominican Republic (1)
	Uruguay (1)	Dominican Republic (1)	Panama (1)
		Ecuador (1)	Puerto Rico (1)
		Jamaica (1)	St. Lucia (1)
		St. Marteen (1)	Trinidad and Tobago (1)
Europe and Central Asia, n = 17 countries	Iceland (2)	Italy (19)	Iceland (1)	Iceland (1)
	Belgium (1)	Norway (2)	Russia (1)
	England (1)	Albania (1)
	France (1)	Belgium (1)
	Germany (1)	Germany (1)
	Holland (1)	Sweden (1)
	Hungary (1)
	Italy (1)
	Ireland (1)
	Russia (1)
	Spain (1)
	Switzerland (1)
Sub-Saharan Africa, n = 11 countries	Ethiopia (1)	South Africa (4)	Malawi (3)	Malawi (1)
	Rwanda (1)	Niger (1)	Kenya (2)
	Uganda (1)	Tanzania (1)	Botswana (1)
			Ethiopia (1)
			Ghana (1)
			Zambia (1)
East Asia and Pacific, n = 6 countries	China (3)	Australia (3)	China (1)
	Australia (2)	China (2)	Vietnam (1)
	Indonesia (1)
	Japan (1)
	Thailand (1)
South Asia, n = 2 countries	India (1)	India (1)	India (1)
		Nepal (1)
Middle East and North Africa, n = 2 countries	Morocco (1)	Kuwait (1)
North America, n = 1 country		Canada (2)
Summary	33 schools sent 394 students to 32 different countries for a total of 56 broadening experiences	42 schools sent 204 students to 28 different countries for 70 clinical education experiences	41 schools sent 1,024 students to 24 different countries for 57 different service-learning experiences	10 schools sent 693 students to 10 different countries for 11 different service experiences

Outcome Measures

Outcome measures were collected by 74% of PTE programs reporting their involvement in international experiences during the 2017–2018 academic year. (For a list of outcome measures reported, see Appendix C, Supplemental Digital Content 3, https://links.lww.com/JOPTE/A89.) The collection of outcomes varied by international experience type. For example, outcomes were collected by 88% of programs sponsoring international clinical education experiences, 66% of programs offering international service learning, 49% of programs offering broadening experiences, and 20% of programs providing service experiences. The collection of outcomes also varied by subject. For example, 88% of respondent programs reported collecting student outcomes, whereas 29% collected institutional outcomes and 19% collected host community outcomes.

DISCUSSION

This study builds upon previous efforts to characterize international experiences in entry-level, US-based PTE programs. The objectives of the current study were to describe: 1) the proportion of US-based PTE programs sponsoring international experiences; 2) the number of physical therapist students participating in each of these activities annually; 3) the location of these programs; and 4) whether outcomes are collected for participating students, institutions, and/or the host community. Nearly 75% of respondent programs reported offering international experiences, with an estimate of 2,316 students participating in these experiences. Most international experiences were offered in LMICs, with 24 different experiences being hosted in Guatemala. Student outcomes were collected for nearly all experiences, whereas host community outcomes were collected by less than 20% of programs.

Program and Student Participation

This study supports earlier predictions of growth in international experiences in US-based PTE programs.^24-26 In 2006, 42% of respondent programs reported participating in “community-based experiential learning.” The number of programs sponsoring international experiences rose to 63% in 2009 and 74% in 2018. This growth is due in part to increased awareness of and access to the world as well as a reduction in the barriers previously identified in studies such as funding, faculty time, and cost to the students.^23,24,44,45

International clinical education is the only individual experience that has comparative data. The results of this study demonstrated little change in the proportion of PTE programs sponsoring these experiences yet saw significant increases in the proportion of students participating in such experiences. It is unknown whether the results are related to the capacity of programs or student interest, or a combination. It is clear that some of the challenges posed by international clinical education identified in the literature, such as funding, communication, student learning and assessment, are being overcome by some but not others.^45,46 More research is needed to better understand this phenomenon. In addition, very little research exists comparing the cost–benefit ratio of international versus domestic clinical education.⁴⁵ Without clear evidence of benefit, programs may be hesitant to explore developing international clinical education opportunities. Guidelines for international clinical education in PTE have been published to help programs maximize benefits and minimize risks for all stakeholders⁴⁷; however, these guidelines do not necessarily address the aforementioned barriers to implementation.

This study is the first to explore the prevalence of US-based PTE programs offering Broadening Experiences—international experiences aimed at maximizing global opportunities for large numbers of students at minimal cost to the sending institution.⁴ These experiences value professional and cultural learning opportunities not experienced in classroom or clinical settings allowing the student to explore PTE and practice. They are primarily, but not exclusively, observational in nature.⁴ Although not new, broadening-like experiences have been documented in the context of PTE as early as 1984,⁴⁸ but the term “Broadening Experience” was not coined in the literature until Audette in 2017.⁴ Arguably, the easiest and lowest-risk experience to offer, with the potential for a high number of students participating, Broadening Experiences were the second least prevalent experience for programs and students participating. Further study is needed to understand why these experiences are not as embraced by students and programs and explore the power of perceived “helping” and “hands-on” experiences compared with more knowledge-focused, observational learning, which is emphasized during a Broadening Experience.

Geography

The US-based PTE programs reportedly sponsor international experiences in nearly one-third of the world's countries, creating an expansive “footprint” across 6 continents. Almost two-thirds of the countries visited were in the Latin America and the Caribbean and Europe and Central Asia regions resulting in a large concentration of resources in 2 major regions of the world. These findings are consistent with previous studies that have also found these regions to be common sites for international clinical education and international service learning.^25,26 This knowledge could be useful in facilitating strategic planning and collaboration between larger institutions, such as the APTA, Pan American Health Organization, the World Confederation for Physical Therapy (WCPT), and the European Network of Physiotherapy in Higher Education. Planning and collaborating at this level could provide opportunity to align resources, increase political influence, and to tackle challenges in communities located in these regions.

Over half of the countries hosting international experiences were considered LMIC. World Bank statistics suggest that 70% of the world's extreme poor live in LMIC and live in conditions associated with poverty, such as lack of access to health care, inadequate water and sanitation, malnutrition, and poor living conditions. Power dynamics must be considered in developing international experiences in any location, but especially in LMICs. There is an unfortunate history of exploitation of poor and underserved communities across the world,^15,49-51 and great care must be taken to ensure that international experiences address community priorities, leverage community assets, and build community capacity.

Assuming international experiences are created alongside the local community, mechanisms must be in place to improve strategic planning and collaboration among PTE programs. For example, 25 different experiences reportedly occur in Guatemala, 13 in Haiti, and 12 in Belize and Peru on an annual basis. Are PTE programs aware of other programs working in the same country? Is there any effort to coordinate experiences and share resources, ideas and curricula? Is the burden placed on local communities to coordinate these efforts? How much integration and collaboration is happening with in-country PTE programs, professional associations, and government ministries? Such collaboration is essential as programs and communities seek to optimize resources while equitably sharing benefits and risks.

There have been attempts to create databases and resources related to international activities in the past. The GHSIG of the APTA has developed resource guides for academic programs and practicing clinicians interested in volunteering overseas. In addition, the WCPT is creating a database of volunteers and experts.⁵² These efforts have been met with challenges related to access and sustainability. At the APTA's 2018 Combined Sections Meeting in New Orleans, there was a charge from the HPA Section leadership to the GHSIG to develop a database of existing programs around the world to gain a better understanding of the magnitude and prevalence of academic activities and to promote interprogram collaboration. The results of this study led to the development of a database (Appendix D, Supplemental Digital Content 4, https://links.lww.com/JOPTE/A90).

Outcomes

Findings from this study show that 75% of US-based PTE programs collected outcome measures related to their international experiences during the 2017–2018 academic year. Outcome measures were most often used during international clinical education and service-learning experiences, whereas outcome measures related to broadening experiences and service experiences were used the least. In addition, most of the outcomes collected across all experiences focused primarily on students, which is consistent with previous research. Although important, the focus on student outcomes is not sufficient in understanding the broad influence of international experiences on key stakeholders. There are inherent risks associated with community-based experiential learning, especially in underserved communities.^11,15 Unique power imbalances, cultural differences, and the temptation to practice beyond one's ability coupled with a lack of accountability pose risk to all parties involved.^10,53 Research by Haines and Lambaria¹³ found that international service learning may reinforce negative attitudes, disrupt community relations and dynamics, and provide inappropriate or poor-quality care. International clinical internships have been shown to increase the burden on low- and middle-income country partners and can create harm when students or faculty have insufficient awareness of cultural norms in the host community.⁵⁴

There is a flawed assumption that these programs are relatively innocuous and provide mutual benefit.^55-57 Although there is research on the benefit to the student and commentary promoting community-based participatory research and collaboration throughout the physical therapy literature,^58,59 the results of this study indicate the need to build on existing literature^12,13,60,61 and continue assessing the impact on other stakeholders such as the community.^13,62,63 In addition, community partners are underrepresented in academic research.^13,50 With APTA's commitment to transform society as is stated in the organization's “Vision Statement for the Physical Therapy Profession,”⁶⁴ student attitudes and satisfaction must complement the assessment of these experiences but should not overshadow patient- and community-centered appraisal of program effectiveness.^46,65 Like medical education,¹⁵ PTE programs must resist relying solely on anecdotal evidence and instead identify and measure outcomes that are meaningful to key stakeholders, including the host organizations, community, and patient population.

Implications for Physical Therapist Education

Programs and Students

The US-based PTE programs and students are increasingly engaging in international experiences. For those already participating, a greater awareness of current activities as well as a collaborative efforts could revolutionize PTE and positively impact communities around the world through the development of common curricula, pooling of resources, and engaging in research. For those who are not currently sending students abroad, the same awareness and collaborative efforts could lead to more connection, inquiry, and learning from others that could assist in the development of new programs. Exploring the potential and learning from others will be vital for future program development. To this end, the HPA Section of the APTA has invested in developing and sustaining a publicly accessible database that will provide information about international programs sponsored by PTE programs across the United States, with an eye toward collecting this information from programs across the world.

To reduce the risks associated with power imbalances and cultural differences, PTE programs should explore ways to best identify and train students to ethically engage in international experiences. The cohort of students selected to travel abroad, especially into underserved communities, require careful consideration and intentional training to ensure they are interested in and capable of working alongside communities in a way that reflects local values and priorities. More thorough selection criteria and vetting could help identify and train students interested in Global Health and community development, prepare students for working in medically underserved areas, and strengthen our profession's ability to transform communities around the corner and around the world.

Geography

With such a high percentage of students and programs traveling to and working in LMIC, PTE programs need to be even more careful about aligning these experiences with existing efforts. Physical therapist education programs going to the same regions of the world should be sharing resources, leveraging existing in-country partnerships, and learning from one another to reduce the risk of duplicative and deleterious efforts and to maximize resource utilization and learning.

Outcomes

Physical therapist education has historically been concerned with student outcomes during educational experiences. With the growing trend in community-based experiential learning, especially in underserved communities, it is the individual and collective obligation of all programs to be concerned with community outcomes as well.²⁷ Is it ethical to work without any objective accountability to the communities we claim to serve? If we do not measure community outcomes, can we really even justify offering these experiences? Whether its purely observational learning or hands-on service, students represent their institutions, the United States, and the PT profession, and they have the potential to do great benefit or harm in communities. The PT Code of Ethics¹ calls for acting in the best interests of the client over oneself and to be accountable for making sound judgments. To ensure this, more rigorous program assessment is needed in the form of outcome measures and research that will provide a clearer understanding of the totality of the education experience specific to all beneficiaries.

Limitations

A number of limitations to this study are recognized by the investigators. Although the definitions used are accepted by experts and used in numerous publications, it is understood that they are not fully adopted and thus may not be understood by all study respondents. This could have led to the misclassification or misrepresentation of experiences. In addition, recall bias could have affected the findings given the participants were asked, in the fall of 2018, to recall information from the 2017–2018 academic year. Finally, given that participation was optional, PTE programs offering international experiences may have been more likely to respond to our survey than PTE programs not offering these experiences.

CONCLUSION

Nearly 3 of 4 responding US-based PTE programs offer international experiences, while the number of students participating in international experiences has grown steadily over the past 2 decades. The high concentration of experiences in specific countries and regions magnifies the importance of working alongside community and academic partners to share ideas and resources. Finally, although the collection of student outcomes is critically important to academic programs, the collection of community outcomes should be considered equally, if not more important in assessing the potential benefit of international experiences.