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Achieving global health understanding among medical learners: a literature review with profession-based recommendations

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Achieving global health understanding among medical learners: a literature review with profession-based recommendations

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ACHIEVING GLOBAL HEALTH UNDERSTANDING AMONG MEDICAL LEARNERS: A
LITERATURE REVIEW WITH PROFESSION-BASED RECOMMENDATIONS
by
Cristina C. Cardet

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2024

GLOBAL HEALTH UNDERSTANDING ii

The following manuscript was contributed to in equal parts by Mariah Walker, Carly Watts,
and Cristina Cardet.

GLOBAL HEALTH UNDERSTANDING iii

Acknowledgements
We wish to express our sincerest gratitude to Dr. Elizabeth Bamgbose, Dr. Erica McCall,
and Dr. Joshua Carr, without your support and tireless guidance this paper would not exist. We
extend a special thanks to the rest of the faculty for your constant encouragement these last three
years. We would also like to acknowledge our classmates without whom this journey would not
have been possible. Thank you, for being by our side in the trenches; there is no greater cohort
we could imagine crossing this finish line with. Lastly, we are forever grateful to our friends and
family who stuck with us through the tough times and helped make our dream come true.

GLOBAL HEALTH UNDERSTANDING iv

Dedication
We dedicate our work to the advancement of international collaboration and global health
understanding among NARs. We hope our work inspires nurse anesthesia programs to join IFNA
and build international partnerships in the future.

GLOBAL HEALTH UNDERSTANDING v

Table of Contents
Acknowledgements ........................................................................................................................ iii
Dedication ...................................................................................................................................... iv
Table of Contents ............................................................................................................................ v
Abstract .......................................................................................................................................... vi
Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Background & Significance ........................................................................................................ 1
Research Question & Specific Aims ........................................................................................... 3
Chapter 2 ......................................................................................................................................... 4
Methods ....................................................................................................................................... 4
Chapter 3 ......................................................................................................................................... 5
Literature Review ........................................................................................................................ 5
Unidirectional Exchange ......................................................................................................... 5
Bidirectional Exchange .......................................................................................................... 11
Virtual Exchange ................................................................................................................... 14
Chapter 4 ....................................................................................................................................... 17
Results ....................................................................................................................................... 17
Chapter 5 ....................................................................................................................................... 18
Discussion ................................................................................................................................. 18
Limitations ................................................................................................................................ 19
Conclusion ................................................................................................................................. 20
References ..................................................................................................................................... 21
Appendix A ................................................................................................................................... 25
Appendix B ................................................................................................................................... 26

GLOBAL HEALTH UNDERSTANDING vi

Abstract
The concept of global health involves applying strategies to reduce health disparities
across national borders. Abundant international travel, migration, and technological advances in
communication have brought global health training to the forefront for medical learners.
International exchange immerses medical learners in global health concepts and plays a critical
role in their ability to develop and integrate global health in their future practice. There is
existing research on various types of medical learners' experiences with global health through
international exchange, but nurse anesthesia residents (NARs) are not well represented. This
literature review explored methods of global health learning among all medical learners to offer
recommendations to best achieve global health understanding among doctor of nurse
anesthesiology educational programs.
Keywords: global health, collaboration, exchange, partnership

1

Chapter 1

Introduction
Global health aims to achieve health equity for people among all social, geographic,
or cultural circumstances. Between 2009 and 2019, global health was most commonly defined in
the literature as an area of research and practice committed to the application of
multidisciplinary, multisectoral, and culturally sensitive approaches aimed at reducing health
disparities across national borders. Global health is inclusive of many themes, including a
multifold approach to worldwide health improvement, and researched through academic
institutions (Salm et al., 2021). Strategies to achieve global health combine the resources,
knowledge, and experience of diverse societies to address health challenges throughout the world
(Koplan et al., 2009). Over the last two decades global health training has become more relevant
for medical learners due to increased international travel, migration, and the ability to rapidly
share information (Mirza et al., 2021). These developments offer medical learners the
opportunity to better understand international health issues prior to entering practice and may
enable them to be better practitioners as a result of cultural and global health exposure (Steeb et
al., 2020). This paper will discuss the concept of global health, the importance of global health
understanding for medical learners, and provide guidance on how to achieve global health
understanding based on results from an extensive literature review.
Background & Significance
Migration and travel have driven global health crises and challenges throughout history,
spreading local health concerns from isolated countries to a global expanse that cannot be
ignored (Freda, 1998). The need for international cooperation and organization to fight infectious
GLOBAL HEALTH UNDERSTANDING 2

disease during the post-World War II era led to the creation of the World Health Organization
(WHO). Since its inception more than 80 years ago, the WHO has championed the concept of
global health and helped to define the field as it is known today (Chen, 2014). The goals of
global health are to understand the spatio-temporal patterns of health issues and their global
impact, investigate the determinants of global health, and create evidence-based global solutions
through the use of strategies, governances, policies, regulations and laws (Chen et al., 2020).
Although global health is within the realm of public health and international health, it has some
critical differences. Unlike international or public health, it deals explicitly with medical and
health issues relevant to the global population and seeks globally based solutions to those
problems. (Chen et al., 2020).
While the utility of a global perspective is vital in all fields of medicine, specialty groups
such as the International Federation of Nurse Anesthetists (IFNA) seek to advance the
availability of nurse-provided anesthesia globally. IFNA was founded in 1989 with a mission to
advance the field of anesthesiology and to support and enhance anesthesia care worldwide. The
mission is achieved by establishing and maintaining means of communication among nurse
anesthetists around the world inclusive of 43 participating countries (Meeusen et al., 2016).
Specifically, the IFNA aids in international communication among nurse anesthetists by hosting
the biennial World Congress of Nurse Anesthesia (WCNA), inviting members from all
participating countries to discuss and disseminate local health concerns and solutions with a
focus on peri-anesthetic care. The association also maintains relationships with The International
Council of Nurses, the World Federation of Societies of Anesthesiology (WFSA), the WHO,
along with many other global medical associations (Chen, 2014; Meeusen et al., 2016).
GLOBAL HEALTH UNDERSTANDING 3

Research Question & Specific Aims
The PIO (population, intervention, outcome) question leading this investigation is: Can
global health learning be achieved among medical learners who participate in international
collaboration? While medical learner is being used as a broad term, information gained from this
literature review will be applied to nurse anesthesia resident (NAR) education.
The specific aims are to:
1. Perform a critical review of the literature regarding international collaboration between
academic institutions.
2. Provide evidence-based practice recommendations regarding integration of international
collaboration of medical learners in academic institutions.
3. Explore and disseminate the benefits of nurse anesthesiology training programs obtaining
IFNA accreditation to increase international collaboration and increase global health
understanding among NARs.
GLOBAL HEALTH UNDERSTANDING 4

Chapter 2
Methods
An extensive literature review was performed using PubMed and CINAHL. Search terms
included: global health, global exchange, international exchange, bidirectional exchange, virtual
exchange, international partnerships, nursing exchange, study abroad, nursing, nurse anesthetist,
medical student, anesthesiology, and medical learner. In order to meet inclusion criteria, an
article was available in English, focused on global health experiences for medical learners,
discussed a partnership involving a physical exchange or virtual exchange, and was published
between 2011 and 2021. Five articles were included as exceptions due to their historical content
and included to provide background information. Exclusion criteria included: articles focusing
on specific diseases, online global health competencies with no international collaboration,
classroom-based global health learning with no collaboration between institutions, virtual
support for SARS-CoV-2, and building new medical programs overseas. Using these search
terms, PubMed returned 852 articles and CINAHL returned 108 articles which were screened for
relevance yielding [10] articles for analysis. Five additional articles were found using the
snowball technique on PubMed for a total of [15] articles for critical appraisal. A PRISMA
diagram in Appendix A depicts this literature screening process.
Literature being used for this PIO project consisted of case studies, expert opinion, and
systematic reviews. A literature matrix summarizing the main concepts, level of evidence,
methods, and the main findings of each article is included in Appendix B.

GLOBAL HEALTH UNDERSTANDING 5

Chapter 3
Literature Review
Unidirectional Exchange
Maas et al. (2011) performed a small qualitative study to determine the benefits of a
unidirectional, one-week international exchange among psychiatric mental health advanced
practice nursing students in the Netherlands with a program in the United States. Students who
participated in the inaugural exchange reported feeling culture shock and difficulty transitioning
to a new healthcare system. As a result of the findings, pre-exchange classes were implemented
in the subsequent exchange to ease these challenges and the following group had fewer reports of
culture shock or difficulties adjusting to the new healthcare system. During these 1-week
exchanges, Dutch students were able to shadow multiple advanced practice nurses in a variety of
mental healthcare settings and present an open dialogue case study to healthcare professionals at
the exchange facility. The authors reported Dutch students acquired new knowledge on the U.S.
healthcare and nursing systems from these open dialogue presentations. One-on-one discussions
found students returned to the Netherlands with a better understanding of the American
healthcare system as well as improving the Dutch student’s mental health practice.
Matthews-Trigg et al. (2019), explored the perceptions of U.S. physicians and global
health program directors on how global health experiences shape healthcare practice and values
in America. Global health physicians and program directors who participate in global health
work were invited to complete a survey. Inclusion criteria for the physicians in the study
consisted of those working in a low or middle-income country (LMIC) at least one month out of
the year and who have completed at least five cumulative years working in global health in a
LMIC. Global health program directors were required to work in an accredited global health
GLOBAL HEALTH UNDERSTANDING 6

program to be included in the survey. Recruitment emails were sent to 159 physicians and
program directors; the questionnaires were designed to encourage physicians and program
leaders to provide open-ended responses about their global health practice, research and program
oversight experiences. The interviews further explored participant’s expertise and questionnaire
responses; themes were identified via qualitative thematic analysis. Eight global health
physicians and four global health program directors completed the online questionnaire; seven
physicians and five program directors participated in a semi-structured interview. Five themes
were identified detailing benefits to medical learners who participate in global health work: (1) a
sense of improved patient rapport, particularly with low-income, refugee and immigrant patients,
and improved more engaged patient care; (2) reduced spending on healthcare services; (3)
greater awareness of the social determinants of health; (4) deeper understanding of the U.S.
healthcare system compared with systems in other countries; and (5) a reinforcement of values
that initially motivated physicians to pursue work in global health. The study authors disclosed
limitations including the small sample size and a homogenous research team that consisted of
predominantly white males who composed the questionnaire and interview questions.
In order to determine the need for cost-effective surgical services, Kühner et al. (2021)
sought to study the Global Surgery course at Karolinska Institutet (KI) in Sweden. The KI course
is offered biannually to fourth-year medical students and consists of theoretical lectures in
Sweden and a two-week clinical rotation in Uganda with training from Swedish and Ugandan
surgeons. The study measured the course’s effects on students’ development of global surgery
knowledge and skills, as well as exploring their approach to consultations with patients of non-
Swedish origin in relation to the immigrant-health aspects of global health before and after the
course. They utilized a mixed-method analysis of a formative assessment, a course evaluation,
GLOBAL HEALTH UNDERSTANDING 7

and case-based interviews. Semi-structured case-based interviews were conducted individually
with 18 students and analyzed using qualitative content analysis. The Kruskal Wallis one-way
analysis of variance, Pearson’s Chi-square, and a Wilcoxon signed-rank test were used to
complete statistical analysis of examination scores as well as course evaluations. The pre and
post-test formative assessment measured knowledge, understanding, and critical thinking about
global-surgery issues using objective and subjective response questions. The median score on the
pre-test was 5 and the post-test median score was 11, showing a significant improvement (p <
0.0001). All 38 students who responded to the course evaluation reported gaining practical skills
and development of new knowledge of medical management with limited resources. Students
also reported learning about differences in health and healthcare systems globally and locally,
and almost all students expressed interest in future engagement in global surgery and global
health. Overall, the students found the course to be beneficial—all students who responded to the
evaluation (38 out of 47 participants) reported having gained useful skills and found the clinical
experience in Uganda to be meaningful.
Brown (2017) found that nursing students benefit from immersion experiences in global
settings by improving their self-efficacy, self-confidence, and self-awareness. Twenty nursing
students participated in a course titled Transcultural Nursing: Belize Experience. The course
included a didactic portion teaching civic engagement and cultural similarities and differences,
and culminated in a field portion in which students were immersed in Belizean villages. Their
goal was to address common health needs such as: nutrition, treating parasitic infections, oral
and personal hygiene, diarrheal disease, puberty, and head lice. Students provided oral hygiene
and first aid supplies, hypertension and diabetes mellitus education, referrals to clinics and
softball equipment to a village team to promote physical activity. Students completed self-
GLOBAL HEALTH UNDERSTANDING 8

reflection papers before the two-week immersion, and group-format reflections during and at the
end of the field-experience. Themes from the intra-field experience reflection included
overcoming challenges such as adapting interventions in real time, schedule changes, physical or
environmental barriers, and cultural considerations. The final student reflection included themes
of culture, family, and resources. Students found there was a general respect and acceptance of
different cultures, and a strong sense of family value in Belize. They expressed appreciation for
health resources in America and frustration with limited resources in Belize, making their
education and interventions difficult. The immersion experience afforded students the
opportunity to practice and grow their communication, collaboration, and leadership skills
through working with the Belizean communities to improve health inequities. They were also
able to show commitment to social justice and compassionate care for vulnerable populations
through advocating and fundraising for more resources. The participants demonstrated a
culturally considerate approach by including local foods and locally developed health education
materials in their interventions. These observations were noted in the students’ self-reflections.
Huffman et al. (2020) set out to develop a new framework to analyze experiences of
Japanese nursing students studying abroad in Asia and North America. The framework proposed
encompassed identity transformation, nursing, and healthcare-related knowledge attainment, and
increased cultural awareness and competence. Fifty undergraduate students from a nursing
college in Tokyo studied abroad at nine programs in North America and Asia. Qualitative data
was collected and analyzed from reflection papers and free-response questionnaire items.
Analysis revealed personal growth, cultural and language identity development, and a better
understanding of global nursing practice and healthcare systems. Students also reported gaining a
better understanding of poverty and public health issues outside of their own country and felt the
GLOBAL HEALTH UNDERSTANDING 9

desire to participate in global health discussions, acknowledging that being more proficient in the
English language would better prepare them for these discussions.
In 2020, Steeb et al. reported an increased demand for global health experiences among
medical learners with roughly 30% of dental students, more than 25% of medical students, and
7% of pharmacy students participating in global health experiences during their professional
program. Subsequently, identified a generic framework to measure global health competency for
health professions. Created by the Consortium of Universities for Global Health (CUGH), the
“global citizen” competencies are recognized as measures all medical learners should achieve
during their global health experience. The CUGH framework highlights learning outcomes for
medicine, nursing, pharmacy, social work, and other health professions with international
experiences. In order to evaluate students’ self-perception of growth among Doctor of Pharmacy
(PharmD) students who participated in an international advanced pharmacy practice experience
(APPE), a mixed-methods design was utilized. The researchers administered a pre and post
Likert scale assessment, based on the CUGH framework competencies, and a qualitative open-
ended question assessment allowed for verification of growth on CUGH competencies and
additional learning outcomes outside of CUGH competencies. Results revealed a significant
growth of 10.2 points across all CUGH competencies among global citizens who participated in
APPEs. Prominent themes among the students who responded to the open-ended questions were:
increased cultural awareness, increased adaptability, improved problem-solving skills, improved
communication skills, self-awareness, cultural awareness, and an open mindset with regard to
cultural and patient care differences that shaped their career outlook. Students in the focus group
reported not having a strong understanding of what global health was before starting their
international APPE, but the knowledge gained through the experience improved understanding
GLOBAL HEALTH UNDERSTANDING 10

of global health issues and contributed to an enhanced global health perspective during patient
care. Students discussed being more aware of how their actions impact health globally and how
global health applies to their local settings.
Steinke and Rogers (2021) looked at an international exchange between 23 United
Kingdom (U.K.) and U.S. nurse practitioner (NP) students and their professors. They aimed to
increase understanding of each other’s health care services and training. A mixed methods
approach was employed, including qualitative data from student responses after two virtual
exchanges, and; one physical exchange visit of U.K. students to the United States. The first
interaction was a discussion among the students, held virtually, and was facilitated through
questions developed by faculty with the goal of comparing and contrasting each other’s health
care systems. The second meeting was also a virtual discussion and was facilitated through
questions developed by the students on any topics they chose. After 2 virtual sessions the
students met in person. Eleven U.K. students and two faculty members visited 13 U.S. students
and their faculty. U.K. students toured a U.S. emergency department, participated in informal
patient simulations, shadowed a NP, and discussed health care–related issues with U.S. students
in a classroom setting. The faculty identified the aim of the project as interprofessional
collaboration to understand and compare advanced practice in another country. Of the students
surveyed, 83% said the virtual discussion met the aim. The discussion questions developed by
faculty were intended to encourage students to identify differences and similarities among
advanced practice education and clinical experience in their countries. Student responses showed
91% would recommend the project to future students and 70% indicated the discussion questions
developed by the students provided good insight into advanced practice in their partner countries.
Key themes from student responses included curriculum differences, healthcare differences, and
GLOBAL HEALTH UNDERSTANDING 11

valuable exchange experience. The authors reported, the U.K. students and faculty valued the
simulation experience U.S. NP students participate in and would like to incorporate ideas and
methods from the United States in their U.K. curriculum. Positive responses from UK students
included: the week with the U.S. students enabled them to support each other more closely, the
in-person exchange was an amazing opportunity individually and as a group, they were able to
form friendships and help each other prepare for exams, and they were able to develop ideas for
global research projects to undertake in their final year of NP study. Steinke and Rogers
recommend offering an international opportunity for students to learn from their international
peers and to incorporate stimulation exercises in their training to hone their diagnostic skills.
Bidirectional Exchange
Arora et al (2017) summarized the benefits and challenges of bidirectional exchanges of
medical learners, specifically when high-resource programs collaborate with limited-resource
partners. The literature review summarizes benefits, challenges, and solutions reported from both
unidirectional and bidirectional exchanges, with a focus on the students from limited-resource
programs. They found the benefits include strengthening ethical partnerships, education of the
global workforce, empowering trainees to be change agents at their home institutions, and
improving training at host institutions. Challenges presented were the additional burdens on
limited-resource programs incurred from hosting trainees from high-resource areas, the lack of
funding for sending their own limited-resource learners to high-resource areas, and the fear of
what is known as “brain drain,” where graduates leave their low resource country to practice in a
high resource one. The authors report these exchanges resulted in unequal learning for high-
resourced program students from their limited-resource partners. The authors believe the middle
ground is to offer bidirectional exchanges where students from low-resource areas are viewed as
partners and receive equitable access to international exchanges are funded and aided by support
GLOBAL HEALTH UNDERSTANDING 12

from the high resource institution as part of the principles of a mutually beneficial global health
partnership.
Hu et al. (2019) used findings from a review of healthcare profession collaboration to
create a theoretical framework, to guide international collaborations between nurse anesthesia
programs globally. The framework was developed by research teams from a Doctor of Nurse
Anesthesia Practice (DNAP) program in the United States and a scholarly Nurse Anesthesia
Research Lab in China. The framework aimed to enhance their collaboration on projects to
advance best practice, education, decision making, and leadership within the nurse anesthesia
student. The authors identified seven interrelated concepts for building international
partnerships: collaboration, environment, structure, process, outcomes, partnerships, and
sustainability. Using this theoretical framework, they developed a horizontal collaborating
partnership which enabled the programs to create shared publications, funding, education
programs, dissemination of research findings, and best practice recommendations for nurse
anesthetists. As a result, there were 11 faculty/student bidirectional exchange experiences, 11
collaborative publications in peer review journals, nine oral presentations at national or
international conferences, and five manuscripts submitted. The two research teams developed the
first education program for advanced practice nurses in anesthesia settings in China which
received recognition from IFNA. The U.S. program also achieved IFNA accreditation. While
there were no specific variables measured regarding learning outcomes, the authors reported the
bidirectional exchange was deemed beneficial based on the sustained partnership between the
international programs and their achievements.
Lawrence et al. (2020) and Abedini et al. (2015) both reported the impact of a 30-year
partnership between the University of Michigan and multiple institutions in Ghana. The
GLOBAL HEALTH UNDERSTANDING 13

bidirectional exchanges occurred between March 2006 and June 2017, the later years of the
partnership. Senior medical students completed 3-4 weeks at each partners institution where they
participated in shadowing specialties such as OBGYN, internal medicine, and surgery, as well as
didactic sessions, simulations, and seminars. The study employed an open-ended retrospective
survey which was distributed immediately following the exchange in Ghana by the University of
Michigan students. The survey was conducted by two reviewers and then analyzed using NVIvo.
The results identified themes such as: exposure to different healthcare environments; exposure to
different diagnoses and patient populations; building cross-cultural professional relationships;
and hands-on experience. Students reported they left with a better understanding of how to
bridge cultural gaps; and the need for more thoughtfulness when ordering tests to eliminate over
utilization. Further, students felt the long-standing nature of the partnership between the
Ghanaian and Michigan institutions made them feel embraced as partners in learning. The main
barrier, as seen with most foreign exchange programs, was language. Other barriers noted were
poor communication from Ghana prior to the exchange, physician strikes during exchange, and
too many trainees at one Ghanian location.
In a subsequent study on the same sample population, Abedini et al. (2015) specifically
explored the benefits for students who travel from low to high resource environments.
Researchers conducted semi-structured interviews with 15 Ghanaian medical learners who had
completed a rotation at the University of Michigan between January 2008 and December 2011.
Their findings showed benefits including increased appreciation for the role of respect and
empathy within medical care, which the students reported helped them to increase rapport with
their patients. The Ghanaian learners also reported that their observations of provider-patient
GLOBAL HEALTH UNDERSTANDING 14

interactions at Michigan altered their idea of how to communicate with their patients in order to
facilitate patient education and involvement in care.
Noone et al. (2019), reported findings from initiating and maintaining a bidirectional
international service exchange for undergraduate nursing students. The program included
students from U.S.-based Oregon Health and Science University and University of Guanajuato in
Guanajuato, Mexico. Researchers evaluated student experiences from 4 cohorts of students, 32
students from the United States and 29 students from Mexico, using survey results, narrative
reflections, debriefings, and student’s community assessments. The following themes were
identified: (1) expanded learning about health care systems and policy; (2) the role of the nurse
in each country; (3) enhanced cultural and ethical awareness. All four cohorts from both
countries reported their exchange experience shaped the way they provide care and view
healthcare upon their return home. Additionally, the first two cohorts were resurveyed for
retained benefits 2-3 years post-graduation. Participants from both countries stated their
experience abroad provided lasting influence over their perspective of their own healthcare
system as well as their cultural awareness.
Virtual Exchange
Bowen et al. (2021) began a qualitative study on bidirectional virtual exchange that
connected global health students at Stanford University to global health students in Lebanon. The
study enrolled 24 students from each university for a total of 48 participants. Researchers utilized
Contact Theory, a framework utilized to enhance exchange of information between two groups
who are unfamiliar with each other's socio-economic and cultural backgrounds. It provides a
structured contact by promoting equity in social status, a purposeful pursuit, and cooperative
rather than competitive environments. The students were separated into small-groups in virtual
rooms and tasked to identify and propose a solution to address the Syrian refugee crisis, a
GLOBAL HEALTH UNDERSTANDING 15

complex global health problem. Immediately following the virtual exchange, a post-exchange
survey was conducted with both United States and Lebanese students using open-ended
questions. Themes from survey responses were identified and coded by one researcher in the
United States and one researcher in Lebanon. The researchers found respondents to be
overwhelmingly positive towards a virtual bi-directional exchange. The researchers documented
themes such as an increase in the understanding of the project through collaboration, a deeper
understanding of each other's culture, and a feeling the exchange had advanced their career by
expanding their network of colleagues.
A stand-alone pediatric hospital in the United States built international relationships with
comparable institutions in Bogota, Colombia and Beijing, China (Mirza et al., 2021). Residents
and fellows in the United States had the opportunity to participate in a bi-directional exchange
with trainees in Colombia and Beijing, China in the spring of 2020. With the onset and
continuation of the Coronavirus pandemic the pediatric institutions in the United States and
Beijing decided to foster their relationship with monthly virtual case discussions and exchange of
ideas. Case reports, open to all physicians from residents to senior staff, were conducted via
Zoom in English and included a presentation on the case followed by a question and answer
session and lessons learned. Positive feedback was gathered from attendees through informal
discussions and post-attendance surveys utilizing yes/no questions following the meetings.
Participants in both the United States and China supported the continuation of the case
discussions. Despite an identified language barrier, many faculty in Beijing felt these exchanges
gave them the opportunity to improve their English. Based on the feedback from faculty, the
authors found these virtual case discussions to be beneficial in providing each country with a
GLOBAL HEALTH UNDERSTANDING 16

different perspective to approach problems while also developing a deeper understanding of the
challenges different countries may face in healthcare.
Bothara et al. (2021) evaluated how global health education, through the use of the
online-based learning platform, may facilitate understanding another country’s health system,
culture(s), and determinants of health. The Global Health Classroom model consisted of two
small groups of medical learners from University of Otago in New Zealand and University of
Samoa in Samoa who present and discuss medical cases and relevant global health concepts via a
90-min video conference, followed by an off-line debrief. The authors used a mixed-methods
approach, utilizing a questionnaire and semi-structured interviews. There were 74 participants
out of 87 who filled out the questionnaire and 21 students participated in the interviews. Of
students surveyed, 82% reported the Global Health Classroom increased their understanding of
cultural influences in health and gained insight into patient’s attitudes and behaviors towards
their healthcare. A large majority of students (89%), agreed the videoconferences increased their
awareness of barriers to healthcare as students compared surprising similarities and
dissimilarities between the two countries. Overall, 75% of respondents stated these
collaborations increased their understanding of the importance of the social determinants of
health. Finally, 79% of students stated their participation in the global health classroom was
valuable to their learning. Samoan students frequently reported they appreciated the opportunity
to learn about global health without having to travel. New Zealand students reported the
videoconference format made learning about global health more tangible for them in comparison
to a traditional class or online module. The authors noted connectivity as a limitation in multiple
sessions, though no session was ever abandoned due to severe connectivity issues.

GLOBAL HEALTH UNDERSTANDING 17

Chapter 4
Results
The authors suggest the following recommendations be used as a general guide for
doctoral nurse anesthesia educational programs to expand global health understanding among
medical learners:
1. Bidirectional exchange: Two-way exchange programs where a group of students from
each institution visit the other institution (Lawrence et al., 2020 & Abedini et al., 2019).
2. Virtual exchange: Exchanges that connect NARs from different geographical locations
virtually offer mutual learning of the partners’ healthcare system, cultures, and
determinants of health (Bothara et al., 2021).
3. IFNA accreditation: The IFNA offers avenues for international collaboration through an
accreditation database as well as a world conference for collaboration between
international nurse anesthesiologists (Meeusen et al., 2016).

GLOBAL HEALTH UNDERSTANDING 18

Chapter 5
Discussion
Global health understanding in medical learners is best achieved via bidirectional
exchanges, offering the greatest amount of collaboration and global health learning with retained
long-term benefits. Learners who participated in a bidirectional exchange have improved ethical
partnerships with their fellow learners and both sides have improvements in their home
institutions' training curriculum due to the knowledge gained during the exchange. Students who
participate in bidirectional exchanges feel more empowered to be agents of change within their
home institutions upon return (Arora et al., 2017). Expanded patient populations and exposure to
new environments enrich student’s learning opportunities and help them build interpersonal
skills such as respect and empathy which can help them more effectively bridge cultural gaps
when providing care (Lawrence et al., 2020 & Abedini et al., 2019). In addition, bidirectional
exchanges may allow for collaboration between institutions to pool financial resources and fund
collaborative research, best practice recommendations, and implement additional educational
programs (Hu et al., 2019). It should be noted, factors limiting bidirectional exchange include the
need to vet international exchanges which may result in an increase in funding needs as well as a
learning inequity between the two populations. (Arora et al., 2017).
The benefits of unidirectional exchanges were only studied among medical learners from
one country and not among medical learners from the host country. The publication of these
types of exchanges is one-sided as the authors of such articles are from only one country in the
exchange. Unidirectional exchange is not included in our recommendations due to these
limitations, as the literature reports only the benefits to the exchanging institution and not the
host institution.
GLOBAL HEALTH UNDERSTANDING 19

Physical exchange programs are shown to be valuable for medical learners, but they can
be costly and may limit the international experience to only a handful of students (Bowen et al.,
2021). Instead, a cross-cultural experience through international videoconferences to discuss best
practice recommendations and case studies may be a more viable option. Both audio and video
exchanges should be considered, given that the internet may be limited in some areas of the
globe (Bothara et al. 2021).
IFNA enables programs to gain contacts and access to global anesthesia programs
through a shared IFNA database (Meeusen et al., 2016). Nurse anesthesia programs can utilize
the database to connect with different programs around the world to form relationships and begin
international exchanges. IFNA also hosts the WCNA every two years, providing opportunities
for academic institutions to meet in person and build relationships.
Limitations
The results of our literature review must be considered within the context of a few
limitations, namely, only papers written in English were included from PubMed and CINAHL
restriction to English-only studies yields the possibility that more studies exist on this topic but
were not included in this literature review, thus restricting the scope of this study. The extremely
low volume findings for anesthesia specific exchanges may mean that there could be
undiscovered benefits or challenges specific to NARs that are not reflected in this review,
however the population we included (medical doctors, advanced practice nurses, and more) are
closely intertwined professions who face similar learning goals and demands as NARs. Results
only yielded one study specifically reviewing NARs and anesthesia related content.
GLOBAL HEALTH UNDERSTANDING 20

Conclusion
Bidirectional exchange is the most beneficial type of exchange. It offers benefits to
medical learners from both participating institutions, but a major barrier to its implementation is
cost. Virtual exchange via audio and video teleconference is a viable alternative for institutions
who cannot implement an in-person exchange. Programs who wish to initiate an exchange (in-
person or virtual) must find and contact another nurse anesthesia institution. Through its library
of accredited institutions, IFNA can facilitate this interaction by providing information and
contact opportunities for programs throughout the world. We believe attaining IFNA
accreditation is the first step to achieving global health understanding among NARs, but future
research is needed on the benefits of IFNA accreditation. As nurse anesthesia programs begin to
build international partnerships, future research is needed on the benefits of an exchange
program for NARs as there is limited research on this population. To determine the effect of
global health understanding on future practice we recommend following these NAR cohorts five
to ten years after the exchange intervention.
GLOBAL HEALTH UNDERSTANDING 21

References
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GLOBAL HEALTH UNDERSTANDING 22

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GLOBAL HEALTH UNDERSTANDING 25

Appendix A

Records identified from*:
Databases (n =
960 )

Additional records
identified through other
sources
(n = 5)
Records screened
(n = 180)
Records excluded**
(n = 100 )
Full-text articles sought for
eligibility
(n = 50 )
Full-text articles excluded
(n = 15 )
Studies assessed for eligibility
(n = 28)
Studies included in review
(n = 15)

Identification of studies via databases and registers
Identification Screening

Included
GLOBAL HEALTH UNDERSTANDING 26

Appendix B
Article Title & APA
Reference
Summary of
Main Concept
Level of
Evidence
Methods
(Design,
instruments,
questionnaires)
Main findings of the study
Article #1
An American and Dutch
Partnership for Psychiatric
Mental Health Advance
Nursing Practice: Nurturing a
Relationship Across the Ocean

Maas, L., Ezeobele, I. E., &
Tetteroo, M. (2012). An
American and Dutch
partnership for psychiatric
mental health advance nursing
practice: nurturing a
relationship across the ocean.
Perspectives in psychiatric
care, 48(3), 165–169.
https://doi.org/10.1111/j.1744-
6163.2011.00319.x

To determine
benefits of a
unidirectional,
one-week
international
exchange among
psychiatric
mental health
advanced
practice nursing
students in the
Netherlands with
a program in the
United States
Descriptive
study
Reflected reports
and discussions with
participants over a
three-year span
Students reported feeling
culture shock and difficulty
transitioning to a new
healthcare system.
Participants acquired new
knowledge on the U.S.
healthcare and nursing
systems and improved their
mental health practice.
Article #2
Understanding perceptions of
global healthcare experiences
on provider values and
practices in the USA: a
qualitative study among global
health physicians and program
directors

Matthews-Trigg, N., Citrin,
D., Halliday, S., Acharya, B.,
Maru, S., Bezruchka, S., &
Maru, D. (2019).
Understanding perceptions of
global healthcare experiences
on provider values and
practices in the USA: A
qualitative study among global
health physicians and program
Qualitatively
examine the
perspective of
US based
physicians and
academic leaders
on how global
health work
shapes their
viewpoints,
values and
healthcare
practices in the
US.
Prospective
qualitative
Online
questionnaires and
open-ended, semi-
structured interviews
with 2 groups: 1)
global health
physicians 2) global
health program
leaders affiliated
with US-based
academic medical
centers. Open coding
procedures and
thematic content
analysis were used to
derive themes for
discussion.

Themes: 1) sense of improved
patient rapport (particularly
with low-income, refugee and
immigrant patients and
improved and more engaged
patient care; 2) reduced
spending on healthcare
services; 3) greater awareness
of social determinants of
health; 4) deeper
understanding of the US’s
healthcare system compared
with other countries; 5)
reinforcement of values that
initially motivated physicians
to pursue work in global
health.
GLOBAL HEALTH UNDERSTANDING 27

directors. BMJ Open, 9(4).
https://doi.org/10.1136/bmjope
n-2018-026020

12 participants
completed
questionnaire, 8 (4
survey respondents,
4 additionally
recruited) in-person
and phone-based
interviews.
Article #3
Global surgery for medical
students - is it meaningful? A
mixed-method study

Kühner, S., Ekblad, S.,
Larsson, J., & Löfgren, J.
(2021). Global surgery for
medical students - is it
meaningful? A mixed-method
study. PloS one, 16(10),
e0257297.
https://doi.org/10.1371/journal.
pone.0257297

There has been
an increase in
global health
courses at
medical
universities in
high-income
countries. Their
effect on
students,
however, is
poorly
understood. In
2016 an elective
global surgery
course was
introduced for
medical students
at Karolinska
instituted in
Sweden. The
course includes a
theoretical
module in
Sweden and a
two-week
clinical rotation
in Uganda.
The present
study aimed to
assess the format
and determine its
effect on
students’
knowledge of
global surgery
and approach
Mixed
methods
design
semi-structured case-
based interviews
were conducted
individually with 18
students and
analyzed using
qualitative content
analysis.
Examination scores
and the course
evaluation were
analyzed with
Kruskal Wallis one-
way analysis of
variance, Pearson’s
Chi-square and a
Wilcoxon signed-
rank test as
appropriate.

The course was appreciated
and students reported gained
insights and interest in global
surgery. Students’ ability to
reason about global surgery
issues was improved after the
course. Students considered
complicating aspects in the
meeting with patients of non-
Swedish origin. Students with
abroad clinical experience felt
less compelled to act on
preconceptions.

GLOBAL HEALTH UNDERSTANDING 28

towards patients
of non-Swedish
origin.

Article #4
Linking public health nursing
competencies and service-
learning in a global setting

Brown. (2017). Linking public
health nursing competencies
and service‐learning in a
global setting. Public Health
Nursing (Boston, Mass.),
34(5), 485–492.
https://doi.org/10.1111/phn.12
330

The purpose of
this article is to
describe an
innovative
approach to
address public
health nursing
competencies
and to improve
the health and
well-being of
indigenous
populations in a
global setting
through
promotion of
collaboration and
service-learning
principles.
Qualitative
review
As part of a hybrid
elective course,
baccalaureate
nursing students
from various nursing
tracks participated in
a 2-week immersion
experience in Belize
that included pre-
immersion
preparation. These
students collaborated
among themselves
and with Belizean
communities to
address identified
health knowledge
deficits and health-
related needs for
school-aged children
and adult
populations.
Commonalities exist between
entry-level public health
nursing competencies and
service-learning principles.
Using service-learning
principles in the development
of public health experiences
increases the likelihood of
success in achieving these
competencies. While students
demonstrated
interprofessional collaboration
in a global setting, these same
collaborative opportunities
can occur in local
communities.
Article #5
Learning experiences and
identity development of
Japanese nursing students
through study abroad: a
qualitative analysis

Huffman, J., Inoue, M.,
Asahara, K., Oguro, M.,
Okubo, N., Umeda, M., Nagai,
T., Tashiro, J., Nakajima, K.,
Uriuda, M., Saitoh, A., &
Shimoda, K. (2020). Learning
experiences and identity
development of Japanese
nursing students through study
abroad: a qualitative analysis.
This study aimed
to qualitatively
analyze the
experiences and
perceptions of
students at a
nursing college
in Japan who
studied abroad in
Asia and North
America, thereby
identifying the
full range of
benefits of study
abroad programs
for Japanese
nursing students.
Qualitative
analysis
Qualitative analysis
of the reflection
papers and free-
response
questionnaire items
completed by 50
Japanese
undergraduate
nursing students who
participated in 9
study abroad
programs in Asia
and North America.
Content analysis of
the data proceeded
from typological and
deductive to data-
The results reveal perceived
benefits in the areas of
English language proficiency
and motivation; knowledge of
nursing practices, healthcare
systems, and global health;
cultural awareness and
sensitivity; and various types
of identity development
(second-language motivation
and identity, national/ethnic
identity, professional identity,
identity as a global citizen,
and personal growth). It was
also shown that students’
perceptions of what they
learned or gained varied
GLOBAL HEALTH UNDERSTANDING 29

International journal of
medical education, 11, 54–61.
https://doi.org/10.5116/ijme.5e
47.cf1b

driven and inductive,
recursively, and
collaboratively.
according to the specific
characteristics of each study
abroad program.
Article #6
Global Health Learning
Outcomes in Pharmacy
Students Completing
International Advanced
Pharmacy Practice
Experiences

Steeb, D. R., Miller, M. L.,
Schellhase, E. M., Malhotra, J.
V., McLaughlin, J. E.,
Dascanio, S. A., & Haines, S.
T. (2020). Global Health
Learning Outcomes in
Pharmacy Students
Completing International
Advanced Pharmacy Practice
Experiences. American journal
of pharmaceutical education,
84(3), 7586.
https://doi.org/10.5688/ajpe75
86

To examine the
global health
learning
outcomes of
Doctor of
Pharmacy
(PharmD)
students from
three US schools
who participated
in international
advanced
pharmacy
practice
experiences
(APPEs).
Mixed
methods,
prospective
study
A mixed-methods,
prospective study
was used to assess
fourth-year PharmD
students at three US
pharmacy schools
who participated in
an international
APPE during the
2017-2018 academic
year and a matched
cohort (control
group) of PharmD
students who did not
participate in an
international APPE.
To evaluate students'
self-perceived
growth in the
Consortium of
Universities for
Global Health
(CUGH)
competencies, all
students completed a
13-item retrospective
pre-post instrument
using a five-point
Likert scale. The
students who had
completed an
international APPE
were invited to
participate in a focus
group (N=22).
Paired and
independent t tests
and multiple linear
regression were used
to analyze data.
The students who completed
an international APPE (N=81)
showed significantly more
growth in CUGH
competencies than students
who did not (mean
improvement in total score of
10.3 [7.0] vs 2.4 [6.0]).
International APPE
participation was the only
significant predictor of growth
in CUGH competencies. The
international APPE students
reported improvements in
cultural awareness and
appreciation, communication
skills, problem-solving skills,
adaptability, self-awareness,
personal and professional
outlook, and global health
perspective.

GLOBAL HEALTH UNDERSTANDING 30

Qualitative open-
ended questions and
focus group data
were mapped to
knowledge, skills,
and attitudes themes.

GLOBAL HEALTH UNDERSTANDING 31

Article #7
Evaluation of an international
program for nurse practitioner
students

Steinke, M. K., & Rogers, M.
(2021). Evaluation of an
international program for nurse
practitioner students. Journal
of the American Association of
Nurse Practitioners,
10.1097/JXX.0000000000000
525. Advance online
publication.
https://doi.org/10.1097/JXX.00
00000000000525

To facilitate an
international
understanding of
health care
services and
compare
curricula of
advanced
practice
programs
through an
international
experience for
first year NP
students from the
United Kingdom
and the United
States.

Qualitative
analysis of 23
students who
participate in
a virtual
exchange
followed by
an in-person
experience to
the United
States

The study used a
qualitative analysis
of responses from
specified questions
provided to both
cohorts of students
before and after the
experience.

Virtual exchange was found
to be valuable and combining
it with the in-person exchange
really helped to solidify
relationships and facilitated
learning. Students felt they
had a better understanding of
different healthcare systems
and even chose to pursue
global research projects
following experience.

Thematic analysis revealed
five themes: Enhanced
Employability as a Nurse;
Exposure to Nursing Beyond
the National Shores; Personal
Growth; Context-Sensitivity
of Nursing Care Delivery;
Language and Citizenship-----
The underpinning contention
around these observations was
the participants’ realization
that despite the presumably
universal nature of the nursing
profession, the delivery of
care was, nevertheless,
sensitive to the context in
which it was delivered

GLOBAL HEALTH UNDERSTANDING 32

GLOBAL HEALTH UNDERSTANDING 33

Article #8

Bidirectional Exchange in
Global Health: Moving
Toward True Global Health
Partnership

Arora, G., Russ, C., Batra, M.,
Butteris, S. M., Watts, J., &
Pitt, M. B. (2017).
Bidirectional Exchange in
Global Health: Moving
Toward True Global Health
Partnership. The American
journal of tropical medicine
and hygiene, 97(1), 6–9.
https://doi.org/10.4269/ajtmh.1
6-0982

Summary of
reported benefits
of hosting
learners from
limited-
resourced
settings, identify
common
challenges, and
highlight
successful
solutions based
on a review of
the literature and
experience
overseeing
bidirectional
exchange of
learners.
Perspective
piece
Literature review Bidirectional exchange paves
the way to provide
collaborative, mutually
beneficial educational
offerings for both partners.
We believe all GH
partnerships should discuss
implementing bidirectional
exchange for their learners.
While the research to date has
supported the benefits of
bidirectional exchange, better
understanding of the value,
pitfalls, and best practices in
hosting international rotators
is needed.
GLOBAL HEALTH UNDERSTANDING 34

Article #9

Building an international
Partnership to Develop
Advanced Practice Nurses in
Anesthesia Settings: Using a
Theory Driven Approach

Hu, J., Yang, Y., Fallacaro, M.
D., Wands, B., Wright, S.,
Zhou, Y., & Ruan, H. (2019).
Building an international
partnership to develop
advanced practice nurses in
anesthesia settings: Using a
theory-driven approach.
Journal of Transcultural
Nursing, 30(5), 521–529.
https://doi.org/10.1177/104365
9619846248

To provide a
theoretical
framework for
nurse anesthesia
programs to
utilize to build
international
relationships and
collaborations
with
international
programs.
Clinical
practice
guidelines
following a
systematic
review
Developed
theoretical
framework based off
findings from
systematic review.
This theoretical framework
can help to improve
collaboration with
international Nurse anesthesia
programs.

GLOBAL HEALTH UNDERSTANDING 35

Article #10
Embedding international
medical student electives
within a 30-year partnership:
the Ghana-Michigan
collaboration

Lawrence, E. R., Moyer, C.,
Ashton, C., Ibine, B. A.,
Abedini, N. C., Spraggins, Y.,
Kolars, J. C., & Johnson, T. R.
(2020). Embedding
International Medical Student
electives within a 30-year
partnership: The Ghana-
Michigan collaboration. BMC
Medical Education, 20(1).
https://doi.org/10.1186/s12909
-020-02093-6

Explores a
collaboration
between
Michigan and
Ghana with a
goal of creating a
long-standing
sustainable
relationship.
Retrospective
thematic
analysis-
qualitative
study
57 reports were
carried out using
NVivo 12 (QSR
International,
Melbourne,
Australia). Two
reviewers separately
reviewed all
narrative short-
answer comments.
-Through
incremental and
iterative coding of
the comments,
arrived at a total of
26 collective
keyword-phrases. -
Generated codes
were used to develop
eight key themes.
Using Excel, basic
counts and
frequencies were
calculated from
background
quantitative data.

"Ninety-five percent of
students planned to engage in
additional international work
in the future.
-Students felt that the long-
standing bidirectional
exchange allowed them to
build cross-cultural
relationships and be
incorporated as a trusted part
of the local clinical team. The
partnership modeled
collaboration, and many
students found inspiration for
the direction of their own
careers."----Importantly, 55 of
57 (96%) of students would
recommend their international
elective experience to future
medical students. When asked
if they want to engage in more
international work in the
future, the vast majority
(54/57; 95%) of students
responded yes, 2 (3.5%) were
unsure, and 1 (2%) responded
no.

GLOBAL HEALTH UNDERSTANDING 36

Article #11
Cross-cultural perspectives on
the patient- provider
relationship: a qualitative
study exploring reflections
from Ghanaian medical
students following a clinical
rotation in the United States

Abedini, N. C., Danso-Bamfo,
S., Kolars, J. C., Danso, K. A.,
Donkor, P., Johnson, T. R., &
Moyer, C. A. (2015). Cross-
cultural perspectives on the
patient-provider relationship:
A qualitative study exploring
reflections from Ghanaian
medical students following a
clinical rotation in the United
States. BMC Medical
Education, 15(1).
https://doi.org/10.1186/s12909
-015-0444-9

Interviews to
capture the
perspectives of
students
traveling from a
resource poor
area to a
resource-rich
settings. In the
US healthcare is
shared-decision
making and
egalitarian
practices vs
Ghana is
paternalistic
model between
healthcare
provider and
patient.
Exploring how
this affects
medical trainees
from the
paternalistic
cultural model.

Retrospective
thematic
analysis-
qualitative
study
15 semi-structured
interviews with
individuals who had
participated in 3–4-
week clinical
rotations. Interviews
were transcribed
verbatim then
independently coded
by 3 investigators.
The investigators
then reached a
consensus regarding
major themes.
Participants reported their
perspective of the patient-
provider relationship were
significantly affected from
international clinical
experience. Themes: 1)
observations of patient
comfort and privacy and
physician-patient interaction
2) reflections on role of
humanism and respect within
patient care. 3) barriers to
respectful care 4)
transformation of student
behaviors and attitudes.
GLOBAL HEALTH UNDERSTANDING 37

Article #12
Fostering Global Health
Practice: An Undergraduate
Nursing Student Exchange and
International Service-Learning
Program

Noone J, Kohan T, Hernandez
MT, Tibbetts D, Richmond R.
Fostering global health
practice: An undergraduate
nursing student exchange and
international service- learning
program. The Journal of
nursing education.
2019;58(4):235-239.
doi:10.3928/01484834-
20190321-09

Nurses
increasingly are
identified as key
health care
members on
global health
initiatives, and
nursing curricula
should address
this competency
to prepare
students to work
in a global
environment.
This article will
share how
processes and
structures were
established for
an international
undergraduate
nursing student
exchange and
service-learning
experience
between two
schools of
nursing.

Qualitative
analysis.
Cohort
evaluation of
international
exchange
program
Survey. The goals of
the project were to
(a) implement an
annual nursing
student exchange of
approximately 3
weeks in length; (b)
select eight students
from each school,
accompanied by a
faculty member, to
participate; and (c)
provide
opportunities for
students to
participate in
service-learning
assessments in
identified
communities.

An international service-
learning opportunity is one
way to improve nursing
students’ ability to provide
culturally competent health
care

GLOBAL HEALTH UNDERSTANDING 38

Article #13
Virtual Exchange in Global
Health: an innovative
educational approach to foster
socially responsible overseas
collaboration

Bowen, K., Barry, M., Jowell,
A. et al. Virtual Exchange in
Global Health: an innovative
educational approach to foster
socially responsible overseas
collaboration. Int J Educ
Technol High Educ 18, 32
(2021). https://doi-
org.libproxy1.usc.edu/10.1186
/s41239-021-00266-x

Stanford created
a virtual
exchange to
reduce costs of
international
exchange.
Created a project
for students at
Stanford and
students in
Lebanon to work
on as a team.
Qualitative
Case study
The study involved
24 students enrolled
at Stanford and 24
students of similar
age enrolled from a
school in Lebanon.
-Faculty used
contact theory,
problem-based
learning, and
collaborative
learning techniques
to build trusting
relationships
between students.
-Detailed surveys
with open-ended
questions sent out
post exchange and
results were
evaluated for
themes.
Students overwhelmingly
expressed appreciation for the
exchange. Described by
students as enriching,
innovative, and unique.
Mutual gain can view
different approaches to a
problem outside of cultural
norm.

GLOBAL HEALTH UNDERSTANDING 39

Article #14
Utilizing Virtual Exchange to
Sustain Global Health
Partnerships in Medical
Education

Mirza, A., Gang, L., & Chiu,
T. (2021). Utilizing Virtual
Exchange to sustain Global
Health Partnerships in medical
education. Annals of Global
Health, 87(1), 24.
https://doi.org/10.5334/aogh.3
179

Pediatric
residency in U.S.
established a
virtual exchange
with institutions
in Colombia and
China. Virtual
meet-ups
occurred to
discuss case
studies and
discuss best
practices.
Expert
Opinion
Assessed success of
exchange through
surveys with yes/no
questions and
informal discussions.
Questions were on
format utilized for
case discussions,
challenges, and
future directions.
-Proposed future
international
collaboration ideas
such as morning
reports involving
both countries
involved.
During the COVID-19
pandemic continuing
international exchange was
beneficial through virtual
experiences. Students still
found the experience valuable
by exchanging ideas.
GLOBAL HEALTH UNDERSTANDING 40

Article #15
Global health classroom:
mixed methods evaluation of
an interinstitutional model for
reciprocal global health
learning among Samoan and
New Zealand medical students

Bothara RK, Tafuna’i M,
Wilkinson TJ, et al. Global
health classroom: mixed
methods evaluation of an
interinstitutional model for
reciprocal global health
learning among Samoan and
New Zealand medical
students. Globalization and
health. 2021;17(1):1-99.
doi:10.1186/s12992-021-
00755-8

Global health
education
partnerships
should be
collaborative and
reciprocal to
ensure mutual
benefit.
Utilization of
digital
technologies can
overcome
geographic
boundaries and
facilitate
collaborative
global health
learning. Global
Health
Classroom
(GHCR) is a
collaborative
global health
learning model
involving
medical students
from different
countries
learning about
each other’s
health systems,
cultures, and
determinants of
health via
videoconference.
Principles of
reciprocity and
interinstitutional
partnership
informed the
development of
the GHCR. This
study explores
learning
outcomes and
experiences in
Mixed
methods
evaluation
This study used a
mixed methods
approach employing
post-GHCR
questionnaires and
semi-structured face-
to-face interviews to
explore self-reported
learning and
experiences among
medical students in
the GHCR. The
GHCR collaboration
studied was between
the medical schools
at the University of
Otago, New Zealand
and the National
University of Samoa,
Samoa
Students reported acquiring
the intended learning
outcomes relating to patient
care, health systems, culture,
and determinants of health
with regards to their partner
country. Interview data was
indicative of attitudinal
changes in relation to cultural
humility and curiosity. Some
reported a vision for progress
regarding their own health
system. Students in the GHCR
reported that learning with
their international peers in the
virtual classroom made
learning about global health
more real and tangible. The
benefits to students from both
countries indicated
reciprocity.
GLOBAL HEALTH UNDERSTANDING 41

the GHCR
between students
from New
Zealand and
Samoa.
GLOBAL HEALTH UNDERSTANDING 42

Abstract (if available)

Abstract The concept of global health involves applying strategies to reduce health disparities across national borders. Abundant international travel, migration, and technological advances in communication have brought global health training to the forefront for medical learners. International exchange immerses medical learners in global health concepts and plays a critical role in their ability to develop and integrate global health in their future practice. There is existing research on various types of medical learners' experiences with global health through international exchange, but nurse anesthesia residents (NARs) are not well represented. This literature review explored methods of global health learning among all medical learners to offer recommendations to best achieve global health understanding among doctor of nurse anesthesiology educational programs.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Cardet, Cristina C. (author)

Core Title Achieving global health understanding among medical learners: a literature review with profession-based recommendations

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2024-05

Publication Date 09/19/2023

Defense Date 05/10/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag collaboration,Exchange,global health,OAI-PMH Harvest,partnership

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bamgbose, Elizabeth (committee chair), Carr, Joshua (committee member), McCall, Erica (committee member)

Creator Email cardet@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113378609

Unique identifier UC113378609

Identifier etd-CardetCris-12394.pdf (filename)

Legacy Identifier etd-CardetCris-12394

Document Type Capstone project

Format theses (aat)

Rights Cardet, Cristina C.

Internet Media Type application/pdf

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Source 20230920-usctheses-batch-1099 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

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