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Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam
Nurse Education Today 89 (2020) 104300
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Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam
T
Sangeun Leea,1, Junghee Kima,1, Jong gun Kima,b, Truong Duc Tuc, Bừi Thi Thanh Loanc, ⁎ Hyeonkyeong Leea, a
Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea Hoseo University, Department of Nursing, 20, 79th Street, Hoseo-ro, Baebang-eup, Asan, Chungnam 31499, Republic of Korea c Quang Tri Medical College, Block 3, East Luong Ward, Dong Ha City, Quang Tri Province, Vietnam b
ARTICLE INFO
ABSTRACT
Keywords: Global health Cultural diversity Education Public health
Background: Owing to globalization, there is a need for enhanced global health competencies among nursing students. In this context, global service learning programs are important opportunities for nursing students. Objectives: To explore the effect of a short-term service learning program in a developing country on the global health competencies of students attending a South Korean nursing college. Design: A mixed methods design. Setting: The Global Nursing Internship is a two-week pre-experience, eight-day on-site, and one-week post-experience program. Participants: The on-site activities involved 15 nursing students participating in global health activities in a rural Vietnamese community. Methods: A self-reported questionnaire was used to assess changes in global health competencies in six domains, measured on a four-point Likert scale. Student satisfaction with each activity was measured on a five-point Likert scale. After completing the program, the participants wrote a self-reflection essay. The Wilcoxon signed rank test was used to analyze global health competencies, and content analysis was used to analyze participants' selfreflections. Results: Regarding global health competencies, the overall mean score showed a significant increase at the postprogram evaluation (Z = −3.41, p = .001). A pre-post-program comparison showed that the domain of “health care in low-resource settings” displayed the greatest increase in scores. The mean overall satisfaction with the program was high (mean = 4.31, standard deviation = 0.17). In the students' view, as expressed in their essays, their global health knowledge and attitude had improved. Conclusions: The program was useful in promoting global health competencies, empathy, and confidence and should be embedded among the essential requirements of nursing curricula. Suggestions are provided to develop an enhanced pre-experience program that could help students prepare better for on-site activities. As cultural competency is crucial for nurses, nursing educators should consider integrating similar global service learning programs into their existing nursing curricula.
1. Introduction With the increasing pace of globalization in recent years, health professionals are faced with growing demands to achieve the global health objectives of the sustainable development goals (SDGs). As primary patient advocates, nurses are required to possess the essential competencies for advancing global health (Global Advisory Panel on the Future of Nursing and Midwifery, 2017). Global health has been
redefined as “a system-based, ecological, and transdisciplinary approach to research, education, and practice which seeks to provide innovative, integrated, and sustainable solutions to address complex health problems across national boundaries and improve health for all” (Wernli et al., 2016). This emphasizes the importance of multidisciplinary work, which includes nursing, to identify sustainable solutions for health equity. In addition, both the Lancet (Frenk et al., 2010) and World Health Organization's (2013) reports on health
Corresponding author. E-mail address: [email protected] (H. Lee). 1 Both authors contributed equally to this work. ⁎
https://doi.org/10.1016/j.nedt.2019.104300 Received 18 April 2019; Received in revised form 11 September 2019; Accepted 18 November 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
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professional education and training have highlighted the importance of competency-based education for implementing educational reforms. In particular, global health competencies (GHCs) have gained significance in nursing over the last decade. Wilson et al. (2012) proposed six areas of GHCs: global burden of disease; health implications of migration, travel, and displacement; social/environmental determinants of health; globalization of health/health care; health care in lowresource settings; and health as a human right and development resource. There is an increased emphasis on these GHCs in nursing curricular and co-curricular activities. In response to the complex global health environment changes of the 21st century, several GHC models have been proposed for students in different health professions, including medical students (Association of Faculties of Medicine of Canada Resource Group/Global Health Education Consortium Committee, 2010), public health students (Calhoun et al., 2008), and nursing students (Wilson et al., 2012). In addition to the competencies required by different types of health professionals, the educational committee of the Consortium of Universities for Global Health (CUGH) has identified 12 core GHCs (Wilson et al., 2014). In recognition of the increasing importance of GHCs in health professions, nursing educators have made attempts to incorporate various programs into nursing education. One such method to gain knowledge, skills, and experience in dealing with global health issues is the implementation of global service learning programs, which have been started in underdeveloped countries. Earlier studies on nursing students have shown evidence of the effects of international service learning programs (Curtin et al., 2015; Hwang et al., 2015; Abunab et al., 2016; Kohlbry, 2016). Most of these were short-term activities in underdeveloped countries including the Philippines, Dominican Republic, Ghana, and Mexico. Participants reported that they were able to play the role of professional student nurses; they also realized their own personal development and reported a widened global perspective after participating in the programs. In addition, the programs were effective in enhancing critical thinking, global leadership capacity, and global cultural capacity (Hwang et al., 2015; Kohlbry, 2016). The programs also improved empathy and the ability to communicate effectively with patients in different environments and helped students develop cultural competency, a sense of social justice, and knowledge of health care systems other than their own (Curtin et al., 2015). Although there have been several studies on nurses and other health care workers (Battat et al., 2016; Cushman et al., 2015; Walpole et al., 2016), studies on what might constitute appropriate education and training for the development of GHCs among nursing students are limited. Nursing students have participated in many global health activities; however, to date, their impact on GHCs has not been studied. Therefore, based on Riner's (2011) framework for globally engaged nursing education, this study aimed to describe the effects of a shortterm global service learning program (Global Nursing Internship [GNI]) focused on the GHCs proposed by Wilson et al. (2014) and to elucidate the lessons learned from the program. It also aimed to assist nurse educators in developing global service learning programs for nursing students.
prestigious nursing institutes around the world. The GNI program aims to provide nursing students with opportunities to become involved in nursing practice in global health, to practice servant leadership, as well as to improve global citizenship despite cultural differences. The GNI 2016 comprised 15 undergraduate students, four coordinators (one undergraduate student and three graduate students), and one faculty member who was responsible for overseeing the program. The participants visited Quang Tri Province in the North Central Coast region of Vietnam, where the program was conducted in collaboration with Quang Tri Medical College. The program involved a two-week preexperience (pre-departure training), seven days of on-site activities, and a one-week post-experience phase. The pre-experience workshops covered topics such as global development cooperation, global health and nursing, gender equality, Vietnam's health and social environment, and safety and preparedness for international health emergencies. This training was focused on providing information about the on-site activities, which included an overview of Vietnamese health issues and interventions, the Vietnamese health care system and nursing education, and health-related cultural issues. After this pre-departure experience, supervised by team coordinators, a week-long group activity was conducted to prepare educational materials and supplies for nursing interventions in Vietnam. During the on-site activities, in the mornings, students administered health center-based interventions such as chronic disease screening, health education, health assessment, and home visits to local residents. In the afternoons, they administered school health interventions on various topics such as cardiopulmonary resuscitation, secondhand smoking prevention, and peer communication to middle school students through a summer camp. On the last day of the on-site activities, the student participants organized a cultural exchange performance, health fair, charity bazaar, and South Korean-Vietnamese student forum in collaboration with Vietnamese students and community residents. Toward the end of every day, the students spent an hour reflecting on what they had gained from the daily activity and gave each other feedback. After returning from the on-site activities, students were directed to discuss the program outcomes, reflect on their activities, and present their experiences to their peers (Table 1). The program was based on a revised version of Riner's (2011) framework for globally engaged nursing education (Fig. 1). The framework comprises six components: goals, core content, program characteristics, learner characteristics, reflection, and perspective transformation. In this study, perspective transformation entailed improving the students' GHCs through the GNI program. 2.3. Measures The CUGH has developed a GHC tool (Wilson et al., 2014), the Korean version of which was used in this study (Lee et al., 2015). The tool consists of 30 items in six areas: (1) global burden of disease, (2) health implications of migration, travel, and displacement, (3) social and environmental determinants of health, (4) globalization of health and health care, (5) health care in low-resource settings, and (6) health as a human right and development resource. Each item was rated on a four-point Likert scale ranging from 1 = “I strongly disagree” to 4 = “I strongly agree.” We assessed GHCs both at the beginning and completion of the program. The participants' satisfaction with the GNI program was also assessed on a five-point Likert scale ranging from 1 = “very dissatisfied” to 5 = “very satisfied.” In addition, each student wrote a self-reflection essay regarding their experiences, learning, and impressions about the program.
2. Methods 2.1. Study design This study adopted a mixed methods design to define the changes in nursing students' GHCs after participation in the global health program.
2.4. Data analysis
2.2. Description of the GNI program
All the quantitative data were analyzed using SPSS version 21.0 (IBM, USA). Descriptive statistics, including averages and standard deviations, were calculated. The Wilcoxon signed rank test was performed to define the differences in GHCs before and after the program. The level of statistical significance was set at p < .05.
The GNI program was designed to develop the GHCs of nursing students who voluntarily applied and were selected by a student committee in 2016. A college of nursing located in Seoul, Korea has been conducting the GNI program since 2012, following the changes in the curricula of 2
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Table 1 On-site activities of the GNI program. Day
Hours
D-1
4
· Local hospital visits
4
· Expert leadership seminar
4
· Home visits · Community health education
3
· School health
1
· Daily evaluation
4
· Disease management
3 1
· School health · Daily evaluation
4
· Children’s health screening
3 1
· School health · Daily evaluation
4
· Community activities
3 1
· School health · Daily evaluation
4
· Cultural and health fairs
2
· Student forum with local students
1 8
D-2
D-3
D-4
D-5
D-6
D-7
Activity
Contents/Intervention · Observation of the local hospitals and understanding the primary health care system in Quang Tri Province, Vietnam · Comparison with South Korean health care system · Seminar with global health experts · · · · · ·
Home visits to 15 vulnerable households: family health assessment and health education Health screenings (BP, BST, urine test) Individual health education for secondhand smoking prevention and chronic disease management Organizing a summer camp (4 days, 3 hours/day) Health education for physical, mental, and social health Self-reflection on daily activities and feedback
· Chronic disease screening for 102 local residents · Health screenings (BP, BST, urine test) · Group health education for 265 local residents (secondhand smoking prevention and chronic disease management such as HTN and DM) · CPR, secondhand smoking prevention skills, hand washing · Self-reflection on daily activities and feedback · · · ·
Health screening for local kindergarteners (Vision, height, weight, anemia test) Sharing the results with the teachers and parents CPR, dental hygiene, food and nutrition, reproductive health education, and peer communication Self-reflection on daily activities and feedback
· · · · ·
Environment improvement activity with local youth union members and students Cleaning up and wall painting in local kindergarten Provision of trash bins with health messages for agricultural waste CPR, reproductive health education, and peer communication Self-reflection on daily activities and feedback
· Daily evaluation
· · · · · · ·
South Korean-Vietnamese student cultural exchange Student health exhibition Charity bazaar for fundraising Health fair with 1,000 local people Comparison of nursing education between South Korea and Vietnam Case competition on community health projects in Vietnam with limited budget Self-reflection on daily activities and feedback
· Site visit
· Cultural experiences in Vietnamese museum, traditional market, palace, etc.
Notes. BP: blood pressure, BST: blood sugar test, HTN: hypertension, DM: diabetes mellitus; CPR: cardiopulmonary resuscitation.
By analyzing the self-report records using directive content analysis, we could confirm the validity of existing theories. Then, by analyzing the content using existing theories or previous research findings, we could propose conceptual expansion (Hsieh and Shannon, 2005). The content was analyzed based on the six categories of GHCs for nurses, as classified by Wilson et al. (2012). Two authors, who were nursing doctoral students with qualitative research training and global health experience, reviewed the participants' self-reflection essays. They read each report carefully, highlighting all meaningful text. All highlighted text was coded based on the six competency categories. Text that could not be coded into any of these categories was categorized separately
under the heading of “soft skills.” The doctoral students then discussed whether the categories and content were appropriate and reviewed the content with the principal investigator, who has expertise in global health research and education. 3. Results 3.1. Demographic characteristics of the participants The demographic characteristics of the participants are reported in Table 2. The average age was 21.80 years (standard deviation
Fig. 1. Global Nursing Internship conceptual framework. 3
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(SD) = 3.65, range 19–34). Among the one male and 14 female students, nine were juniors and six were at the sophomore level. In total, 87% of the students (n = 13) had international experience, with an average length of stay of 202 days. All the participants reported their English proficiency to be above the mid-high level.
in the six competencies, formed a different category. The themes extracted from the analysis included (1) “understanding global health” from the “global burden of disease” domain, (2) “understanding health care considering cultural differences” from the “health implications of migration, travel, and displacement” domain, (3) “impact of poor environment on access to health care services” and “influence of communication factors on health care” from the “social and environmental determinants of health” domain, (4) “understanding health care systems in different countries” from the “globalization of health and health care” domain, (5) “vulnerable health care environment” and “nursing interventions according to cultural characteristics” from the “health care in low-resource settings” domain, and (6) “understanding global health organization” from the “health as a human right and development resource” domain. In the domain of soft skills, positive perspective, empathy, and confidence were identified from the themes “positive perspective expanded through activities,” “empathy as a global citizen,” and “confidence in strengthening global health.”
3.2. GHC level and subsequent changes
4. Discussion
The participants' pre-test mean of the GHCs was 2.79 (SD = 0.35); this significantly changed to 3.49 (SD = 0.23) in the post-test (Z = −3.41, p = .001). Participants scored the lowest in the “globalization of health and health care” domain (pre-test, mean (M) = 2.43, SD = 0.47; post-test, M = 3.14, SD = 0.33) and highest in the “social and environmental determinants of health” domain (pre-test, M = 3.39, SD = 0.48; post-test, M = 3.88, SD = 0.18). The pre-post program changes in all six GHC domains were significant: “global burden of disease” (Z = −2.82, p = .005), “health implications of migration, travel and displacement” (Z = −3.18, p = .001), “social and environmental determinants of health” (Z = −2.81, p = .005), “globalization of health and health care” (Z = −2.93, p = .003), “health care in low-resource settings” (Z = −3.42, p = .001), and “health as a human right and development resource” (Z = −3.15, p = .002; Table 3).
In line with the growing need for GHCs in nursing students, the goal of this study was to evaluate the effectiveness of the GNI program, a short-term program in developing countries aimed at enhancing the GHCs of nursing students. According to the quantitative results, participants' overall GHC level was significantly increased while the qualitative results also showed an enhanced confidence in the knowledge of global health and culturally adaptive nursing practice. In particular, nursing students reported that the program was a valuable experience for learning about the aspects of GHCs, such as the global burden of disease; health implications of migration, travel and displacement; social and environmental determinants of health; globalization of health and health care; health care in low-resource settings; and health as a human right and development resource. These findings show an increased understanding of the health problems in a developing country as well as growing global cultural sensitivity in students. The GNI program played a significant role in enhancing the cultural competencies of nursing students as identified from the analysis of their self-reflective journals. Cultural competency building would have resulted from Vietnamese cultural education, global health collaboration, and global development cooperation, which resulted from the (a) oneweek advance education, (b) on-site primary health screening test for local residents, (c) South Korean-Vietnamese student health forum, and (d) students' cultural education. In Curtin et al.'s (2013) study, interaction with people from a different culture was found to positively affect participants' self-confidence. In another study of American students who participated in a one to three-week international service learning program, cultural competency in terms of cultural knowledge and skills significantly increased after the training program. Students learned that different cultures have different health care norms and that they have to be creative in finding solutions that take into consideration the patients' cultural beliefs while providing them with care (Kohlbry, 2016). In the current multicultural society, our findings have implications for clinical
Table 2 General characteristics of the participants. Variables Age (years) Gender School grade Overseas experience English proficiency
Categories
n (%)
Female Male 2nd 3rd Yes No Mid-high level
14 1 6 9 13 (87%) 2 (13%) 15 (100%)
M (SD)
Range
21.80 (3.65)
19–34
202 days
3.3. Program satisfaction To evaluate satisfaction with the program, we considered preliminary preparation, local activities, satisfaction with each activity, and goal achievement. The mean overall satisfaction score was 4.31 (SD = 0.17). The participants evaluated their goal achievement to be high (M = 4.50, SD = 0.33) while their satisfaction with the pre-departure program was low (M = 3.95, SD = 0.42). They were most satisfied with primary health care for children and school-based health education, whereas they felt that the South Korean-Vietnamese student health forum needed improvement. 3.4. Themes and students' quotes The self-reflective journals were analyzed based on the six categories of GHCs (Table 4). Students' soft skills, which were not included
Table 3 Changes in global health competencies pre- and post-global health program (N = 15). Variables
Total global health competencies Global burden of disease Health implications of migration, travel, and displacement Social and environmental determinants of health Globalization of health and health care Health care in low-resource settings Health as a human right and development resource
Pre-test
Post-test
M (SD)
M (SD)
2.79 2.82 2.89 3.39 2.43 2.66 2.56
3.49 3.44 3.51 3.88 3.14 3.55 3.38
(0.35) (0.60) (0.41) (0.48) (0.47) (0.54) (0.41)
4
(0.23) (0.35) (0.30) (0.18) (0.33) (0.36) (0.49)
Z
p
−3.41 −2.82 −3.18 −2.81 −2.93 −3.42 −3.15
.001 .005 .001 .005 .003 .001 .002
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Table 4 Themes and significant statements. Category
Themes
Significant statements
I. Global burden of disease
- Understanding global health
II. Health implications of migration, travel, and displacement
- Understanding health care considering cultural differences
III. Social and environmental determinants of health
- Impact of poor environment on access to health care services - Influence of communication factors on health care
IV. Globalization of health and health care
- Understanding health care systems in different countries - Vulnerable health care environment - Nursing interventions according to cultural characteristics - Understanding global health organization - Positive perspective expanded through activities - Empathy as a global citizen - Confidence in strengthening global health
V. Health care in low-resource settings VI. Health as a human right and development resource VII. Soft skills: positive perspective, empathy, and confidence
- “The Global Nursing Internship program was an opportunity to understand Vietnam's health care system and health problems, to carry out health education and health activities, and to gain an overall understanding of global development cooperation and global health.” - “…It made one think about how to perform nursing in the context of cultural differences.” - “…I felt that if the people we treat are from other cultures, we realize the degree and extent to which we need to become sensitive when providing nursing services.” - “Owing to the cultural differences, there was a lot of discussion among participants on the progress of the program, and I realized how much the process was helpful.” - “I understood the low level of medical access and poor medical conditions in rural areas through a discussion with grandmothers.” - “I regretted not knowing any Vietnamese and felt it would have been nice if I knew a little of the language before the program.” - “The most memorable thing is that when I screened for chronic diseases, I learned short Vietnamese sentences from the translator and used them to tell the residents to exercise well and avoid eating salty food.” - “…The process of visiting a medical institution and comparing it to the South Korean system and medical institutions was quite interesting.” - “Very vulnerable to infection problems …” - “I realized they really needed nursing interventions tailored to the community.” - “…It was an opportunity to understand the activities of global organizations related to global health and to increase global citizenship.” - “I thought I was going to serve, but I realized I learned more …” - “Communication with local residents from different cultural backgrounds provides opportunities for global citizenship and capacity building…” - “I feel good about myself for having served … I have confidence in myself and the system…”
This service learning program strengthened the GHCs of participating nursing students. In recent years, interprofessional education has become important in global health programs to improve the health status of the participants in a community (Jogerst et al., 2015). Interprofessional education has shown a significant effect on health outcomes in various institutions (Herath et al., 2017). Student-related improvements have included enhanced teamwork, communication skills, confidence, and professional identity (Granheim et al., 2018). Therefore, future studies must implement an interprofessional education component in global health service learning programs. This study had several strengths. First, it developed a theory-driven program specific to nursing students based on Riner's (2011) framework, which provides useful guidelines for developing global service learning programs right from goal setting to outcome evaluation. Second, using a mixed methods design that included a self-report survey and a reflection essay helped identify not only overall program satisfaction and GHCs but also the participants' experiences and the personal changes they observed. Finally, the study illustrates that this service learning program can help health professionals develop and acquire GHCs. However, the relatively small sample size and short duration of the program make it difficult to generalize these results. Since the short preparation time is a drawback, future research should consider the benefits of increasing the preparation time by linking this program to regular courses. In addition, teamwork between nurses and nursing educators could contribute to successful curriculum design and implementation.
practice both locally and globally as cultural competency is crucial for nurses. Thus, nursing educators should consider integrating similar global service learning programs into their existing nursing curricula. In addition, an enhanced sense of global citizenship was found to be the most positive feedback in the students' evaluation. An Australian study reported an increase in participants' global citizenship after a fourweek Cambodian international learning program. Nursing and midwifery students who participated in this program also reported that they were positively affected by the cultural diversity and challenges (Tuckett and Crompton, 2014). In this study, during the child health assessment and school-based activities, the nursing students were required to adapt to cultural differences through a high level of interaction with the local residents, which would help improve their global citizenship. The on-site activities provided students with numerous opportunities to develop soft skills, such as empathy with vulnerable populations, positive perspectives on different cultures, and confidence to interact with local residents whose lifestyles differed from their own. All these are essential attributes of global citizenship, and should, therefore, form the basis of the development of GHCs in nursing students. In this study, language proficiency and communication skills influenced active interaction with local interpreters, which helped improve cultural acceptance and global citizenship in the country. Nursing students recognized that communication barriers were a social determinant preventing effective delivery of health care services through the GNI program. A previous study reported a positive correlation between cultural competencies and foreign language skills in nursing students (Yang et al., 2013). In addition, after participating in service learning programs, interaction with a translator was found to be more effective (Curtin et al., 2015). This is consistent with Hwang et al.'s (2015) findings on the communication skills of South Korean nursing students who participated in a global health program. In the global health context, nurses' communication skills are an important factor in assessing community residents' health and providing the necessary care. Therefore, it is essential to teach students the language of the target community before the commencement of global service learning programs.
5. Conclusions This study explored the effect of the GNI program in promoting the GHCs of nursing college students. The GNI program, a short-term service learning program in a developing country consisting of pre-departure activities, on-site activities, and a post-program evaluation, is an exemplary training program for providing nursing students with a cultural emersion opportunity. The findings of this study demonstrate the effectiveness and value of global service learning programs for 5
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developing GHCs, which have been gaining greater attention in nursing education as a method to voice nurses' opinions and increase the nursing impact for achieving the SDGs.
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Declaration of competing interest None. Acknowledgements We express our appreciation to all study participant and Quang Tri community for their constant effort in this study. We are also grateful to all the members of Happy Quang Tri Project. Funding sources This research was supported by 2016 Global Nursing Internship Program in Yonsei University College of Nursing. Ethical approval Not applicable. References Abunab, H.Y., Dator, W.L.T., Laoingco, J.R.C., Reinhard, C., 2016. Global health competencies of nurse students in Philippines. i-Manager’s. J. Nurs. 6 (1), 35–42. https:// doi.org/10.26634/jnur.6.2.6044. Association of Faculties of Medicine of Canada (AFMC) Resource Group/Global Health Education Consortium (GHEC) Committee, 2010. Global health essential core competencies. Retrieved from. https://www.mcgill.ca/globalhealth/files/globalhealth/ 2009-10_ghp_annual_report.pdf. Battat, R., Jhonson, M., Wiseblatt, L., Renard, C., Habib, L., Normil, M., Remillard, B., Brewer, T.F., Sacajiu, G., 2016. The Haiti Medical Education Project: development and analysis of a competency based continuing medical education course in Haiti through distance learning. BMC Medical Education 16 (1), 275. https://doi.org/10. 1186/s12909-016-0795-x. Calhoun, J.G., Ramiah, K., Weist, E.M., Shortell, S.M., 2008. Development of a core competency model for the master of public health degree. Am. J. Public Health 98 (9), 1598–1607. https://doi.org/10.2105/AJPH.2007.117978. Curtin, A.J., Martins, D.C., Schwartz-Barcott, D., DiMaria, L., Ogando, B.M.S., 2013. Development and evaluation of an international service learning program for nursing students. Public Health Nurs. 30 (6), 548–556. https://doi.org/10.1111/phn.12040. Curtin, A.J., Martins, D.C., Schwartz-Barcott, D., 2015. A mixed methods evaluation of an international service learning program in the Dominican Republic. Public Health Nurs. 32 (1), 58–67. https://doi.org/10.1111/phn.12117. Cushman, L.F., Delva, M., Franks, C.L., Jimenez-Bautista, A., Moon-Howard, J., Glover, J., Begg, M.D., 2015. Cultural competency training for public health students: integrating self, social, and global awareness into a master of public health curriculum. Am. J. Public Health 105 (S1), S132–S140. https://doi.org/10.2105/AJPH.2014. 302506. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P.,
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Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam
T
Sangeun Leea,1, Junghee Kima,1, Jong gun Kima,b, Truong Duc Tuc, Bừi Thi Thanh Loanc, ⁎ Hyeonkyeong Leea, a
Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea Hoseo University, Department of Nursing, 20, 79th Street, Hoseo-ro, Baebang-eup, Asan, Chungnam 31499, Republic of Korea c Quang Tri Medical College, Block 3, East Luong Ward, Dong Ha City, Quang Tri Province, Vietnam b
ARTICLE INFO
ABSTRACT
Keywords: Global health Cultural diversity Education Public health
Background: Owing to globalization, there is a need for enhanced global health competencies among nursing students. In this context, global service learning programs are important opportunities for nursing students. Objectives: To explore the effect of a short-term service learning program in a developing country on the global health competencies of students attending a South Korean nursing college. Design: A mixed methods design. Setting: The Global Nursing Internship is a two-week pre-experience, eight-day on-site, and one-week post-experience program. Participants: The on-site activities involved 15 nursing students participating in global health activities in a rural Vietnamese community. Methods: A self-reported questionnaire was used to assess changes in global health competencies in six domains, measured on a four-point Likert scale. Student satisfaction with each activity was measured on a five-point Likert scale. After completing the program, the participants wrote a self-reflection essay. The Wilcoxon signed rank test was used to analyze global health competencies, and content analysis was used to analyze participants' selfreflections. Results: Regarding global health competencies, the overall mean score showed a significant increase at the postprogram evaluation (Z = −3.41, p = .001). A pre-post-program comparison showed that the domain of “health care in low-resource settings” displayed the greatest increase in scores. The mean overall satisfaction with the program was high (mean = 4.31, standard deviation = 0.17). In the students' view, as expressed in their essays, their global health knowledge and attitude had improved. Conclusions: The program was useful in promoting global health competencies, empathy, and confidence and should be embedded among the essential requirements of nursing curricula. Suggestions are provided to develop an enhanced pre-experience program that could help students prepare better for on-site activities. As cultural competency is crucial for nurses, nursing educators should consider integrating similar global service learning programs into their existing nursing curricula.
1. Introduction With the increasing pace of globalization in recent years, health professionals are faced with growing demands to achieve the global health objectives of the sustainable development goals (SDGs). As primary patient advocates, nurses are required to possess the essential competencies for advancing global health (Global Advisory Panel on the Future of Nursing and Midwifery, 2017). Global health has been
redefined as “a system-based, ecological, and transdisciplinary approach to research, education, and practice which seeks to provide innovative, integrated, and sustainable solutions to address complex health problems across national boundaries and improve health for all” (Wernli et al., 2016). This emphasizes the importance of multidisciplinary work, which includes nursing, to identify sustainable solutions for health equity. In addition, both the Lancet (Frenk et al., 2010) and World Health Organization's (2013) reports on health
Corresponding author. E-mail address: [email protected] (H. Lee). 1 Both authors contributed equally to this work. ⁎
https://doi.org/10.1016/j.nedt.2019.104300 Received 18 April 2019; Received in revised form 11 September 2019; Accepted 18 November 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
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professional education and training have highlighted the importance of competency-based education for implementing educational reforms. In particular, global health competencies (GHCs) have gained significance in nursing over the last decade. Wilson et al. (2012) proposed six areas of GHCs: global burden of disease; health implications of migration, travel, and displacement; social/environmental determinants of health; globalization of health/health care; health care in lowresource settings; and health as a human right and development resource. There is an increased emphasis on these GHCs in nursing curricular and co-curricular activities. In response to the complex global health environment changes of the 21st century, several GHC models have been proposed for students in different health professions, including medical students (Association of Faculties of Medicine of Canada Resource Group/Global Health Education Consortium Committee, 2010), public health students (Calhoun et al., 2008), and nursing students (Wilson et al., 2012). In addition to the competencies required by different types of health professionals, the educational committee of the Consortium of Universities for Global Health (CUGH) has identified 12 core GHCs (Wilson et al., 2014). In recognition of the increasing importance of GHCs in health professions, nursing educators have made attempts to incorporate various programs into nursing education. One such method to gain knowledge, skills, and experience in dealing with global health issues is the implementation of global service learning programs, which have been started in underdeveloped countries. Earlier studies on nursing students have shown evidence of the effects of international service learning programs (Curtin et al., 2015; Hwang et al., 2015; Abunab et al., 2016; Kohlbry, 2016). Most of these were short-term activities in underdeveloped countries including the Philippines, Dominican Republic, Ghana, and Mexico. Participants reported that they were able to play the role of professional student nurses; they also realized their own personal development and reported a widened global perspective after participating in the programs. In addition, the programs were effective in enhancing critical thinking, global leadership capacity, and global cultural capacity (Hwang et al., 2015; Kohlbry, 2016). The programs also improved empathy and the ability to communicate effectively with patients in different environments and helped students develop cultural competency, a sense of social justice, and knowledge of health care systems other than their own (Curtin et al., 2015). Although there have been several studies on nurses and other health care workers (Battat et al., 2016; Cushman et al., 2015; Walpole et al., 2016), studies on what might constitute appropriate education and training for the development of GHCs among nursing students are limited. Nursing students have participated in many global health activities; however, to date, their impact on GHCs has not been studied. Therefore, based on Riner's (2011) framework for globally engaged nursing education, this study aimed to describe the effects of a shortterm global service learning program (Global Nursing Internship [GNI]) focused on the GHCs proposed by Wilson et al. (2014) and to elucidate the lessons learned from the program. It also aimed to assist nurse educators in developing global service learning programs for nursing students.
prestigious nursing institutes around the world. The GNI program aims to provide nursing students with opportunities to become involved in nursing practice in global health, to practice servant leadership, as well as to improve global citizenship despite cultural differences. The GNI 2016 comprised 15 undergraduate students, four coordinators (one undergraduate student and three graduate students), and one faculty member who was responsible for overseeing the program. The participants visited Quang Tri Province in the North Central Coast region of Vietnam, where the program was conducted in collaboration with Quang Tri Medical College. The program involved a two-week preexperience (pre-departure training), seven days of on-site activities, and a one-week post-experience phase. The pre-experience workshops covered topics such as global development cooperation, global health and nursing, gender equality, Vietnam's health and social environment, and safety and preparedness for international health emergencies. This training was focused on providing information about the on-site activities, which included an overview of Vietnamese health issues and interventions, the Vietnamese health care system and nursing education, and health-related cultural issues. After this pre-departure experience, supervised by team coordinators, a week-long group activity was conducted to prepare educational materials and supplies for nursing interventions in Vietnam. During the on-site activities, in the mornings, students administered health center-based interventions such as chronic disease screening, health education, health assessment, and home visits to local residents. In the afternoons, they administered school health interventions on various topics such as cardiopulmonary resuscitation, secondhand smoking prevention, and peer communication to middle school students through a summer camp. On the last day of the on-site activities, the student participants organized a cultural exchange performance, health fair, charity bazaar, and South Korean-Vietnamese student forum in collaboration with Vietnamese students and community residents. Toward the end of every day, the students spent an hour reflecting on what they had gained from the daily activity and gave each other feedback. After returning from the on-site activities, students were directed to discuss the program outcomes, reflect on their activities, and present their experiences to their peers (Table 1). The program was based on a revised version of Riner's (2011) framework for globally engaged nursing education (Fig. 1). The framework comprises six components: goals, core content, program characteristics, learner characteristics, reflection, and perspective transformation. In this study, perspective transformation entailed improving the students' GHCs through the GNI program. 2.3. Measures The CUGH has developed a GHC tool (Wilson et al., 2014), the Korean version of which was used in this study (Lee et al., 2015). The tool consists of 30 items in six areas: (1) global burden of disease, (2) health implications of migration, travel, and displacement, (3) social and environmental determinants of health, (4) globalization of health and health care, (5) health care in low-resource settings, and (6) health as a human right and development resource. Each item was rated on a four-point Likert scale ranging from 1 = “I strongly disagree” to 4 = “I strongly agree.” We assessed GHCs both at the beginning and completion of the program. The participants' satisfaction with the GNI program was also assessed on a five-point Likert scale ranging from 1 = “very dissatisfied” to 5 = “very satisfied.” In addition, each student wrote a self-reflection essay regarding their experiences, learning, and impressions about the program.
2. Methods 2.1. Study design This study adopted a mixed methods design to define the changes in nursing students' GHCs after participation in the global health program.
2.4. Data analysis
2.2. Description of the GNI program
All the quantitative data were analyzed using SPSS version 21.0 (IBM, USA). Descriptive statistics, including averages and standard deviations, were calculated. The Wilcoxon signed rank test was performed to define the differences in GHCs before and after the program. The level of statistical significance was set at p < .05.
The GNI program was designed to develop the GHCs of nursing students who voluntarily applied and were selected by a student committee in 2016. A college of nursing located in Seoul, Korea has been conducting the GNI program since 2012, following the changes in the curricula of 2
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Table 1 On-site activities of the GNI program. Day
Hours
D-1
4
· Local hospital visits
4
· Expert leadership seminar
4
· Home visits · Community health education
3
· School health
1
· Daily evaluation
4
· Disease management
3 1
· School health · Daily evaluation
4
· Children’s health screening
3 1
· School health · Daily evaluation
4
· Community activities
3 1
· School health · Daily evaluation
4
· Cultural and health fairs
2
· Student forum with local students
1 8
D-2
D-3
D-4
D-5
D-6
D-7
Activity
Contents/Intervention · Observation of the local hospitals and understanding the primary health care system in Quang Tri Province, Vietnam · Comparison with South Korean health care system · Seminar with global health experts · · · · · ·
Home visits to 15 vulnerable households: family health assessment and health education Health screenings (BP, BST, urine test) Individual health education for secondhand smoking prevention and chronic disease management Organizing a summer camp (4 days, 3 hours/day) Health education for physical, mental, and social health Self-reflection on daily activities and feedback
· Chronic disease screening for 102 local residents · Health screenings (BP, BST, urine test) · Group health education for 265 local residents (secondhand smoking prevention and chronic disease management such as HTN and DM) · CPR, secondhand smoking prevention skills, hand washing · Self-reflection on daily activities and feedback · · · ·
Health screening for local kindergarteners (Vision, height, weight, anemia test) Sharing the results with the teachers and parents CPR, dental hygiene, food and nutrition, reproductive health education, and peer communication Self-reflection on daily activities and feedback
· · · · ·
Environment improvement activity with local youth union members and students Cleaning up and wall painting in local kindergarten Provision of trash bins with health messages for agricultural waste CPR, reproductive health education, and peer communication Self-reflection on daily activities and feedback
· Daily evaluation
· · · · · · ·
South Korean-Vietnamese student cultural exchange Student health exhibition Charity bazaar for fundraising Health fair with 1,000 local people Comparison of nursing education between South Korea and Vietnam Case competition on community health projects in Vietnam with limited budget Self-reflection on daily activities and feedback
· Site visit
· Cultural experiences in Vietnamese museum, traditional market, palace, etc.
Notes. BP: blood pressure, BST: blood sugar test, HTN: hypertension, DM: diabetes mellitus; CPR: cardiopulmonary resuscitation.
By analyzing the self-report records using directive content analysis, we could confirm the validity of existing theories. Then, by analyzing the content using existing theories or previous research findings, we could propose conceptual expansion (Hsieh and Shannon, 2005). The content was analyzed based on the six categories of GHCs for nurses, as classified by Wilson et al. (2012). Two authors, who were nursing doctoral students with qualitative research training and global health experience, reviewed the participants' self-reflection essays. They read each report carefully, highlighting all meaningful text. All highlighted text was coded based on the six competency categories. Text that could not be coded into any of these categories was categorized separately
under the heading of “soft skills.” The doctoral students then discussed whether the categories and content were appropriate and reviewed the content with the principal investigator, who has expertise in global health research and education. 3. Results 3.1. Demographic characteristics of the participants The demographic characteristics of the participants are reported in Table 2. The average age was 21.80 years (standard deviation
Fig. 1. Global Nursing Internship conceptual framework. 3
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(SD) = 3.65, range 19–34). Among the one male and 14 female students, nine were juniors and six were at the sophomore level. In total, 87% of the students (n = 13) had international experience, with an average length of stay of 202 days. All the participants reported their English proficiency to be above the mid-high level.
in the six competencies, formed a different category. The themes extracted from the analysis included (1) “understanding global health” from the “global burden of disease” domain, (2) “understanding health care considering cultural differences” from the “health implications of migration, travel, and displacement” domain, (3) “impact of poor environment on access to health care services” and “influence of communication factors on health care” from the “social and environmental determinants of health” domain, (4) “understanding health care systems in different countries” from the “globalization of health and health care” domain, (5) “vulnerable health care environment” and “nursing interventions according to cultural characteristics” from the “health care in low-resource settings” domain, and (6) “understanding global health organization” from the “health as a human right and development resource” domain. In the domain of soft skills, positive perspective, empathy, and confidence were identified from the themes “positive perspective expanded through activities,” “empathy as a global citizen,” and “confidence in strengthening global health.”
3.2. GHC level and subsequent changes
4. Discussion
The participants' pre-test mean of the GHCs was 2.79 (SD = 0.35); this significantly changed to 3.49 (SD = 0.23) in the post-test (Z = −3.41, p = .001). Participants scored the lowest in the “globalization of health and health care” domain (pre-test, mean (M) = 2.43, SD = 0.47; post-test, M = 3.14, SD = 0.33) and highest in the “social and environmental determinants of health” domain (pre-test, M = 3.39, SD = 0.48; post-test, M = 3.88, SD = 0.18). The pre-post program changes in all six GHC domains were significant: “global burden of disease” (Z = −2.82, p = .005), “health implications of migration, travel and displacement” (Z = −3.18, p = .001), “social and environmental determinants of health” (Z = −2.81, p = .005), “globalization of health and health care” (Z = −2.93, p = .003), “health care in low-resource settings” (Z = −3.42, p = .001), and “health as a human right and development resource” (Z = −3.15, p = .002; Table 3).
In line with the growing need for GHCs in nursing students, the goal of this study was to evaluate the effectiveness of the GNI program, a short-term program in developing countries aimed at enhancing the GHCs of nursing students. According to the quantitative results, participants' overall GHC level was significantly increased while the qualitative results also showed an enhanced confidence in the knowledge of global health and culturally adaptive nursing practice. In particular, nursing students reported that the program was a valuable experience for learning about the aspects of GHCs, such as the global burden of disease; health implications of migration, travel and displacement; social and environmental determinants of health; globalization of health and health care; health care in low-resource settings; and health as a human right and development resource. These findings show an increased understanding of the health problems in a developing country as well as growing global cultural sensitivity in students. The GNI program played a significant role in enhancing the cultural competencies of nursing students as identified from the analysis of their self-reflective journals. Cultural competency building would have resulted from Vietnamese cultural education, global health collaboration, and global development cooperation, which resulted from the (a) oneweek advance education, (b) on-site primary health screening test for local residents, (c) South Korean-Vietnamese student health forum, and (d) students' cultural education. In Curtin et al.'s (2013) study, interaction with people from a different culture was found to positively affect participants' self-confidence. In another study of American students who participated in a one to three-week international service learning program, cultural competency in terms of cultural knowledge and skills significantly increased after the training program. Students learned that different cultures have different health care norms and that they have to be creative in finding solutions that take into consideration the patients' cultural beliefs while providing them with care (Kohlbry, 2016). In the current multicultural society, our findings have implications for clinical
Table 2 General characteristics of the participants. Variables Age (years) Gender School grade Overseas experience English proficiency
Categories
n (%)
Female Male 2nd 3rd Yes No Mid-high level
14 1 6 9 13 (87%) 2 (13%) 15 (100%)
M (SD)
Range
21.80 (3.65)
19–34
202 days
3.3. Program satisfaction To evaluate satisfaction with the program, we considered preliminary preparation, local activities, satisfaction with each activity, and goal achievement. The mean overall satisfaction score was 4.31 (SD = 0.17). The participants evaluated their goal achievement to be high (M = 4.50, SD = 0.33) while their satisfaction with the pre-departure program was low (M = 3.95, SD = 0.42). They were most satisfied with primary health care for children and school-based health education, whereas they felt that the South Korean-Vietnamese student health forum needed improvement. 3.4. Themes and students' quotes The self-reflective journals were analyzed based on the six categories of GHCs (Table 4). Students' soft skills, which were not included
Table 3 Changes in global health competencies pre- and post-global health program (N = 15). Variables
Total global health competencies Global burden of disease Health implications of migration, travel, and displacement Social and environmental determinants of health Globalization of health and health care Health care in low-resource settings Health as a human right and development resource
Pre-test
Post-test
M (SD)
M (SD)
2.79 2.82 2.89 3.39 2.43 2.66 2.56
3.49 3.44 3.51 3.88 3.14 3.55 3.38
(0.35) (0.60) (0.41) (0.48) (0.47) (0.54) (0.41)
4
(0.23) (0.35) (0.30) (0.18) (0.33) (0.36) (0.49)
Z
p
−3.41 −2.82 −3.18 −2.81 −2.93 −3.42 −3.15
.001 .005 .001 .005 .003 .001 .002
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Table 4 Themes and significant statements. Category
Themes
Significant statements
I. Global burden of disease
- Understanding global health
II. Health implications of migration, travel, and displacement
- Understanding health care considering cultural differences
III. Social and environmental determinants of health
- Impact of poor environment on access to health care services - Influence of communication factors on health care
IV. Globalization of health and health care
- Understanding health care systems in different countries - Vulnerable health care environment - Nursing interventions according to cultural characteristics - Understanding global health organization - Positive perspective expanded through activities - Empathy as a global citizen - Confidence in strengthening global health
V. Health care in low-resource settings VI. Health as a human right and development resource VII. Soft skills: positive perspective, empathy, and confidence
- “The Global Nursing Internship program was an opportunity to understand Vietnam's health care system and health problems, to carry out health education and health activities, and to gain an overall understanding of global development cooperation and global health.” - “…It made one think about how to perform nursing in the context of cultural differences.” - “…I felt that if the people we treat are from other cultures, we realize the degree and extent to which we need to become sensitive when providing nursing services.” - “Owing to the cultural differences, there was a lot of discussion among participants on the progress of the program, and I realized how much the process was helpful.” - “I understood the low level of medical access and poor medical conditions in rural areas through a discussion with grandmothers.” - “I regretted not knowing any Vietnamese and felt it would have been nice if I knew a little of the language before the program.” - “The most memorable thing is that when I screened for chronic diseases, I learned short Vietnamese sentences from the translator and used them to tell the residents to exercise well and avoid eating salty food.” - “…The process of visiting a medical institution and comparing it to the South Korean system and medical institutions was quite interesting.” - “Very vulnerable to infection problems …” - “I realized they really needed nursing interventions tailored to the community.” - “…It was an opportunity to understand the activities of global organizations related to global health and to increase global citizenship.” - “I thought I was going to serve, but I realized I learned more …” - “Communication with local residents from different cultural backgrounds provides opportunities for global citizenship and capacity building…” - “I feel good about myself for having served … I have confidence in myself and the system…”
This service learning program strengthened the GHCs of participating nursing students. In recent years, interprofessional education has become important in global health programs to improve the health status of the participants in a community (Jogerst et al., 2015). Interprofessional education has shown a significant effect on health outcomes in various institutions (Herath et al., 2017). Student-related improvements have included enhanced teamwork, communication skills, confidence, and professional identity (Granheim et al., 2018). Therefore, future studies must implement an interprofessional education component in global health service learning programs. This study had several strengths. First, it developed a theory-driven program specific to nursing students based on Riner's (2011) framework, which provides useful guidelines for developing global service learning programs right from goal setting to outcome evaluation. Second, using a mixed methods design that included a self-report survey and a reflection essay helped identify not only overall program satisfaction and GHCs but also the participants' experiences and the personal changes they observed. Finally, the study illustrates that this service learning program can help health professionals develop and acquire GHCs. However, the relatively small sample size and short duration of the program make it difficult to generalize these results. Since the short preparation time is a drawback, future research should consider the benefits of increasing the preparation time by linking this program to regular courses. In addition, teamwork between nurses and nursing educators could contribute to successful curriculum design and implementation.
practice both locally and globally as cultural competency is crucial for nurses. Thus, nursing educators should consider integrating similar global service learning programs into their existing nursing curricula. In addition, an enhanced sense of global citizenship was found to be the most positive feedback in the students' evaluation. An Australian study reported an increase in participants' global citizenship after a fourweek Cambodian international learning program. Nursing and midwifery students who participated in this program also reported that they were positively affected by the cultural diversity and challenges (Tuckett and Crompton, 2014). In this study, during the child health assessment and school-based activities, the nursing students were required to adapt to cultural differences through a high level of interaction with the local residents, which would help improve their global citizenship. The on-site activities provided students with numerous opportunities to develop soft skills, such as empathy with vulnerable populations, positive perspectives on different cultures, and confidence to interact with local residents whose lifestyles differed from their own. All these are essential attributes of global citizenship, and should, therefore, form the basis of the development of GHCs in nursing students. In this study, language proficiency and communication skills influenced active interaction with local interpreters, which helped improve cultural acceptance and global citizenship in the country. Nursing students recognized that communication barriers were a social determinant preventing effective delivery of health care services through the GNI program. A previous study reported a positive correlation between cultural competencies and foreign language skills in nursing students (Yang et al., 2013). In addition, after participating in service learning programs, interaction with a translator was found to be more effective (Curtin et al., 2015). This is consistent with Hwang et al.'s (2015) findings on the communication skills of South Korean nursing students who participated in a global health program. In the global health context, nurses' communication skills are an important factor in assessing community residents' health and providing the necessary care. Therefore, it is essential to teach students the language of the target community before the commencement of global service learning programs.
5. Conclusions This study explored the effect of the GNI program in promoting the GHCs of nursing college students. The GNI program, a short-term service learning program in a developing country consisting of pre-departure activities, on-site activities, and a post-program evaluation, is an exemplary training program for providing nursing students with a cultural emersion opportunity. The findings of this study demonstrate the effectiveness and value of global service learning programs for 5
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developing GHCs, which have been gaining greater attention in nursing education as a method to voice nurses' opinions and increase the nursing impact for achieving the SDGs.
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Declaration of competing interest None. Acknowledgements We express our appreciation to all study participant and Quang Tri community for their constant effort in this study. We are also grateful to all the members of Happy Quang Tri Project. Funding sources This research was supported by 2016 Global Nursing Internship Program in Yonsei University College of Nursing. Ethical approval Not applicable. References Abunab, H.Y., Dator, W.L.T., Laoingco, J.R.C., Reinhard, C., 2016. Global health competencies of nurse students in Philippines. i-Manager’s. J. Nurs. 6 (1), 35–42. https:// doi.org/10.26634/jnur.6.2.6044. Association of Faculties of Medicine of Canada (AFMC) Resource Group/Global Health Education Consortium (GHEC) Committee, 2010. Global health essential core competencies. Retrieved from. https://www.mcgill.ca/globalhealth/files/globalhealth/ 2009-10_ghp_annual_report.pdf. Battat, R., Jhonson, M., Wiseblatt, L., Renard, C., Habib, L., Normil, M., Remillard, B., Brewer, T.F., Sacajiu, G., 2016. The Haiti Medical Education Project: development and analysis of a competency based continuing medical education course in Haiti through distance learning. BMC Medical Education 16 (1), 275. https://doi.org/10. 1186/s12909-016-0795-x. Calhoun, J.G., Ramiah, K., Weist, E.M., Shortell, S.M., 2008. Development of a core competency model for the master of public health degree. Am. J. Public Health 98 (9), 1598–1607. https://doi.org/10.2105/AJPH.2007.117978. Curtin, A.J., Martins, D.C., Schwartz-Barcott, D., DiMaria, L., Ogando, B.M.S., 2013. Development and evaluation of an international service learning program for nursing students. Public Health Nurs. 30 (6), 548–556. https://doi.org/10.1111/phn.12040. Curtin, A.J., Martins, D.C., Schwartz-Barcott, D., 2015. A mixed methods evaluation of an international service learning program in the Dominican Republic. Public Health Nurs. 32 (1), 58–67. https://doi.org/10.1111/phn.12117. Cushman, L.F., Delva, M., Franks, C.L., Jimenez-Bautista, A., Moon-Howard, J., Glover, J., Begg, M.D., 2015. Cultural competency training for public health students: integrating self, social, and global awareness into a master of public health curriculum. Am. J. Public Health 105 (S1), S132–S140. https://doi.org/10.2105/AJPH.2014. 302506. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P.,
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