|ORIGINAL RESEARCH PAPER
|Year : 2011 | Volume
| Issue : 1 | Page : 259
An International, Multidisciplinary, Service-Learning Program: An Option in the Dental School Curriculum
EA Martinez-Mier, AE Soto-Rojas, SM Stelzner, DE Lorant, ME Riner, KM Yoder
Indiana University, Indianapolis. IN, USA
|Date of Submission||12-Sep-2008|
|Date of Acceptance||04-Nov-2010|
|Date of Web Publication||29-Apr-2011|
E A Martinez-Mier
415 Lansing St., Indianapolis, IN 46202
Source of Support: None, Conflict of Interest: None
Introduction: Many health professions students who treat Spanish-speaking patients in the United States have little concept of their culture and health related traditions. The lack of understanding of these concepts may constitute major barriers to healthcare for these patients. International service-learning experiences allow students to work directly in communities from which patients immigrate and, as a result, students gain a better understanding of these barriers.
Objective: This article describes the implementation of an international, multidisciplinary, service-learning program in a dental school in the United States.
Program Description: The Indiana University International Service-Learning program in Hidalgo, Mexico began in 1999 as an alternative spring break travel and clinical experience for medical students, focusing on the treatment of acute health
problems. Travel-related preparatory sessions were offered, and no learning or service objectives had been developed. The program has evolved to include a multidisciplinary team of dental, medical, nursing, public health and social work students and faculty. The experience is now integrated into a curriculum based on the service-learning model that allows students to use their clinical skills in real-life situations and provides structured time for reflection. The program aims to enhance teaching and foster civic responsibility in explicit partnership with the community. Preparatory sessions have evolved into a multidisciplinary graduate level course with defined learning and service objectives.
Program Evaluation Methods: In order to assess the program's operation as perceived by students and faculty and to evaluate student's perceptions of learning outcomes, evaluation tools were developed. These tools included student and faculty evaluation questionnaires, experiential learning journals, and a strengths, weaknesses, opportunities and threats analysis.
Findings: Evaluation data show that after program participation, students perceived an increase in their cultural awareness, crosscultural communication skills and understanding of barriers and disparities faced by Latinos in the United States. Faculty evaluations offer insights into the lessons learned through the implementation process.
Conclusion: The development of a service-learning based curriculum has posed challenges but has enriched international service experiences.
Keywords: Dental education, educational models, international education exchange, service-learning
|How to cite this article:|
Martinez-Mier E A, Soto-Rojas A E, Stelzner S M, Lorant D E, Riner M E, Yoder K M. An International, Multidisciplinary, Service-Learning Program: An Option in the Dental School Curriculum. Educ Health 2011;24:259
|How to cite this URL:|
Martinez-Mier E A, Soto-Rojas A E, Stelzner S M, Lorant D E, Riner M E, Yoder K M. An International, Multidisciplinary, Service-Learning Program: An Option in the Dental School Curriculum. Educ Health [serial online] 2011 [cited 2020 Apr 5];24:259. Available from: http://www.educationforhealth.net/text.asp?2011/24/1/259/101466
Cultural competence for the health professions represents a core set of skills learned in order to respectfully and effectively treat and communicate healthcare information with diverse patient populations1,2. Culturally competent providers communicate with an awareness of disparities in health outcomes and barriers to access to care faced by certain populations, with an understanding that socio-cultural factors have important effects on health beliefs and behaviors, and they have the skills to manage these factors appropriately.
Most education programs addressing cultural competence in the United States (US) are based on traditional models of cross-cultural education that were designed primarily to decrease barriers to provision of effective healthcare for immigrants, refugees, and others on the socio-cultural margin. Previous efforts have aimed to teach about the attitudes, values, beliefs, and behavior of certain groups, most of them using traditional pedagogical methods that result in memorization of concepts3.
A more effective approach would be to expose students to these concepts through experiential learning and familiarize them with the use of practical clinical models. These models may help them understand how social, cultural or economic factors influence patients’ and clinicians’ health values, beliefs and behaviors. They emphasize curiosity, empathy and respect, as well as an understanding of the patient's social context. The framework for cultural effectiveness created by this approach should also help students realize that developing patient-provider trust and communicating efficiently with patients leads to improved health outcomes, and must be carefully planned and role modeled by experienced faculty in order for the lessons learned to be incorporated into students’ behavior4.
Health professional training programs should provide a variety of experiences in order to improve training of healthcare providers to serve American communities that have seen a dramatic increase in diversity, including growth in the mobile populations that migrate to and from the US. The service-learning model is especially suited to improve patient–provider communication and increase cultural awareness. As a teaching-learning pedagogy, it includes structured orientation, community service, student self-assessment, promotion of the ethics of service, and student reflection. It encourages self-directed learning and further understanding of educational content, a broader understanding of the discipline, enhanced sense of personal values and civic responsibility5.
As an active learning strategy, service-learning contributes to the development of competencies in a variety of domains. Studies have shown participation in service-learning to increase commitment to social responsibility6,7, to facilitate cross-cultural understanding, to reduce stereotypes and to increase the ability to solve complex problems in real settings1,8. Additionally, service-learning participants have been reported to develop leadership and communication skills as they work with others to address community needs9. They have developed the skills and attitudes that enable them to become civic-minded professionals who regard their skills and expertise as a public good rather than a private gain10,11.
International service-learning (ISL) experiences have also been linked to enhanced cross-cultural communication skills12. These experiences allow students from countries with large numbers of immigrant populations to work in communities in the countries of origin of their patients. As a result, these experiences facilitate the development of a greater appreciation of cultural differences, folk medicine traditions, and societal forces behind immigration, all important in providing quality healthcare13,14.
This case study aims to describe the implementation of an international, multidisciplinary service-learning program in a US dental school that provides services responsive to a community’s needs in rural Mexico. It also describes the program’s approach to integrating research opportunities for faculty and students.
This ISL program at Indiana University (IU) began in 1998 as an alternative spring break experience for medical students. In 1999, the IU dental and nursing schools joined the effort. Initially, the program focused solely on providing services including the treatment of acute health problems, and it was not conducted in coordination with local healthcare providers. Simple travel-related preparatory sessions were offered, and no learning or service objectives had been developed.
In order to continue expanding and providing an increasingly valuable academic experience to students, six years into the program, in 2005, deep structural changes were required in the IU ISL program. A need to include the ISL experiences under the umbrella of a single academic course was identified. Consequently, a set of learning and service objectives was developed. These objectives integrated the experience into the broader medical, nursing and dental school curricula and enhanced students’ progress towards achieving competencies IU has developed, based on the American Medical, Nursing and Dental Associations’ standards. The IU Schools of Medicine, Nursing and Dentistry utilize competency assessments to evaluate their students in their academic coursework and patient care. Competencies for School of Dentistry students are defined as the knowledge and skills that students must possess to provide oral healthcare at a professionally acceptable level as newly graduated general dentists. A series of universal preparatory sessions was designed to accomplish those objectives, with student reflection activities included within all experiences and incorporated into all assessment tools.
Currently, students register for a semester-long class and, as part of this class, they live and work for ten days in Calnali, a small rural municipality located in the State of Hidalgo, Mexico. This class is offered under different formats to meet individual school needs. It is a rotation for medical students, an independent study for nursing students and a clinical elective for dental students. The program has evolved to include a multidisciplinary team composed of IU dental, medical, nursing, public health and social work students along with faculty advisors. It also includes students and faculty from the state university in Hidalgo, the Universidad Autonoma del Estado de Hidalgo (UAEH). Participation by non-academic units at IU, such as the Center for Service and Learning (CSL) and the Office of International Affairs, has enhanced the components of cultural orientation, service-learning and international education.
Two hundred thirty-four students and faculty have participated in the program since 1998. Twenty-five percent of them have participated more than once and have become student leaders who receive a stipend supported by the CSL as service-learning assistants. Students and faculty have participated from the IU dental, nursing, medical, public health, optometry, and social work schools. Most participating students are able to speak some level of Spanish, although being fluent is not required. From UAEH, sixty-five medical and dental students and faculty have participated.
The experience is integrated into a curriculum based on the service-learning model to use academic skills in real-life situations and structured reflection time to enhance teaching and foster civic responsibility. Preparatory sessions for the service-learning experience have evolved into a multidisciplinary graduate level course, which was developed with support from a two-year Clarian Values Fund Education grant from IU Health and the CSL faculty fellowship program. Dental, medical and nursing students attend these sessions together. The course requires students to attend six two-hour long sessions which address the following topics: (1) orientation to service-learning, international partnerships, and becoming active in one’s local community, (2) politico-historical perspectives on Mexican immigration, (3) cultural competency and use of practical clinical models, (4) traditional health beliefs and practices, (5) changing focus from individual patients to communities of patients (e.g., adaptation of triage and treatment planning), and (6) common health problems in Calnali and how these compare to those of immigrants to Indianapolis, as well as health disparities for the US Latino population more generally and efforts to eliminate them. In addition to these six sessions, students are guided to complete self-reflection exercises.
Some of these sessions are jointly taught by multidisciplinary faculty from both IU and UAEH utilizing videoconferencing technology. A detailed description of the development of these videoconferences has been published elsewhere15. Further, a second series of educational sessions has been designed to help students develop health education presentations for patients. These sessions are conducted in small, discipline-based student groups. Principles of participatory decision-making are used to assess, plan, provide and evaluate students’ health education programs with their patients. Students’ health promotion education activities are presented in Spanish and targeted to kindergarten, elementary, junior high, and high school students and to local health professionals.
The ISL program has both learning and service objectives. Learning objectives are for the students to be able to: (1) explain cultural competence and examine biases and pre-conceptions to avoid cultural generalizations while caring for patients from diverse backgrounds, (2) discuss the meaning of oral health and illness for patients from different cultures, (3) cite the disparities in healthcare access and health outcomes faced by underserved populations, (4) compare and contrast underserved Latino cultural and dental health practices to those of the majority of the Indiana population, (5) adapt triage and treatment planning skills to meet community needs and clinical setting, (6) integrate this experience to form a global view of dental health and increase readiness to take an active role in their local community, and (7) demonstrate an ability to communicate with dental patients from Latino culture and language groups.
Service objectives include: (1) providing dental services and oral health education to underserved populations in Latin America in response to their needs, (2) partnering with on-site community organizations to incorporate their assets into both the service and learning aspects of the program, and (3) participating in a collaborative, interdisciplinary format for training, providing clinical services and conferencing among the health professions.
Reflection sessions take place every evening after clinics, when students, faculty and local providers share their impressions of the day, make plans, get prepared for the following day and offer suggestions on how to improve services. Suggestions generated in these meetings range from ways to improve the logistics of the education talks and clinics for patients the following day to long-term projects for the program.
Recognizing the importance of partnerships in the service-learning model, the program uses a campus-community partnership approach in collaboration with UAEH16. Since 1993, the partnership with the community’s healthcare workers has grown into formal contacts with public health officials and a formal written agreement with the local authorities in Calnali and UAEH. The partnership includes IU health professions students and faculty, the community of Calnali, Friends of Hidalgo (a small Indiana-based non-profit organization that supports multiple capacity-building efforts in Calnali), UAEH, and public health officials in Hidalgo.
The partners have agreed to meet the following services and activities to benefit the community: (1) provide quality health education to the community with the help of Calnali healthcare students and providers, concentrating on public health issues affecting the pediatric and adult populations in the town and surrounding villages, (2) provide clinical experience to the local healthcare students through direct medical and dental care to the population of Calnali and surrounding villages, (3) empower local community groups and students to continue education regarding health promotion and disease prevention, (4) partner with providers and organizations to better provide culturally and linguistically effective education and services to the residents of Calnali and exchange opportunities both in Indianapolis and Mexico, (5) identify funds for health providers from Calnali to provide sustainable healthcare for acute problems, manage chronic problems, provide treatment plans that are affordable, and (6) locate sources of support for ongoing health education and disease prevention projects.
In order to assure culturally-appropriate care, build the healthcare capacity of the local community and improve the health of children in Calnali, health professionals from Calnali and UAEH students and faculty work side by side with IU faculty and students to provide the health education presentations and preventive services. Since 2001, the week has been divided equally between provision of pediatric clinical services and the health education presentations and workshops taught by the students and faculty. After the partnership with the local health providers, the Municipality of Calnali and UAEH was solidified, the team conducted both needs and asset-based community assessments. Local healthcare providers and Calnali residents participated in focus groups that assessed needs and assets in their community. In addition, key informant interviews were conducted. These assessments have guided the transition from those initial direct health services to the development of health infrastructure in collaboration with the local providers17.
Communication with community members and organizations has helped identify areas where community needs match university capabilities for research. Following the model of community-based participatory research, students and faculty have conducted projects to assess oral health needs and risk factors. In addition, IU and UAEH faculty have engaged in the scholarship of service-learning and civic engagement, through publications and multiple presentations15,17. Two pediatric dentistry residents have conducted research projects in order to fulfill their requirements for a degree in Masters in Dental Science.
The project follows recommendations of the Pan American Health Organization18 in developing treatment plans and providing services. Institutional review board (IRB) clearance has been obtained to report services provided and learning outcomes. Patients seen in the clinics sign an IRB-approved informed consent. Cross-infection guidelines are followed in the clinics19. Dental services are provided with the use of portable dental, sealant, and light curing units and steam sterilizers.
In order to assess various aspects of the program’s operations as perceived by students and faculty and the students’ perception of learning outcomes, evaluation tools were developed. These tools included a student evaluation questionnaire, experiential learning journals, a faculty evaluation questionnaire, and a strengths, weaknesses, opportunities and threats (SWOT) analysis.
Five-point Likert-scale statements in the student evaluation questionnaire inquire about their perceptions of meeting learning outcomes, as well as about the planning and logistics of the trip. An open-ended field after each section is included to allow students to note comments.
Initially, only students who received support in the form of a service-learning assistantship stipend from the CSL (two to four students per year) were required to keep experiential learning journals and present a report on their experiences to the student body and local organizations. Since 2007, all students have been required to keep journals. Instructions given to students about these journals ask them to record questions that arise from interactions with patients or people in Calnali, their reflections on the experience, and how well it is meeting their needs. They are asked to record how their learning in this course relates to what they are learning in other learning venues, their feelings about the experience and their progress towards meeting IU competencies.
Faculty evaluations have been conducted yearly. In 2007, a faculty retreat was organized to redefine and reassess the program’s objectives and future direction. Participating faculty were asked to answer a pre-retreat questionnaire that included a description of the strengths and weaknesses of the program, as identified by the students. Faculty members defined their own personal and professional short- and long-term goals, as well as those of their departments. Armed with this information, faculty performed a SWOT analysis. A description of the retreat’s outcomes as well as a task list was then developed and circulated.
Quantitative data from the five-point Likert-scale (1 = strongly disagree to 5 = strongly agree) were tabulated. Content analysis of open ended questions was performed. Responses to questions inquiring about student’s perceptions of learning outcomes were categorized in two domains constructed after conducting an extensive review of cultural competency models and assessment tools and the open-ended questions content analysis3. These two domains were: (1) impact of values and belief systems on healthcare access and utilization, and (2) cross-cultural communication. Reponses are presented both as mean scores and as percentages of students who selected agree or strongly agree.
Results of evaluations from 67 of the 72 dental students from IU (93%) who participated in the program from 2002 to 2009 are presented in this article. They were second, third and fourth year dental and dental hygiene students; 37 were male and 30 were female. The age range was 24-32, with a median age of 25. Fourteen faculty members participated in the program since 2002 and completed annual evaluations. Eight faculty members participated more than once and completed evaluations multiple times. Therefore, results from thirty-five individual evaluations are reported.
Table 1: Student’s evaluation of learning domains, didactic sessions and trip logistics
Learning Objectives and Domains
Impact of Values and Belief Systems on Healthcare Access and Utilization Domain
The majority of students agreed or strongly agreed that as a result of their involvement in the program, they had a better understanding of Latino culture, the issues that Latino immigrants face when they seek medical assistance, and the forces that influence their decision to immigrate to the United States (Table 1). Students also generally reported that through participation they felt better prepared to take an active role in their local community.
Representative excerpts from students’ open-ended comments about the experience in general read as follows: '…I believe a major intent of this program is to provide students (and faculty) with an experience that brings to life the reality from which many of our Latino patients come..;' and 'After traveling in the back of pick-up trucks to small villages in the mountains of Mexico, hours away from the nearest health clinic or hospital, I have a much better understanding of the background of the people, their struggles as well as their impressive need….' Also, '…it was interesting to see the amount/type of care the town’s people have access to and expect. …to see the different values and types of procedures by the locals, often indicating (differences in) education about health issues that Americans would consider basic.' And finally, 'this trip has given me a better understanding of how these people live and where they come from. Their diet, social life, and all around personality is different from what I always imagined.'
Cross-Cultural Communication Domain
Fifty-four percent of our students reported that the rotation was an excellent opportunity to practice their communication and language skills. Most students agreed or strongly agreed that the experience provided them an opportunity to address the cross-cultural communication needs of individuals. Excerpts from selected student evaluations read as follows: 'The trip is crucial in preparing me to work with Hispanic patients in the U.S. The ability to strengthen language skills is a great feature of the trip.' and '…I also realize the importance of being able to communicate with patients and understand (even on a basic level) their cultures and beliefs.'
The sessions on history of immigration and common health problems among Calnali and Indianapolis residents scored consistently highest and were reported as most relevant to help students achieve the learning objectives. On the other hand, the session on traditional health beliefs ranked lowest among students, with many students stating they still had much to learn on that topic.
Evaluations of the sessions used to develop health education presentations showed that the majority of students agreed or strongly agreed that the presentations gave them an opportunity to learn how to meet the needs of their patients in a culturally-appropriate manner. Excerpts from selected student evaluations read: '…After developing this play, I am sure I will not forget there is no tooth fairy in Mexico, but a tooth mouse!!' On average, students scored the sessions devoted to health education presentations as a 3.5/5.0, due to their relevance in achieving the course learning objectives.
Planning Phase and Trip Logistics
When asked about the planning phases of the trip, most students agreed or strongly agreed that they were sufficiently prepared and involved in setting goals for the trip. Suggestions for improvement included the need for a description of individual responsibilities and a detailed description of service activities. Many students stated in their evaluations that they wanted to participate for a second year. In relationship to the trip logistics and the service-learning activities per se, most students reported that working together and receiving equal treatment as a member of a multidisciplinary team was valuable.
Faculty members have shared their thoughts on the benefits of participating in the program. They report a deeper knowledge of how much students appreciate learning and serving alongside students from other disciplines (86% of respondents agreed or strongly agreed), and a better understanding of how to develop effective communication among the faculty, students and community members (77% agreed or strongly agreed). The SWOT analysis developed as part of the 2007 faculty retreat is presented in Table 2.
Table 2: SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis Performed by Faculty
Challenges posed by the program reported in faculty evaluations were: the difficulty for students to understand the concept of service-learning versus provision of direct health services; the logistics and organization of a large group, the communication among IU, UAEH, and the Calnali community; the difficulty of building intentional reflection sessions into a very busy clinic day; and the need to constantly be assessing the community situation for changes that may impact the program.
Faculty unanimously agreed or strongly agreed that constant communication among all participants, setting clear and realistic short- and long-term goals, and defining clear student expectations, are crucial for the success of a program. Seventy-four percent of faculty also agreed or strongly agreed that although developing and sustaining the partnerships with a local university, community members and local health providers is challenging and increases the complexity of the program, this element is indispensable for the ability of the program to achieve its goals. Finally, most faculty members (89%) also agreed or strongly agreed that without these partnerships, the program would lose cultural relevance.
This service-learning program connects meaningful community service, community-based research, cultural competence and communication skills development with community development. The program connects school-based learning, personal growth and civic responsibility.
Program evaluation data show that after having participated in this rich ISL experience, even students who have had previous contact with Latino patients report having gained a better concept of their culture or the forces that influenced their decision to immigrate to the United States. This highlights the ability of immersion international experiences to increase students’ awareness of health issues and disparities faced by Latino patients, which may aid in overcoming barriers to culturally, linguistically and cost-effective healthcare. Our results provide evidence for the program’s ability to increase students’ awareness of how some health disparities faced by Latino patients in the United States are strongly related to US healthcare providers’ lack of cross-cultural understanding.
As reported by Godkin and Savagiau11 for their students, a high percentage of our students noted how participation improved their language and cultural sensitivity skills. Also, as previously reported by Stukas and Clary7, Allen and Young13, and Berry14, students stated that the international experience facilitated cross-cultural understanding and reduced their previously conceived stereotypes.
Evaluations of the trip planning and logistics support the development of ISL programs with comprehensive orientation and reflection components. Our results also support our approach to assure culturally-appropriate care, build the healthcare capacity of the local community and improve the communities’ health. Students’ evaluations mention the campus-community approach of the program as one of its strengths and find it extremely valuable.
It is also important to note that implementing an ISL program that centers on campus-community partnerships has presented many challenges. Communication among IU and multiple international partners with various degrees of access to distance communication tools has posed obstacles. Faculty and students have often found themselves 'lost in translation', particularly as it relates to cultural dimensions of philanthropy.
Certain limitations of the evaluation data merit further discussion. Many, but not all, dental students perceived their understanding of another culture improved and they valued the experience. However, we have not assessed how their practice as future dentists will be affected by this experience nor if they will be more effective in their interactions with people of different cultures. It must also be noted that some students reported they still had much to learn about cultural competence and traditional health beliefs.
The development of a service-leaning based curriculum has posed challenges but has enriched the experience. The program offers an opportunity for American students to have a hands-on, interactive experience in the native environment of many of their Latino patients. Students also learn to develop teaching materials and methods of conveying information that are culturally, educationally and linguistically appropriate. The program has been a vehicle to encourage collaboration between various disciplines at IU at both the student and faculty level. The program is a link between an American university community and the residents, and health professionals of Calnali and a Mexican university. This model should be appropriate for students in countries that experience high immigration and communities in countries whose populations tend to emigrate. This partnership approach seeks to enhance self-sufficiency in sending communities and health professions students’ understanding of patients from countries that experience high emigration.
Special thanks to Mrs. Juana Watson, who extended the initial invitation to the Indiana University Health Professions Schools to provide services in Calnali, to Drs. Jose Luis Antón, Elizabeth Cobbs, Laura Cornejo, Daniel Gomes, Ana Gossweiler, Julie Hatcher, Steve Jones, Ramsi Nasir, Deanna Reinoso, Mark Tiritilli, Humberto Veras and Ms. Irma Villanueva for their assistance with this project. Special thanks are also due to Ms. Sharon Gwinn and Mrs. Marilyn Richards. This project is part of the research outfit Bi-National/Cross-Cultural Health Enhancement Center. It has received support from an IUPUI Signature Center grant, the IUPUI Center for Service and Learning, a Delta Dental grant, a Clarian Values Fund grant and multiple West Foundation grants.
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