1. Johanson, Linda S. EdD, MS, RN, CCNE

Article Content

AS THE WORLD grows more interconnected, the migration of people, cultures, and diseases across borders has increased the need for competence in addressing the emerging healthcare challenges of globalization. The need for students in healthcare professions to regard the health and well-being of all humanity is universally recognized. A focus on global health concepts in educational programs has the capacity to increase students' cultural competence, their likelihood of working with underserved populations, their awareness and sensitivity to healthcare cost issues, and their understanding of national health problems through comparative study.1 Still, there's been debate and uncertainty regarding the best way to attain this goal. This article outlines one potential integration method through its investigation into the outcomes of a study abroad nursing course in Mexico.



Short-term global immersion experiences have been shown to enhance students' personal growth and awareness of the value of multicultural care.2 Some authorities recommend integrating global health initiatives into formalized predeparture training for students who'll be embarking on a study abroad experience.1 In general, formal preparation has been shown to improve the competence of global service volunteers.3


Strategies for integrating global health competencies into professional educational programs have ranged from creating elective courses that focus on these concepts to revising an entire curriculum to emphasize global health as core content.1,4,5 Interprofessional education has been utilized as a tool to help students understand key principles of global health.6 Service-learning principles have also been shown to effectively convey this content.7


Regardless of the strategy, educators should initiate global health concept integration using clearly identified competencies and outcomes to guide curriculum development.8



In order to investigate the effect of the integration of global health concepts into an existing nursing elective study abroad course, the author conducted a pilot study after securing university institutional review board approval. The hypothesis for this quasi-experimental pretest-posttest research was as follows: Knowledge of global health concepts will increase in nursing students who participate in an elective study abroad course in which global health concepts are integrated.


A test was created to measure knowledge of global health content. A pretest was administered to a convenience sample of 11 participants (8 nursing students and 3 prenursing students) upon their enrollment in an elective study abroad nursing course given in the Yucatan region of Mexico. The course took place over the university's 2016 spring break week. Global health content filled pretravel meetings and the week of education abroad. A posttest was administered to students upon their return home to test the validity of the hypothesis.


Assessment tool

The author used the literature on global health to construct a multiple-choice test covering common global infectious diseases, global health statistics, and the United Nations sustainable development goals, which address imperatives such as eradicating poverty and preventing treatable deadly diseases.9 A known-groups technique certified the test's validity. A group of 25 healthcare professional board members of Health Teams International, a service organization that supports and participates regularly in global medical missions, took the test first. This group was expected to perform well and achieved an average of 80% correct responses.


In comparison, a group of 50 high school health class students expected to score lower as a group averaged only 50%. A cosmetology community college class of 25 students took the test twice to verify the test's reliability. Comparison of the first test and the retest was highly correlated with the resulting r = .97.


Course description

The study abroad course objectives already contained a service-learning component as well as a required analysis of the Mexican healthcare system compared with its counterpart in the United States. In previous years that the course had run, students traditionally toured various healthcare facilities and nursing schools, attended markets and festivals, completed service work at a long-term-care facility and a Mayan village, and visited various archeological sites while abroad.


The intentional infusion of focused global health content into this course began with four monthly predeparture meetings. Here, students were introduced to United Nations sustainable development goals and statistics regarding health and disease globally and comparatively to Mexico. As a course assignment, students researched these issues further and developed them into a formal paper.


During the week abroad, the global health issues theme was integrated into each day's events and discussed during evening debriefings. Topics included the United Nations sustainable development goals; poverty and its global health impact; natural disasters, such as earthquakes and hurricanes; man-made disasters, such as terrorism and war; and pandemics and infectious diseases, such as Ebola, cholera, and tuberculosis. Current articles related to these topics were distributed to students for reference during the week. Students made connections to their experiences in their journal entries and in daily discussions. At the end of the course, students wrote a posttrip essay about global health concepts and took a posttest.


Convenience sample

The convenience sample consisted of students enrolled in the study abroad elective course for the semester during which this study took place and who agreed to participate in the study. The cohort was all female and comprised of five senior nursing students, three junior nursing students, and three sophomore prenursing students. The participants' age range was 20 to 23.



On the pretest, students scored an average of 72.7% with a range of 40% to 100%. On the posttest, all students improved their grades (except for two students who scored 100% on both the pretest and the posttest). The average posttest scores was 95.45% with all but three students receiving a score of 100%.


Because the sample was small and nonrandom, we converted data to categorical for a nonparametric statistical analysis. A score of 80% (the average score obtained by the experts during validity testing) was considered passing. For the pretest, five students received passing scores and six students received failing scores. All students passed the posttest. Chi-square analysis was performed revealing a P value of .0004 (< .001) and a significant relationship between the global health-focused study abroad experience and improvement in test scores.


Students were also asked to rate the following statement on a Likert-type scale: This study abroad experience broadened my awareness of global health issues. In their responses to this statement, nine students selected "strongly agree," and two students selected "agree."


Students also shared their thoughts and feelings in written journal entries, which they completed nightly during their week abroad, as well as in a reflection essay. Several student comments involved the connections they made regarding global health.


Discussion and conclusions

This pilot study represents an effort to study the effect of a focused concentration of global health concepts in a study abroad course on the awareness of those concepts in participants. The sample size was small, nonrandom, and homogenous, and the research involved only one study abroad course in one country. Due to these limitations, this study should be repeated with other global study courses, larger groups, and for longer engagement periods. However, the results are encouraging, in that a statistically significant improvement in the posttest scores was demonstrated in the sample following the concentrated study as compared to the pretest scores.


During a study abroad experience, students are exposed to other cultures and conditions. Examples of global health concepts become real and reinforced as students experience a destination country, discuss health issues in debriefing sessions, and journal about their thoughts and insights. It's imperative that educators include global health concepts in some purposeful way in nursing curricula. If the curriculum includes a study abroad experience, this might be a logical and effective way to begin this incentive.




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