Guidelines for Undergraduate Health-Related Programs Abroad

Updated March 2013

There is a growing interest in global health among college students in the U.S. Some are interested because of a passion to “help people”; others see pursuing a health related activity as a way to gain experiences that will help them be successful when applying to medical school, or another health profession. With the increase in interest in global health, has come an increase in organizations trying to serve these students, and give them experiential learning opportunities in health settings. The concern that has been raised by many focuses on the safety and ethical nature of the types of experiences these students are having when abroad. These standards have been created to support sending institutions and hosts that serve students who are involved in experiential learning in health-related settings outside the United States.

These guidelines should be used to augment The Forum’s Standards of Good Practice for Education Abroad.

These guidelines are designed for a wide range of program types including: academic, for-credit, direct enrollment, hybrid, center-based, field research and non-credit bearing internship and volunteer programs. They are applicable to: semester, year-long, summer, and short-term programs; and programs organized by domestic and international universities, and education abroad providers.

These guidelines are specific to programs serving students registered at a U.S. undergraduate institution and participating in volunteer, experiential, observation, internship, or other learning activity in a clinic, hospital or community health setting. Such experiences provide an excellent learning opportunity for students but also present unique challenges not typically encountered in other education abroad programs. While any experiential-based learning activity can involve interfacing with individuals or communities, public health or patient-care activities involve interactions that affect health and well-being, and therefore have the potential of putting individuals, community’s and the students health at risk.

Additionally, students who travel abroad for health related programs will frequently find themselves in under-resourced communities. This is particularly true for students who have an interest in public health and healthcare, because they have a strong desire to serve others. While there may be some validity to this assumption, there are also some serious challenges faced by both students and programs when students confuse service with learning. When students go abroad and participate in service-learning programs (e.g. volunteer, internship etc.) in under-resourced communities where there may be health workforce shortages and overburdened health professionals, students may be viewed as being there to help fill the human resources needs in a healthcare or public health settings. This can put students, patients and communities at risk. If health professionals in other countries are not fully aware of the students’ present level of education, they may assume students are prepared to provide services for which they have not yet been trained. Additionally, students from resource-rich countries, like the United States, may have an inflated opinion of their own skills and talents. When given the opportunity to participate in direct patient-care, these untrained students may not recognize the risk they pose to themselves and to patients.

  1. Purpose: All programs (including sending institutions, hosts, and experiential settings) that arrange and provide experiential opportunities for students in hospitals, other clinical settings, or community/public health settings should provide appropriate and relevant learning and observation experiences for the students. By doing so, they will ensure the safety of the patients and communities with whom the student interacts.
  1. Program Planning and Development: Programs serving undergraduate students should assure experiences that take into consideration the needs of the community and patients in coordination with the students learning needs. Therefore, all programs should:
    1.  Respect the public health and health care needs of the community when developing learning opportunities for students.
    2. Match student capacity including knowledge, skills, and competencies with the capacity necessary for the experiences they are engaged in so patient and community well-being are not compromised.
    3. Ensure students receive training that articulates and limits their patient-interaction to the same level of patient/community interaction that they would have in a volunteer position in the United States.
    4. Ensure that students understand and comply with all applicable licensing policies, visa policies, research ethics, data privacy and security and any other health policy related to their experiential position.
    5. Ensure all experiential sites are legitimate and adhere to international, national and local laws with regard to providing patient and community care (e.g. patient privacy training, immunizations, etc).
    6. Ensure students meet language competency or that language services are available for students in all settings. Programs should consider compensating translators when they are required to assist in student interactions.
    7. Ensure pre-departure training, onsite orientation and reentry assessment and feedback are available for all students. These should address ethics and impart an understanding of the student’s responsibility for their actions while abroad.
  1. Student Learning and Development: Programs should identify appropriate student learning and development outcomes specific to the experience:
    1. Ensure learning and development outcomes are appropriate for undergraduate students.
    2. Ensure learning outcomes focus broadly on professionalism, standards of practice, ethics, cultural competency, language proficiency, community health, patient safety and personal safety.
  1. Academic Framework: Programs should clearly articulate the academic requirements of students prior to placing them in an experiential setting.
    1. Ensure undergraduate students have adequate academic education that matches expectations in the experiential setting, including but not limited to medical language skills.
    2. When students are involved in research, assure all projects are reviewed by the appropriate oversight body for every entity involved.
  1. Clinical or Community Health Experiences: Experiential opportunities should be offered in collaboration with established, licensed health care and public health organizations located in the host communities. Prior to students participating in an experience, host programs should negotiate and come to agreement with the experiential institutions to ensure student learning and safety objectives will be met. Through negotiation, host programs and experiential institutions will:
    1. Establish that the primary purpose of the experience is learning about health care and public health and provide an opportunity for students to learn through observation, as well as relevant and appropriate activities that do not exceed the student’s education and training level.
    2. Clearly distinguish between the learning role and the service role of students and ensure any student service is within their scope of training and education.
    3. Ensure that the sending institution, the host and the experiential setting staff understand student’s current capability and level of education, and provide a learning experience that is relevant.
    4. Ensure that students are educated to understand the local culture that influences the healthcare and public health of the community and that student are prepared to function professionally and interact appropriately with local practitioners and community members.
    5. Engage with existing healthcare and public health organizations and avoid ignoring, displacing, disregarding or circumventing those organizations and professionals by providing experiences outside of those systems.
    6. Negotiate and clearly articulate supervision responsibilities by all involved organizations. Ensure the safety of the student and those whom the student interacts with and that the student remains in the observer and learner role.
    7. Provide support for clear and efficient communication between the host, experiential setting and the student.
    8. Ensure students have a safe place to report activities they are asked to perform that are out of scope of their education, training, knowledge and skills.
    9. Ensure that any research results, project reports audio/visual products are submitted to and reviewed by the local institutions prior to submission for publication. Provide credit and acknowledgement for local authors and contributors.
  1. Prepare for the Learning Abroad Environment: Both sending institution and host ensure that students are appropriately prepared for their learning abroad experience in a public health or patient care setting and that students are aware of and can articulate appropriate and inappropriate activities.
    1. Sending institutions and hosts provide orientation information that puts health in a social-cultural context and provides sufficient comparative information about health systems, health status, and public health allowing students to adjust their perceptions and expectations prior to participating in experiential settings.
    2. Hosts and experiential settings provide ongoing orientation and teaching of relevant and appropriate skills to ensure the health and well-being of both students and those they are interacting with.
    3. Sending institutions and hosts clearly articulate that the experience is intended as an observation and learning experience only.
    4. Students are made aware of their obligation to act appropriately and not engage in activities beyond their education level.
  1. Student Selection and Code of Conduct: Programs provide a fair and transparent policy for student selection and conduct.
    1. Programs clearly articulate the expected knowledge and competencies needed to be successful in the experiential setting. These will include language, cultural, interpersonal, and academic knowledge.
    2. Students are selected based on the expected knowledge and competencies required for the program.
    3. Programs have clearly articulated code of conduct that is provided in writing to students.
    4. Students agree to abide by the code of conduct while participating in the program.
  1. Organizational and Program Resources: Programs and experiential settings have adequate financial, human and facility resources to provide health services and a learning environment for students.
    1. Programs are sufficiently staffed to train and oversee the students while in an experiential setting.
    2. Students are made aware of the limits of an organization’s resources and to be respectful of the resources they are using in the interest of meeting their educational objectives.
  1. Health, Safety, and Security:Sending institutions will articulate clear expectations for hosts and their partnering experiential sites regarding health, safety and security of the students. Sending institutions will explain that if expectations are not met, partnerships may be dissolved and students removed from the site. Sending institutions should:
    1. Select host partners and experiential settings with comprehensive health, safety, security and risk management policies to protect students, patients and the community’s health and well-being.
    2. Provide students with information about infectious diseases endemic to the host community and any potentials health risks that students might be exposed to during their program.
    3. Arrange for students to have appropriate supervision at the experiential site and compensate supervisors or other persons supporting students in a mutually-agreed upon fashion.
    4. Include in pre-departure and/or on-site orientation information about safety protocols when working in patient-care settings and training on what to do in the case of an incident of exposure.
    5. Clearly articulate policies to protect the health and safety of students in patient care or community health settings in the event of an outbreak or other health risks.
    6. Ensure that students are made aware that they are responsible for recognizing their own limitations, educate and empower them to decline when asked to perform activities outside their scope of training to protect themselves, the patients and the community.
    7. Have policies in place to address students who work outside their scope of practice and clearly articulate those policies to students during orientation.
  2. Ethics and Integrity: 
    1. Sending institutions or organizations have an ethical obligation to ensure that supervisors/host sites understand the level of education and qualifications (or lack thereof) of the student, as well as the appropriate nature, scope and limitations of the student’s activities.
    2. Sending institutions and organizations should recognize the implicit power differential that exists in educational partnerships that involve partners with disparate levels of resources and influence.
    3. Sending institutions and organizations should recognize the risk of paternalism, exploitation, and neocolonial behavior on behalf of institutions from resource-rich environments when engaging with partners in low-resource settings.
    4. Sending institutions or organizations as well as host institutions and local supervisors should be familiar with and utilize relevant ethical guidelines and best practices.
    5. Human dignity and patient autonomy should be prioritized such that educational agendas of the student or the sending organization should not be prioritized over patient safety, autonomy, dignity and the provision of health services.
    6. If culturally acceptable, host sites and onsite supervisors should make patients aware of the student’s learner status and ask patient permission for student presence during and involvement in clinical encounters.
    7. Meet World Health Organization quality and process standards for donation of equipment, pharmaceuticals, and other medical supplies.