T he blurring of national boundaries and the emergence of a global economy requires health professionals to promote health and well-being throughout the world. The ideological, political, and economic dimensions of health have become international issues, encompassing health system reform, disease prevention and control, health promotion and protection, environmental protection, and sustainable development (Berlinguer, 1993; ChichUnisky, 1994; Frenk et al., 1994; Garret, 1996; Geliert, 1993; Munasinghe, 1993; Thurrow, 1996).
Nursing educators and other health professionals must prepare health care providers to work and thrive in this new international environment (Booth, 1994; Hall-Long, 1995; ICN, 1994). This requires schools of nursing and universities to become more integrated into world affairs and undertake innovative education and practice strategies.
A mid-Atlantic university-based school of nursing is responding to this challenge by creating a new international health program, based on the new perspective of international health, offered jointly with other schools and institutes of the university. The program is being designed to offer students the opportunity to develop a broad perspective of the international health and its interfaces with national health.
The conceptual framework for this study was the "Critical-Holistic International Health Models" (Wright, 1994, 1996). Health is viewed as an issue of international relations and there is an international dimension to health (Godue, 1992, 1996; Panisset, 1992, 1996; Rovere, 1992). This approach differs from the traditional approach by analyzing the political, economic, social, cultural, and military aspects of health problems at the national and international levels.
The study compared the traditional, transitional, and new perspectives of international health. The traditional approach views international health in the context of offering aid to third-world nations, meaning the transfer of the methods, techniques, and practices of developed institutions and countries to the recipients of the aid (Frenk & Chacón, 1992; Godue, 1992, Gomez-Dantes & Khoshnood, 1991). The underlying cultural perspective is patronizing in nature: the advanced countries help the backward countries to solve the problems of poverty that the advanced countries solved long ago through vaccination, sanitation, and nutritional education. The one-way transfer reflects a relationship of dominancedependence as a consequence of economic and political relationships between these two worlds. By diminishing diseases in the backward countries, the benefactors reduce the risk that they will spread to the advanced countries. The traditional perspective promotes stereotypes and one size fits all solutions: underdeveloped countries are implicitly considered to be much alike and can develop by following the path and policies followed previously by the currently developed countries.
The transitional international health perspective focuses on interdependence among developed and developing countries as a consequence of international trade (Panisset, 1996, Frenk & Chacón, 1992; Godue, 1992; Gomez-Dantes & Khoshnood, 1991). It recognizes that: (1) developing countries differ widely among themselves and there is a continuum from less developed countries (LDC) to more developed countries (MDC); (2) LDCs also have the pathologies of the rich nations (cancer, heart disease) that should be part of the international health agenda; and (3) LDCs have something to offer MDCs.
Transition activities, however, fall short of being true partnerships. They are characterized by a lack of reciprocity, equality, and formal agreements among institutions, relying instead on ad-hoc personal relationships. An example is an MDC student that spends a few weeks or months as an intern at a LDC institution under the supervision of a professor who spent her sabbatical at an MDC institution. The host institution is not paid for the services provided. Liability concerns may preclude the MDC institution from offering such internships to students, and LDC students have to meet formal enrollment requirements and pay fees to study at MDC institutions. Another example is an MDC faculty researcher that enlists LDC hosts in data collection, but not in the definition of research priorities, strategies, design, place and language of publication, or publication credits.
The new perspective, in contrast, focuses on the development of international partnerships, meaning equitable roles where LDC and MDC counterparts have equal statue and share planning, resources, results, and credits. The new ideology has the support of foreign policy and health promotion models. It takes into account the dialectic process of power, interest, knowledge, and leadership in addressing health as an issue of international relations and the international dimension of health. This introduces a new view of international health into education and practice.
PURPOSE AND METHODS
The purpose of this study was to identify health perspectives and experiences of students and faculty at a private, university-based school of nursing in the U.S. mid-Atlantic region.
A previous research project surveyed the U.S. and selected Latin American and Caribbean schools of nursing regarding perspectives and activities in international health, based on questionnaires filled out by the associate deans for academic affaire (Wright & Komiewicz, 1997). Those questionnaires involved no direct input by either faculty or students, focusing on the assistant deans' description of faculty activities and student programs.
The current project employed a case study methodology to examine directly the international health perspectives of faculty and students at a mid-Atlantic school of nursing. While limited in scope to one school, the case study permits individual faculty and students to define their perspectives of international health and provide data on the background and experiences associated with their interest in this field.
A faculty expert in international health developed a questionnaire with input from nurse researchers, representatives from the Pan American Health Organization (PAHO), and an information systems specialist. The items included both fixed choice and open-ended responses. A four-point Likert scale was used to assess perspectives about international health. Respondents were asked to indicate agreement or disagreement with statements describing the traditional, transitional, and new perspectives of international health. Other items surveyed included involvement in international health activities, and integrating international health into the curriculum. The survey questionnaire was revised based upon input from faculty and PAHO experts who assessed its content validity.
The school of nursing target group included all 76 full-and part-time faculty, 136 graduate students, and 333 undergraduate students. The questionnaires were placed in faculty mailboxes and given to students at the beginning or end of a class. A cover letter explained the purpose and intended use of the survey. Participation was voluntary and responses confidential. The questionnaire was returned by 211 undergraduate students (63%, comprised of 54 freshmen, 56 sophomores, 68 juniors, and 33 seniors); 23 graduate students (17%, the majority from the midwife program); and 38 faculty members (50%). Faculty respondents included part-time and full-time teachers and reflected the profile of almost no instructors under 40 years of age, but with few tenured faculty.
A full 91.8% of the 190 undergraduate student respondents were U.S. citizens. English was the native language of 95.8%. Other native languages included Chinese, Farsi, French, Korean, and Tagalog. Forty-one percent of undergraduate students had resided in two or more locations within the U.S. or abroad. Eight percent of undergraduate students (7) were citizens of other countries, while 13% (27) listed countries of origin other than the U.S., including Australia, China, Ireland, the Philippines, Pakistan, Senegal, and Trinidad. Only one graduate student respondent was not from the U.S.
Data were analyzed using STATISTDC computer software. Descriptive statistics were computed and comparisons analyzed using Kruskal-Wallis, one-way, nonparametric analysis of variance (ANOVA). Open-ended responses were analyzed for trends and tallied.
Students' Travel Experience
Almost all undergraduate students indicated that they had traveled in the United States (95.6%) or in foreign countries (96.8%), with tourism being the most common reason in both instances. Eightynine percent of U.S. travel was for tourism; other reasons included visiting relatives and educational or cultural activities. The most common locations visited outside the United States were the Caribbean, England, Ireland, and Mexico.
Interest in International Health
Most students and faculty respondents expressed interest in international health (92%); over one-third of students and 42% of faculty indicated work in international health as a career goal. Of those interested in international health, 54.6% of faculty and 45% of graduate students had been interested for more than five years.
Most faculty and graduate students became involved in international health activities through personal or other nonprofessional initiatives. Twenty percent of faculty respondents had participated in overseas projects at some point in their careers. Education, research, and volunteerism were the reasons listed for these international experiences.
Undergraduate students expressed an interest in learning more about international health through courses, international health clinical experiences, volunteer experiences, and guest speakers. A wide variety of regions of the world were of interest to students, with the most common being Europe, Africa, and Central America. Additionally, students indicated a desire to participate in activities related to the domestic aspect of international health, including working with homeless populations, minorities, disabled persons, and community organizations.
International Health Perspectives
To survey respondents' perspectives on international health, subjects were asked to indicate degree of agreement with items describing the traditional, transitional, and new perspectives. Differences in perspectives among faculty, graduate students, and undergraduate students were compared using the Kruskal-Wallis, nonparametric analysis of variance statistics appropriate for the ordinal level of measurement and unequal group sizes.
There were no significant difference in responses among faculty, graduate students, and undergraduates (F = 0.25 to 2.68; p = 0.778 to 0.068). Both students and faculty showed a statistically significant trend of greater agreement with statements describing the traditional perspective of international health than either the transitional or new perspectives (Kruskal-Wallis ANOVA1 F = 6.58; p = .001).
Faculty and graduate students were asked their definitions of international health. Responses were analyzed for content and sorted into the traditional, transitional, or new perspective based on the dominant perspective. Twenty-nine faculty and graduate students recorded definitions: 11 represented the traditional perspective; 9 the transitional view; and 9 the new perspective.
There was substantial interest in international health among students and faculty at this private, university-based, U.S. school of nursing, as found earlier among U.S. schools generally (Wright & Korniewicz, 1997). Faculty respondents expressed strong interest in international health and had participated in numerous international experiences as volunteers or educators. Student respondents had traveled abroad, most were interested in international health, and about a third considered thie field a career priority. They wanted international health educational opportunities integrated into the curriculum and were interested in taking international health courses, traveling to other countries, and engaging in international clinical experiences and related domestic work.
This case study revealed more new perspective definitions of international health than were found in the more general survey by Wright and Korniewicz (1977). However, faculty and students etili indicated greater agreement with statements describing traditional perspectives of international health than those that described the transitional and new perspectives. Traditional statements on the questionnaire described actions to improve health conditions and provide health care assistance to developing countries but did not mention partnership or collaboration as key elements. The new perspective statements emphasized broader activities, including the exchange of health knowledge and resources, collaboration among countries on health issues, and the international nature of health care.
A majority of respondents also agreed with statements describing transitional and new perspectives, although less strongly than their agreement with the traditional perspective. Wright and Korniewicz (1997) also found less strong agreement on the new perspective among U.S. schools of nursing in general and, in addition, few schools of nursing actually practiced these concepts or included them in nursing education. This presents a challenge for nursing education because of the current and future need for international partnerships that depend on the new perspective.
In the United States, traditional medical and public health paradigms have influenced the integration of international health activities in schools of nursing. As described by Gomez-Dantes & Khoshnood (1991): (1) the medical model emphasizes treating disease and containing its dissemination along commercial routes Unking the developed countries to their under* developed neighbors; and (2) the public health model was developed and implemented by international organizations and schools of public health. The public health model creates additional disease control measures for ports and borders, develops preventive measures in all countries to control transmissible diseases, and introduces top-down campaigns to improve health in developing countries.
These paradigms support the development of isolated international health courses and experiences, but fail to provide a broad, interdisciplinary, and international framework for students. As an educational strategy, this traditional perspective perpetuates the ideology of aid and assistance rather than cooperation and partnership. Leininger (1997, p. 254) states that "nursing curricula, faculty, and staff can no longer be uniculturally focused if they are to help students of many different cultures function in our multicultural world."
The survey revealed mixed opinions about the best way to integrate international health into the nursing curriculum. Most respondents viewed international health as a program of study within the school of nursing. This indicated that the concepts of collaboration, partnership, and multidisciplinarity are not fully appreciated. International health is an interdisciplinary area of study, practice, and research. Nursing, a specific discipline, cannot by itself offer all the elements for the new perspective of international health.
Training nurses as "nurses only" places them at a disadvantage vis-a-vis other health professionals with respect to leadership roles in international health. Nurses need to complement their specific knowledge with a general knowledge of economics, business, international relations, and public policy to fully develop their potential as health professionals and assume leadership positions in the international health arena. More opportunities for faculty international health experiences, education, and development must be available if faculty are to educate students about the broader perspective. An immersion experience may be necessary to develop greater cultural awareness and a more holistic perspective of the interaction, integration, and equilibrium of different social, economic, and cultural factors.
International health education and awareness need not be confined to foreign travel, nor is it necessary to span large distances to study the international dimensions of health. There are many opportunities to study the foundations of international health on the domestic level in most major U.S. cities. Education about the international dimensions of health may begin close to home through work with immigrant communities and minorities.
The results indicated that the school of nursing was not clearly aligned with the new perspective of international health. To move toward the new perspective, the school is joining in multidisciplinary programs in international health and moving to explicitly adopt the new perspective of international health and to align its practices with this perspective.
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