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Year : 2021  |  Volume : 34  |  Issue : 1  |  Page : 3-10

An evaluation of a medical student international service-learning experience in Southeast Asia

1 Office of Education, Duke-NUS Medical School; Adolescent Medicine Service, KK Women's and Children's Hospital; Singhealth Duke-NUS Global Health Institute, Singapore
2 Office of Education, Duke-NUS Medical School, Singapore
3 Department of Medicine, University of California, San Francisco, CA, USA

Date of Submission06-Oct-2017
Date of Decision08-Aug-2018
Date of Acceptance26-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Courtney Davis
Division of Paediatric Medicine, KK Hospital, 100 Bukit Timah Road, 229899
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_265_17

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Background: International service-learning trips (ISLTs) are structured experiences in a different country where students interact and engage in cross-cultural dialog with others. Month-long ISLTs originating from North American or European medical schools enhance clinical acumen, cultural awareness, and global health familiarity. The impact of experiences shorter than 1 month or those that originate from Asia is unknown. We aimed to determine the impact of a short-term ISLT on medical students' clinical and cultural competence. Methods: At Duke-National University Singapore, we developed an ISLT incorporating peer-assisted learning and a 1-week on-site experience delivering supervised primary care, health screening, and health education in an underserved Southeast Asian community. Using a prospective controlled design, we assessed its impact on medical students' clinical and cultural competency using validated surveys. We compared medical students who participated in the ISTL (intervention group) to a control group of students before and after the ISTL experience. We analyzed responses using univariate analysis and the Kruskal–Wallis test. Results: Sixty-six students responded to the survey (100%). After the ISTL, the intervention group (n = 32) showed an increase in their ratings of clinical competency (preexperience mean = 3.39, postexperience mean = 3.81, P < 0.01) as well as an increase in their cultural competency domains (preexperience mean = 3.61, postexperience mean = 4.12, P < 0.01). Post the ISTL, students in the intervention group rated their clinical and cultural competency higher than the control group (n = 34) (clinical: intervention postexperience mean = 3.81, control postexperience mean = 3.30, P < 0.01; cultural: intervention postexperience mean = 4.12, control postexperience mean = 3.50, P < 0.01). After the ISTL, the intervention group reported increased ratings of self-efficacy (pre mean = 3.99, post mean = 4.29, P = 0.021), which were higher than the control group (pre mean = 4.29, post mean = 3.57, P < 0.01). Discussion: This short-term ISLT in an Asian medical school improved students' clinical and cultural competency and self-efficacy. Our findings suggest a positive impact of short-term ISLTs if designed and implemented with a student learning focus.

Keywords: Cultural competence, global health, international service-learning, medical education, medical student, self-efficacy, service-learning, Southeast Asia

How to cite this article:
Davis C, Chan BY, Zhen Ong AS, Koh Y, Wen Yap AF, Goh SH, Vidyarthi AR. An evaluation of a medical student international service-learning experience in Southeast Asia. Educ Health 2021;34:3-10

How to cite this URL:
Davis C, Chan BY, Zhen Ong AS, Koh Y, Wen Yap AF, Goh SH, Vidyarthi AR. An evaluation of a medical student international service-learning experience in Southeast Asia. Educ Health [serial online] 2021 [cited 2023 Jun 6];34:3-10. Available from:

  Background Top

In an increasingly globalized world, understanding global health issues and an awareness of social determinants of health is necessary for today's medical students.[1],[2],[3] Both medical students and medical teaching institutions recognize this importance. In the United States, by 2004, 23% of graduating medical students had participated in an international global health clinical experience, compared to 5.9% in 1978.[3] Moreover, the General Medical Council in the United Kingdom has suggested the integration of an awareness of global health issues broadly into the medical curriculum.[4] One educational strategy for medical students to develop an awareness of global health issues is by participating in international service-learning trips (ISLTs). ISLTs are structured academic experiences in a country different from their school where students participate in an organized service activity, learn from direct interaction and cross-cultural dialog with others, and reflect on their experience to gain further understanding.[5]

Service-learning in general is a “teaching and learning strategy that integrates meaningful community service with instruction and reflection to enrich learning experience, teach civic responsibilities, and strengthen communities.”[6] Service-learning through ISLTs in medical school may include practicing medicine in a supervised manner in a resource-limited environment. This allows students to witness health-care disparities firsthand, appreciate cultural differences, increase clinical competence, and challenge them beyond their comfort. This may, in turn, improve their self-efficacy which can be defined as their belief in their ability to succeed.[7] Medical schools throughout North America, Europe, and the United Kingdom offer such experiences which are often termed international or global electives/postings and generally involve >4 weeks in the host country.[8],[9],[10] The experiences have shown to improve clinical acumen, cultural awareness, and knowledge of the challenges in health-care delivery and an increased appreciation of global health education and cross-cultural collaborations in participating medical students.[11],[12] Some medical schools in Asia also offer these types of experiences, and the published literature on these is limited to descriptions of programs without learner evaluation.[13],[14],[15],[16],[17],[18]

Acknowledging that these experiences are valuable and consistent with future goals of medical education, it is important to extend the opportunities for students to participate. Although month-long experiences show positive results, these require significant resources making it challenging for some students and faculty. Short-term experiences may mitigate this challenge, but their impact is unknown. In addition, with multiple medical schools in Asia, ISLTs sponsored by these institutions may offer this experience to a more diverse group of students. The impact on student learning from Asian medical school ISLTs is also unknown.

At Duke-National University Singapore (DukeNUS), we developed a 1-week ISLT with an associated year-long preparatory learning program. The primary goal of this program is to increase students' clinical and cultural competencies. Interested students are selected to participate through peer interview and volunteer to spend their spring break on the trip. Over the course of the year, the students collectively organize all logistics, and the senior students develop cultural and clinical training sessions for the junior students. Faculty advisors assist with the training sessions and the connections to a host-country nongovernmental organization (NGO). Our project specifically has partnered with One to One Cambodia (2015); 2016 Crisis Relief Singapore (2016; to Indonesia).[19],[20] During the week-long trip, senior students co-facilitate community health education, health screening, and primary care services overseeing the junior students. Faculty supervise all activities, including precepting all medical services, and facilitate daily reflections. The NGO partners collaborate throughout and ensure follow-up for patients and communities as required.

In order to understand the impact of the DukeNUS short-term ISLT on students' clinical and cultural competence, we conducted a prospective controlled survey study. Participating students completed validated surveys before and after their participation in the program. Their self-reported ratings were analyzed over time and compared to the self-reported ratings of students who were interested but could not participate in the program.

  Methods Top

This prospective controlled study assessed the impact of the DukeNUS ISLT on students' clinical and cultural competence using validated surveys.

Participants and program

DukeNUS is a graduate-entry 4-year medical school in Singapore which matriculates approximately 60 students annually. Students are primarily from Asia, and a majority hold bachelor's degrees in science or engineering.

All 1st- and 3rd-year medical students at DukeNUS are eligible to participate in the program. Interested students are interviewed and a subset are selected to participate in the program based on a student committee's assessment of prior service experience, commitment to service, and teamwork potential. We prospectively enrolled participants in 2015 and 2016. The intervention group consisted of students who were selected and participated in the ISLT experience. The control group consisted of students who were interviewed but did not participate in the ISLT experience. Common reasons for nonparticipation included scheduling conflicts and unsuccessful visa applications. Students in the intervention arm participated in pretrip logistical planning, peer-assisted training sessions, and a 1-week onsite experience in Cambodia (2015) or Indonesia (2016). Faculty supervised all activities and facilitated reflection during the trip. The National University of Singapore's Committee on Human Research approved this study.


To test the a priori hypothesis that the ISLT experience would improve clinical and cultural competencies, we performed a literature search to identify previously known and published factors influencing and assessing these domains. We created a survey based on the Mini-Milestones Assessment (MAS) by the McMaster Pediatric Residency Program and the Regan Fellowship Survey on Cultural Competency for clinical and cultural competency respectively.[21],[22] We then developed new questions for relevant areas where these tools were lacking, resulting in a 46-question, quantitative survey assessing the following domains: demographics (3 questions), clinical competency (27 questions), and cultural competency (16 questions). The clinical competency domain was divided into the following 6 subscales according to the MAS – history: data gathering (2 questions: ability to prioritize their care to patient when required to perform other operational and administrative matters and ability to present the case of the patient in an appropriate, succinct, and hypothesis-driven manner), ethics: empathy (1 question), communication via an interpreter (1 question), communication skills (6 questions), physical examination skills (10 questions), and patient management (7 questions). The three subscales for cultural competency were derived from factor analysis based on the “eigenvalue > 1 rule”[23] to determine how many factors to retain which included: role of cultural competency in health care (6 questions, eigenvalue = 7.826), interpersonal skills (6 questions, eigenvalue = 2.034) and self-efficacy (4 questions, eigenvalue = 1.161).

The survey was piloted by faculty advisors and medical students who were not involved with the ISTL experience. Based on this pilot, the survey was modified to ensure content validity, after which it was reworded and reformatted to ensure readability and comprehension. All survey measures were rated on a five-point Likert agreement scale (1 = strongly disagree, 5 = strongly agree) unless otherwise specified. The survey is included in [Appendix 1].

Data collection

Written consent was obtained from each participant. The survey was electronically distributed to the intervention and control groups. Responses were collected anonymously for 1 month before the program start and up to 3 months after the trip for 2 academic years. There was no incentive for completing the survey.

Statistical analysis

Univariate analysis was used to characterize the distribution of medical student responses to the survey questions. Then, highly correlated questions were grouped into a scale and averaged. Correlation for the Clinical Competency and Cultural Competency Scales was determined by evaluating internal consistency with Cronbach's alpha. Subscales within clinical and cultural competency were determined using factor analysis and averaged. The subscale mean results were compared for statistical significance using Kruskal–Wallis test (for nonparametric data) and ANOVA (for the averaged subgroups) of the intervention and control groups, pre- and postexperience. Statistical significance was set at P ≤ 0.05. All analyses were conducted using nonparametric tests, initially, and then tested again using parametric tests. There were no substantive differences in the results, and as such, we reported the means of all ratings for ease in interpretation and reporting. Statistical analysis was carried out using the Statistical Package for the Social Sciences version 24.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp, 2016).

  Results Top


All the students (100%) responded to the survey (intervention n = 32, control n = 34). The majority were female and ethnically Chinese, and there were no major demographic differences between the groups [Table 1].
Table 1: Medical student demographics over 2 years of the program

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Clinical competency

The Cronbach's alpha for the Clinical Competency Scale (27 items in total) was 0.934. For overall clinical competency, the intervention group's scores improved from pre- to post-ISLT experience (mean = 3.39, mean = 3.81, P < 0.01). While the control group also improved over time, this improvement was not statistically significant. Post the ISLT, students in the intervention group rated their clinical competency higher than those in the control group [Table 2]. All clinical competency subscales followed the overall domain pattern described above, with the exception of empathy. The pretest empathy ratings were high at baseline for both the groups and did not show statistically significant change over time. Full details on the subscale ratings of clinical competency are found in [Table 2].
Table 2: Clinical competency domain and subgroups

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Cultural competency

The Cronbach's alpha for the cultural competency scale (16 items in total) was 0.926. The intervention group improved from pre- to post-ISLT (preexperience mean = 3.61, postexperience mean = 4.12, P < 0.01). The control group did not show statistically significant change over time. Post the ISLT experience, students in the intervention group rated their cultural competency higher than those in the control group [Table 3]. All cultural competency subscales followed the overall domain pattern described above. Full details on the subscales of cultural competency are found in [Table 3].
Table 3: Cultural competency domain and subgroups

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Notably, in the self-efficacy subscale which included four items measuring confidence, self-invigoration, sense of social responsibility, and likelihood to serve, both the intervention and control groups had high baseline ratings, but only the intervention group increased over time (intervention: preexperience mean = 3.99, postexperience mean = 4.29, P =0.02; control: pre mean = 4.29, post mean = 3.57, P < 0.01). After the ISTL, the intervention group had higher reported ratings compared to the control group (intervention: postexperience mean = 4.29; control: postexperience mean = 3.57, P < 0.01) [Table 3].

  Discussion Top

In this study of a week-long ISLT in Asia, medical students who participated in the experience reported higher levels of all measured facets of clinical and cultural competency after the experience compared to their peers. This suggests positive impacts of a short-term ISLT, specifically 1-week on-site experience, if designed and implemented with a student learning focus, for medical students.

Several studies suggest the importance of a preexpedition program to enhance the acquisition of clinical and cultural competence, and we believe that this also influenced our positive findings.[24],[25],[26],[27] A unique feature of our preexpedition program is peer-assisted learning (PAL). PAL has been shown to enhance clinical learning when implemented alongside a formal medical school curriculum but has not previously been examined within the dynamic context of an ISTL.[28] Although we cannot distinguish PAL from the other aspects of our program to assess its individual impact, we believe that as a foundation of our program, it plays a significant role in the positive findings across multiple domains. Specifically, for the senior students who acted as teachers, they may improve both their clinical competence, by reinforcing skills and improving their self-confidence. For the students who were learners, the near-peer learning experience may also increase their self-confidence and overall self-efficacy. The extent of the PAL in our overall findings cannot be discerned and will be the topic of further study.

One of the overarching goals of any global service activity is to enhance cultural competency. In medicine, cultural competency is defined as “recognition of an appropriate response to key cultural features that affect clinical care.”[21] Cultural competency has been shown to enhance clinical acumen and patient satisfaction.[29] The students who participated in our ISLT reported higher levels of cultural competency after the program and compared to their peers. These findings suggest that this short-term ISLT, which may be possible for other schools to emulate, may not only have a positive impact on the participant but also their future patients where this competency can be applied.

Our students' self-efficacy improved post-ISLT and overall compared to their peers. Self-efficacy is broadly defined as one's belief in one's own ability to succeed in specific situations and accomplish a task.[7] For the purpose of this study, we conceived of self-efficacy as related to specific situations within global health service and defined it as the composite of four topics: “self-confidence,” “invigorated as a doctor,” “sense of social responsibility,” and “likely to volunteer for the underserved.” Although it is possible that students with high baseline self-efficacy self-select for this program, the increase in the intervention group and not the control group scores over time suggest a positive impact of the program on self-efficacy. on this important domain associated with the program. This is notable as self-efficacy is widely recognized as foundational in resilience, career fulfillment, and overall success.[30] Further evaluation to explore the factors of this program that increases self-efficacy will be prudent given the far-reaching impact on learners in medical school and lifelong.

The short-term nature of this ISLT has multiple positive aspects that are balanced with potential risks. The in-country portion of our program is limited to a week which makes it widely accessible to medical students. Specifically, it is conducted over a standard vacation week, thus not requiring an extended leave or trade-off from another curriculum, and is financially manageable for all interested students given smaller budgetary requirements than longer ISLTs. That said, the short-term nature of this experience also poses potential risks to the communities served.[31],[32],[33] We attempted to mitigate ethical concerns of “medical tourism” by collaborating closely with the embedded NGO, ensuring that our program complemented their existing long-term work with the community.[34],[35],[36] In addition, we attempted to provide opportunities for capacity building within the communities by partnering with local schools (medical, nursing, and others) to provide translation and interpretation services, thus exposing them to service-learning. Further research will be required to better understand the impact of our program on the communities and local partners.

Our study has limitations. We had a small number of participants from a single institution, which may limit the generalizability of our findings. Our participants and controls were both self-selecting. In addition, the control group was defined by subjective, along with objective criteria. Both of these factors make our findings subject to selection bias. Our findings relied on the self-reports of participants which may under- or overestimate their true competency. Medical students' perception of their own competence and self-efficacy is, in and of itself, though germane. Our findings may have been confounded by the differences over 2 years of the program including faculty and site. The foundations of the program structure over these 2 years though remained constant. Future research would add value by additionally querying faculty to assess students' competence and following students longitudinally to assess their perceptions and actions over time. Finally, although the study is not randomized, it is possible that there are differences in the groups that may result in the treatment effect despite similar baseline characteristics.

In conclusion, we found a short-term ISLT that is grounded in PAL was effective at improving students' clinical and cultural competency and notably self-efficacy. Our findings may encourage other medical schools to consider developing other similar short-term programs which would bring the benefits of an ISLT to a wider range of students. Although there are potential ethical concerns in developing short-term programs, these concerns can be addressed by collaborating closely with community-specific organizations, developing sustainable partnerships, and evaluating the programs in a multifaceted way.[37] As the field of medicine aims to ensure health across borders, ISLTs may instill in young physicians the ethos, competence, and mindset to serve in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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