UTCOM Global Health Forms
STUDENT FORM 6
STUDENT EVALUATION OF PROGRAM
To be completed by student upon return (ideally on the flight home)
from your global health experience and returned to the UTCOM Office of Global Health within one week
of your return.
Student Name___________________________________________________________
Global Health Site________________________________________________________
Experience Dates______________________________________________________
Student permanent email & phone (for possible 3-12 month follow-up)
________________________________________________________________________
Adapted from “Perceptions of an International Healthcare Mission Questionnaire” by Mary Gallagher and
used in Glenn Geelhoed’s 2008 dissertation, “Transformational Learning in Health Care Students through
International Service in Developing World Environments.”
Directions: Please circle the number that best corresponds to your reply to each question. There is no
right or wrong answer. The question response reflects your thoughts and feelings about your
experiences as a healthcare professional student during your global health experience.
l. From participating in the global health experience you just had, how much new knowledge did
you learn about:
None
1
Minimal
2
Moderate
3
Significant Tremendous
4
5
a different country
1
2
3
4
5
health care in another country
1
2
3
4
5
a different culture
1
2
3
4
5
health beliefs in another culture
1
2
3
4
5
healthcare professionals in
another country
1
2
3
4
5
Directions: For the next series of questions, please rate the degree of change in your
thinking/cognitive skills that you can attribute to your participation in the global health experience you
just had.
2. From participating in this global health experience, how much did your thinking/cognitive
skills improve in the areas listed below?
1
No
Change
1
Tremendous
Significant
change
4
5
Minimal
2
Moderate
3
gathering patient health
history information
1
2
3
4
5
collecting pertinent information
about the patient’s environment
1
2
3
4
5
considering information about a
patient’s economic status
1
2
3
4
5
gathering information about the
patient’s support system
1
2
3
4
5
considering other resources
available to the patient
1
2
3
4
5
ease of using previously learned
physical assessment skills
1
2
3
4
5
“new” uses for learned physical
assessment skills
1
2
3
4
5
learning about the strengths of
of other healthcare disciplines
1
2
3
4
5
learning your health discipline’s role
on the healthcare team
1
2
3
4
5
learning about diseases not
typically found in the U.S.
1
2
3
4
5
learning about treatments not
typically considered in the U.S.
1
2
3
4
5
considering alternatives to
traditional “Western” medical care
1
2
3
4
5
Directions: For the next series of questions, please rate how much you may have changed your ideas
about the United States healthcare system after participating in the global health experience you just had.
3. After participating in this global health experience….
Strongly
disagree
1
Disagree
2
Not
Sure
3
Agree
4
Strongly
agree
5
my view of the U.S. healthcare
resources became more positive
1
2
3
4
5
my view of U.S. healthcare quality
became more negative
1
2
3
4
5
2
my opinion of U.S. healthcare
availability became more positive
1
2
3
4
5
my beliefs on healthcare
availability for the indigent in
the U.S. became more negative
1
2
3
4
5
my opinion of US healthcare
services for persons from another
country in the U.S. became more
positive
1
2
3
4
5
I believe people from another
culture or country receive quality
health care in the U.S.
1
2
3
4
5
Directions: For the next series of questions, please rate how your self confidence may have changed
after participating in this global health experience.
4. The IHM experience changed my confidence….
Decreased
No change
Minimal
improvement
Moderate
improvement
Significant
improvement
Tremendous
improvement
0
1
2
3
4
5
working with patients
0
1
2
3
4
5
working on a multi-disciplinary
health team
0
1
2
3
4
5
working on a multi-cultural
healthcare team
0
1
2
3
4
5
working with families from
cultures other than mine
0
1
2
3
4
5
working as a healthcare
professional
0
1
2
3
4
5
helping others work with people
from other cultures
0
1
2
3
4
5
Directions: For the next series of questions, please rate your beliefs about any changes in your abilities
to perform various professional tasks after participating in the global health experience you just had.
5. This global health experience changed my ability to……….
Decreased
No change
Minimal
improvement
Moderate
improvement
Significant
improvement
Tremendous
improvement
0
1
2
3
4
5
3
assess patient health problems
0
1
2
3
4
5
assess patient needs
0
1
2
3
4
5
plan patient treatment(s)
0
1
2
3
4
5
provide patient education
0
1
2
3
4
5
provide patient treatment(s)
0
1
2
3
4
5
evaluate plan of patient
care/treatment(s)
0
1
2
3
4
5
evaluate results of patient
education
0
1
2
3
4
5
effectively work on a
multidisciplinary team
0
1
2
3
4
5
effectively work on a
multicultural team
0
1
2
3
4
5
work with patients/families from
cultures other than my own
0
1
2
3
4
5
help co-workers understand the
needs of patients or people from
another cultures
0
1
2
3
4
5
Directions: The next series of questions asks you about how the global health experience you just had
may have changed your attitudes. Please rate how much the experience changed your attitudes in each of
the areas listed below:
6. To what degree did this global health experience increase my awareness of….
No change
1
Minimal
2
Moderate
3
Significant Tremendous
4
5
the culture of a different
country
1
2
3
4
5
a different type of healthcare
1
2
3
4
5
the influence of culture on
health
1
2
3
4
5
the influence of environment on
health
1
2
3
4
5
1
2
3
4
5
the influence of individual
beliefs on health
the influence of economic status
on health
4
the influence of support
systems on health
1
2
3
4
5
my pre-conceptions of
individuals from another
country
1
2
3
4
5
the need to mediate for
individuals of another culture
in the U.S.
1
2
3
4
5
Directions: The next series of questions asks about how the global health experience you just had may
have changed your feelings. Please rate how much the experience changed your feelings in each of the
areas listed below:
7. To what degree did participation in this global health experience change my ….
Decreased
No
Change
Minimal
improvement
Moderate
improvement
Significant
improvement
Tremendous
improvement
empathy towards others on
return from the IHM
0
1
2
3
4
5
ability to be sensitive to the
needs of those from a different
culture
0
1
2
3
4
5
ability to be sensitive to the
needs of those from a different
country
0
1
2
3
4
5
ability to be patient with non-U.S.
citizens
0
1
2
3
4
5
tolerance towards beliefs other
than my own
0
1
2
3
4
5
adaptability in different
situations
0
1
2
3
4
5
0
1
2
3
4
5
Directions: The next series of questions asks you about how the global health experience you just had
may have been a “life changing” experience for you. Please rate how much you may have changed in each
of the areas listed below.
8. To what degree did this global health experience help me to ……
No change
1
Minimal
2
Moderate
3
Significant Tremendous
4
5
learn about myself?
1
2
3
4
5
reflect on my beliefs?
1
2
3
4
5
5
connect with the emotions of caring
for and comforting individuals, or
non-technological aspects of care
1
2
3
4
5
recognize patients as unique
individuals?
1
2
3
4
5
gain respect for other healthcare
team members
1
2
3
4
5
gain respect for my peers
1
2
3
4
5
gain respect for patients
1
2
3
4
5
gain respect for people from other
cultures
1
2
3
4
5
gain respect for people from other
religions
1
2
3
4
5
gain respect for people from other
economic classes
1
2
3
4
5
Participant Demographics
What is your gender?
Male
Female
Which age range are you in?
20—24
25—29
30—34
Over 35
In which health care discipline are you a student?
Nursing graduate
Nursing undergraduate
Medicine graduate
Medicine undergraduate
Physician assistant
Pharmacy
Public Health
Other (please specify)____________________
6
How far along are you into your health care professional program?
First year
Second year
Third year
Fourth year
Other (please specify)____________________
In which group do you consider yourself a member?
American Indian or Alaska Native
Asian
African or African American
Hispanic
Native Hawaiian or other Pacific islander
Caucasian
Do you affiliate with a religious denomination? If so, which one?
Buddhist
Catholic
Hindu
Jewish
Muslim
Protestant
Other (please specify)____________________
No religious affiliation
What language(s) besides English do you speak? (Circle as many as apply)
Arabic (including Farsi and Urdu)
Spanish
French
Chinese (any dialect)
Indian (any dialect)
Other (please specify)____________________
At the time of your first global health experience, how far along were you into your health care professional
program?
First year
Second year
Third year
Fourth year
Other (please specify)____________________
How many global health or similar international missions have you participated in?
None
One
Two
Three
Four or more
7
How long ago was your last global health experience?
Within the last month
One to three months ago
Four to six months ago
Seven to nine months ago
Ten to twelve months ago
Over a year ago
Have you had any travel to an impoverished population (in, or outside, the USA) prior to your first global health
experience?
Yes
i) Where?_______________________ ii) Purpose?______________________
No ____________
Your preparation for the experience (1-not at all to 5-excellent)
1 ----- 2 ----- 3 ------ 4 ------ 5
How could you have been better prepared: _______________________________________________________
Did you receive a scholarship or other financial assistance: ____ Yes
____ No
Source: ______________________________________________________________________________
How did you find out about the experience: __________________________________________________
_____________________________________________________________________________________
Would you recommend this program for other students:
____ Yes
____ No
Why/Why Not: ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Comments (feel free to use back):
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QUALITATIVE PART OF THE SURVEY
For each of the following questions, you may feel free to extend your response to the backside of this page or
add extra sheets if you would care to expand on your answers.
1.
Please list the factor (s) that influenced your decision to participate in this experience.
2. What issues or ambiguities about this trip may have made you anxious, and what did you expect to
encounter that might have been unpleasant or uncomfortable, which were realized, and which were least,
which most surprising? What fears did you have about the travel, the mission venue or the peoples
served or the companions you would be working with or health care workers you would be guided by?
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3.
Could you describe how this global health experience may have changed you?
4. In what way do you think this medical mission has changed you with respect to: a) what you know about
medicine; b) how you will feel about patients who need care; c) the variety of different people and their
lifestyles you will have encountered; d) and how do you think it has changed you personally?
Thank you very much for your participation in this research and evaluation of your global health experience.
All your responses will be carefully protected to assure anonymity. You may be asked to complete another
survey three to twelve months after return from your global health experience.
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