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Educational, Personal, and Cultural Attributes of Dental Students’ Humanitarian Trips to Latin America

Key words: dental education, international humanitarian trips, cultural competence

Submitted for publication 01/28/08; accepted 09/11/08

	Abstract

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
This article evaluates the educational, personal, and cultural attributes that motivate or inhibit dental students’ participation in humanitarian and educational trips to underserved communities in Latin America. Interviews, concentrating on students’ expectations and experiences, were conducted with students who participated in the trips and with those who did not. A survey of a larger group of students (including those interviewed) was also conducted; the survey included demographic data, ethnic affiliation, cultural competence, motivators and inhibitors to attend trips, and trip attributes. One hundred and seventy-four students at one dental school completed the survey; the group interviews were conducted with twenty-three students who attended humanitarian and educational trips and nine students who did not. This research found that skill development, educational opportunity, and philanthropy were the most important motivators for trip participation. Cost and time commitments were the strongest inhibitors to participate. Exposure to infectious diseases, substandard working and living conditions, threat of crime, and language barriers were mostly considered as "not important." However, female dental students were more concerned than males about crime, living conditions, and infectious diseases during the trips. Cultural education, increased knowledge, cross-cultural professional relationships, increased self-confidence, and public health awareness were the most important attributes of the trips. This study indicates that the undergraduate humanitarian educational trips to underserved Latin American communities have a most significant personal, professional, and social impact on dental students.

The University of Florida College of Dentistry (UFCD) humanitarian and educational (H&E) trips began in 1986 and became an official elective course, International Health Through Education, in 2003. The goals of the course are to help underserved populations in Latin American countries while advancing students’ professional knowledge, experience, and cultural competence. Trips have taken place in a variety of Latin American countries (see Table 1 and Figures 1 and 2). Although each trip offers unique experiences, there are a number of common factors: a) all involve UFCD students under the supervision of UFCD faculty; b) all are scheduled for one week once per year during academic vacation periods to avoid interference with the students’ regular studies; c) the students must be in good academic and conduct status and are responsible for covering their own expenses; d) two scholarships are provided by the UFCD alumni association to cover airfare for each trip; and e) students are encouraged to seek donations from various sources (family, friends, dentists, church communities, etc.) to pay for their trips. In addition to offering their time, work, and good will, the students also gather donations of dental materials and equipment, topical fluoride, toothbrushes, toothpaste, dental floss, disposable materials, anesthetics, etc. that are used during the trip. The students can choose to use the experience to satisfy either community service or academic requirements. The trips give students extensive dental practice and opportunity to achieve the UFCD cultural competence goals.

View larger version (137K): [in this window] [in a new window]   Figure 1. Undergraduate dental students providing oral hygiene education and fluoride applications to children in an underserved area in Costa Rica

View larger version (108K): [in this window] [in a new window]   Figure 2. Undergraduate dental students performing extractions on children in an underserved area in México

To address these concerns and better justify academic support and the expenditure of university resources to support H&E trips, we initiated a study to investigate three questions: 1) what motivates or inhibits dental students’ participation in H&E trips? 2) are there differences between the students who do or do not participate in service trips? and 3) what are the perceived effects of the trips on student participants?

	Methods

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
Following approval of the planned study by the Institutional Review Board of the University of Florida, a mixed methods design employing both quantitative and qualitative approaches was used. A survey designed to collect descriptive and inferential data was developed from existing instruments and the literature.^{2,6,11,13–17} The survey (Appendix 1) consisted of five sections: A) demographics; B) ethnic affiliation/identification; C) cultural competence; D) trip participation motivators and inhibitors; and E) attributes of the trips (this section was to be completed only by students who had previously attended an H&E trip). Semi-structured group interviews were also held with H&E trip participants before and after the trip, as well as with a group of nonparticipants. Informed consent and a brief demographic form were completed by all participants before the interviews. The interviews consisted of six prompts (see Appendix 2) and addressed the students’ expectations of the H&E trips and their experiences after participation. The prompts were similar for the pre- and post-trip groups except in those instances in which it was necessary to change the tense. A similar semi-structured interview was conducted with students who had not participated in H&E trips during their time as dental students. All interview groups were conducted by one member of the research team (RWG), who is experienced in conducting interview groups and is not a member of the dental school faculty. Coleaders consisted of one or more of the other authors. Interviews were tape-recorded, and field notes were made of the proceedings.

The survey was to be administered to dental students from all four academic classes. All of the participants in trips were invited to attend interview groups, and efforts were made to schedule these groups at a time convenient for the largest number of participants.

For the statistical analysis, a standard statistical software program (JMP 6, Statistical Discovery, from SAS Institute Inc., Cary, NC, USA, 2006) was utilized. Responses on the survey were compared across gender, class, and trip participation. Differences between numerical values were analyzed with ANOVA, and differences of distribution of variables by class or gender were analyzed with the Kruskal-Wallis test.

	Results

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
Survey Results
One hundred and eighty-two surveys (seventy-five freshmen, forty-eight sophomores, four juniors, fifty-one seniors, and four without class information, totaling approximately 52 percent of the total student body) were collected. The four surveys from the junior class were excluded since the limited number made it impossible to carry out statistical comparisons with the other classes, and the four surveys with missing class year information were also excluded since they could not be included in the between-class comparisons. Therefore, the statistical analyses were done using 174 surveys. It should be noted that not every survey included the requested information for all items. Statistically significant differences in survey responses from all sections are listed in Table 2 for gender, Table 3 for trip participation, and Table 4 for class.

Section B. Ethnic affiliation/identification.
Questions in this section measured interactions and comfort with individuals from ethnicities other than one’s own. Female students gave statistically higher scores than male students for Item B-5, "I like meeting and getting to know people from ethnic groups other than my own," and for Item B-6, "I enjoy being around people from ethnic groups other than my own" (Table 2). Students who previously attended trip(s) gave statistically higher scores to Item B-7, "I do not try to become friends with people from other ethnic groups," and for Item B-9, "I feel good about my cultural or ethnic background" (Table 3). Senior students also gave statistically significant lower scores to Item B-7, "I do not try to become friends with people from other ethnic groups" (Table 4).

Section C. Cultural competence.
Questions in this section assessed the respondents’ cultural competence and their perceptions of cultural competence. Male and female dental students differed significantly on four questions, with female students giving statistically higher scores to Item C-4, "Cultural competence can be taught at school"; Item C-5, "I place value in decisions made by patients as influenced by their culture, even if I disagree as a professional"; Item C-10, "It is important for dentists to be involved in international outreach programs"; and Item C-13, "Cultural presentations or trips during dental school are important aspects of a dental education" (Table 2).

Students who had attended H&E trips gave statistically higher scores than students who had not participated on four prompts: Item C-1, "I have some interest in practicing dentistry internationally"; Item C-2, "Exposure to people of diverse cultures and backgrounds increases my confidence and ability to provide quality dental care"; Item C-4, "Cultural competence can be taught in dental school"; and Item C-13, "Cultural presentations or trips during dental school are important aspects of a dental education" (Table 3).

Sophomore students gave significantly higher scores than the other two classes for Item C-1, "I have some interest in practicing dentistry internationally," and Item C-10, "It is important for dentists to be involved in international outreach programs" (Table 4).

Section D. Motivators and inhibitors of H&E trip participation.
The vast majority of the students considered dental skill development, educational opportunity, and philanthropy as the most important motivators for participation in the H&E trips (Table 5). Pure enjoyment, improvement of interpersonal skills, and opportunity to travel were also strong motivators. Cost and time commitments were rated as the strongest inhibitors to participate in the trips. Exposure to infectious diseases, substandard working and living conditions, threat of crime, and language barriers were not considered as "very important" by most of the students.

Although all the trips had a similar intent of providing dental services to underserved populations in Latin America, each trip had its own character that was influenced by its history, mix of social and service aspects, and interaction with local dental students (Table 1). Students were aware of these differences as expressed through their observations and in their selection of trip. Across all the interview groups, the following themes were most consistent and pronounced in the participants’ discussions.

Altruism/helping others.
As might be expected, across all groups there was a strong desire to help others less fortunate than themselves. A number of students said that their gratitude for their own material comfort and opportunities was expressed by giving back through the service trips. The students attributed their valuing of service activities to a number of sources including life experiences, personal responsibility, religious faith, and acknowledgment of the good feeling that comes from doing for others. Students who participated in the interview prior to going on the H&E trips (Dominican Republic and México) expressed a positive orientation toward service before the actual experience.

Following the H&E trips, the students expanded on the theme of altruism. They commented on the uniqueness of experiencing different cultures, the gratitude of the individuals served, and making a positive difference in the world. Students often commented that they felt they had received much more than they had given and felt energized. The cross-cultural experience also provided them an opportunity to reflect on their own lives and culture and the experiences that helped to define them as a person. Many expressed that they wanted to preserve this aspect of themselves even after achieving professional status. The experience helped the students identify how they wanted to practice as dentists in the future.

Dental education.
All students discussed the contribution of the H&E trips to their dental education. Observations about the trip included citing opportunities they’d had to gain specific technical knowledge and clinical skills. Dental practice on the trip was seen as "pure practice"—the opportunity to do just dentistry without extensive paperwork and other administrative tasks. The H&E trips provided second-year students with the opportunity to gain clinical experience in advance of their scheduled clinical rotations during the third year of dental school. Third-year students recognized how much they had learned in dental school, a recognition further reinforced through opportunities to assist and supervise second-year dental students. Those students who had the opportunity to interact with dental students from other countries (México trip) stated that they gained an international perspective on dental education and came to recognize that the training and experience of these dental students were comparable to their own dental school experience.

The students observed a conflict between their altruistic desire to help others less fortunate and the opportunity to practice their emerging dental skills under less-threatening circumstances in underserved settings in Latin America. Students made a point of stating that the best possible care was offered in both settings; however, it was thought that the patients in Latin America would bring different—i.e., lower—expectations to the H&E clinical setting, thus making the students’ initial foray into practice easier. Students wrestled with these ideas and struggled to reconcile their opportunities to learn new clinical skills without appearing as though they were taking advantage of the individuals for whom they were providing service. Following the service trips, students reported greater confidence in their dental skills, and their experience as competent providers made the experience seem less exploitative.

Students who had clinical experience at the dental school contrasted the overwhelming gratitude of the individuals served on the H&E trips with what was described as "ingratitude" exhibited by patients at the U.S. dental clinics. This factor also contributed to diminishing the feeling of taking advantage of underserved populations. A few students also contrasted the concern they felt over potential malpractice suits brought by U.S. patients with the freedom from similar concerns when participating in a service trip. Another difference with the U.S. dental clinic observed by the students was the opportunity to work with supervising faculty in a relaxed and mentoring atmosphere. Overall, the students felt they had gained increased sensitivity to patients.

Insight into the social world of dental school.
Discussions of what motivated students to go on H&E trips resulted in a snapshot of the social world of dental school. Students who participated in the trips observed that some of the students in the school were very competitive and that aspects of dental education could at times be very competitive, such as securing dental patients, scheduling needed clinic time, and obtaining the required number of points for work accomplished. Students described how this intra-class competition affected relations and interactions in the classroom and clinic. There were strong negative feelings about "gunners"—students who were very point- and rank-conscious, who seemed to interact and behave only to get ahead in the system. This was contrasted with feelings on the trip, where the focus was on helping underserved populations, camaraderie, and more experienced students teaching and assisting the less experienced students. Furthermore, it was seen in the group interactions and heard in comments during the interviews that the experience of the H&E trips helped to forge significant bonds among students and between students and faculty. This sense of group and mutual support appeared to exist for an extended time following the trip and often led students to plan to participate in subsequent H&E trips. Students who had an opportunity to interact with dental students from other countries observed a noncompetitive welcoming atmosphere in the clinics and dental school that was inviting and markedly different from their experience in the United States.

It was observed that service trip participation gave second-year students clinical experience in advance of their peers. Second-year service trip participants balanced their opportunity to receive a "head start" on clinical education and their confidence entering third-year clinical rotations by observing that they expected the entire class to have equal skills by the end of the third-year rotations.

Inhibitors to service trips.
Students who participated in H&E trips did not have a clear understanding of why other students did not participate. They offered four suggestions that were repeated in a variety of forms: some students would not go to underserved communities in Latin America because of a) what was perceived as the lack of creature comforts on the trips, b) an inability to secure a spot on the trip because there were more interested students than could be accommodated, c) limited free time available during dental school, and d) preference to spend their free time in other ways. Money was an underlying concern but was not raised as an obstacle, and it appeared that students who were really interested in participating in the trips found ways to pay the expenses.

Personal safety was identified as a barrier to participation by only two students who attended an H&E trip. Both students spoke of adjusting their behavior to be safer during the trips such as not jogging alone or not journeying alone into unknown areas. Overall, the students indicated that the trips were seen as being very safe and well organized.

Three interview groups were held with a total of nine students who had not attended an H&E trip and would be unable to participate in future trips. The questions used in these interviews were modified to address the different circumstances of the nonparticipants; however, they addressed the same topics as the participant interviews. It was difficult to recruit students who had not attended the trips, and we do not present these students’ responses as representative of all nonattending students. Self-selection of the nonparticipants also makes a direct demographic comparison with the participants difficult. However, it was noted that these nine students tended to be older, four of the nine were married, and two had dependents. Six of the nine students identified themselves as Caucasian. The other three participants identified their ethnicity as Hispanic, Asian, and Arabic. Because of the limited number of nonparticipants taking part in interviews, we have only summarized their comments on three areas: dental skills, use of personal time, and exclusiveness of trips. Their responses provide an alternative perspective to the participants’ observations.

The nonparticipants observed that trip participants returned from the H&E trips with increased clinical confidence. However, one nonparticipant observed that the participants’ confidence was not necessarily based on increased skill and was not evident in their clinical performance. It was also pointed out that everyone’s skills, participants and nonparticipants alike, were perceived by the students to be equal at the end of the four years of training.

Nonparticipants listed a number of reasons for not participating in H&E trips. These reasons included cost, loss of income due to absence from work, family obligations, medical reasons such as allergies, and a belief that service trips were something that could be done in the future and therefore other activities including personal recreation during school holidays could take priority.

It was observed that H&E trip participants had stronger social bonds with other trip participants than with their other peers. This was considered a problem in light of the perceived selection process of H&E trip participants. It was thought that H&E trip participants more frequently chose or recruited new trip participants who were their friends. This made the selection process seem closed to students who were not members of these social groups. Nonparticipating students expressed the belief that students who did not get involved in the trips by their sophomore year found it increasingly difficult to be selected to participate due to the priority given to students who had already participated and their social networks.

Nonparticipants also relayed negative comments of H&E trips that participants did not share during their interviews. Nonparticipants observed that trip participants had reported being hot, sick, and sometimes encountering problems with housing. Nonparticipating students did state that the participants indicated that these problems were not seen as major issues. Nonparticipating students also observed that participants expressed a greater appreciation of the standard of living in the United States and seemed to have a new lease on life after the trips. However, nonparticipants pointed out that this emotional state did not last long and that participants resumed complaining about "life in the dental school" just like everyone else.

In summary, nonparticipating students provided a different perspective regarding increased clinical confidence and experience that resulted from the trip. Both groups made a point of emphasizing that all students had equal skills at the end of their training. Although this point was not pursued in the interviews, this issue appeared to be important and requires further investigation. Nonparticipants expressed concerns about the perceived exclusiveness and lack of fairness of the selection process and provided recommendations to improve the selection process and to provide more service trip spots. They also suggested a need for more local or U.S.-based service opportunities.

	Discussion

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
This study was initiated to answer three questions: 1) what motivates or inhibits dental students’ participation in service trips? 2) are there differences between the students who do and do not participate in service trips? and 3) what are the perceived effects of the trips on student participants? Each question is discussed in turn.

There was strong agreement across most of the students surveyed that the improvement of dental skills, educational opportunities, and philanthropy/ altruism were important motivators for participation. Cost and time commitments were seen as the two most significant barriers. The percentage of agreement for these motivators in the survey responses ranged from 76.0 percent to 82.4 percent, and the percentage of agreement for the barriers was from 62.0 percent to 68.4 percent. Although cost and time were barriers mentioned during the interviews, trip participants did not perceive these as major obstacles. Despite the consistency observed in student responses, it would appear that many variables are considered in choosing to participate in an H&E trip. A more detailed understanding of this decision-making process is necessary to better address factors that might inhibit student participation.

The survey responses and interviews did not demarcate clear demographic distinctions between participants and nonparticipants; however, background information provided by our sample supports the observation that many H&E trip participants were international students or they or their parents were immigrants to the United States and as a result had more international travel experiences. Students who went on the trips also tended to be younger and had fewer personal obligations or responsibilities, such as taking care of dependents, being married, or working. If these observations hold true in further studies, it will be important to find ways to encourage and support U.S. students to participate in international activities and to provide more local service-learning opportunities that do not encroach as extensively on their personal obligations.

The students’ discussion of the impact of the trip was revealing and provided intriguing yet still preliminary insights into the students’ perceptions of clinical training. Most interesting were students’ observations of the competition among classmates balanced against the perceived need to maintain equality across the class cohort. Students also reflected on their struggle to balance the increased clinical comfort they derived from the opportunity to learn dental skills on patients from underserved communities with the good these services were providing. Students who had not participated in H&E trips commented negatively on the social processes involved in the participant selection process and suggested that this keeps others from participating.

The students’ observations about the social environment in dental school and its impact on service trip participation provide important clues as to the range of factors that need to be considered to increase participation. The trip participants expressed ethical and social responsibility toward their Latin American patients and balanced their need to develop dental skills with cross-cultural awareness and respect. If service trips become a larger part of the competitive clinical environment of dental education, it will be important not to subvert this cross-cultural respect only for practice experience. Despite the positive nature of the trips, it is easy to overlook the possibility that the selection process can become self-limiting and present an unforeseen barrier to wider student participation.

This study was limited to one U.S. dental school, and the students surveyed and interviewed are not necessarily representative of all U.S. dental students. In addition, the failure of the study to enroll junior students limited interclass comparisons. Although it is generally acceptable to have fewer participants in qualitative studies, our inability to recruit a sufficient number of nonparticipants for interviews decreased the strength of the information they provided and limited our ability to draw conclusions. Despite these limitations, the study has made an initial attempt through a mixed methods approach to more fully understand the motivators and inhibitors of dental student participation in H&E service trips.

Our findings on the benefits of participation in the UFCD H&E trips are in accordance with the observations of Van Engen¹ that H&E trips are expected to achieve humanitarian, social, educational, cultural, and tourist goals. In fact, our study indicates that the students who participated in the H&E trips achieved their philanthropic objectives combined with a unique learning experience (professional, language, and personal), travel, and enjoyment. Moreover, philanthropy and the desire to learn significantly diminished the negative influence of inferior living and working conditions, the possible exposure to crime in a foreign country, and the fear of taking advantage of the local population. This study has also provided some insights into the process that supports and inhibits student participation in service-learning. Although additional study is needed, we believe the insights gained from this study support the following recommendations to expand and increase service-learning opportunities for dental students:

1. Despite the appeal of international travel to some students, it is important to provide comparable service-learning opportunities in both local and international locations.
   
2. If service-learning is going to occur locally, it is important to attempt to recreate the important group cohesion and support functions that occur during H&E trips to international and/or remote locations.
   
3. Selection processes should be reviewed to ensure that they are perceived as fair and open.
   
4. As H&E trips become more incorporated into the regular curriculum, they can be more affected by competition or other less desirable elements of the social environment. Although we cannot predict what this would mean for H&E trips, it is nonetheless important to reflect on the impact of increased participation and find ways to continue the unique and social aspects of these trips.
   

	APPENDIX I

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
CULTURAL COMPETENCE SURVEY

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	APPENDIX II

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

"We are meeting with you today to better understand why students choose to participate in cross-cultural medical/dental experiences and what you hope to learn or experience by participating on this trip and the barriers that inhibit participation of your peers. In this discussion, we are most interested in your perceptions and decisions you have made to participate in this trip."

1. Have any of you had cross-cultural experience or traveled outside the United States before this trip? Follow-up and explore reasons and experiences.
   
2. What were your reasons for participating in this trip to the Dominican Republic? Hear from all participants.
   
3. Do you think this experience will affect you as a student? As a dentist? In what ways? How?
   
4. How will this trip make you different from your peers who have not participated in a cross-cultural medical/dental experience?
   
5. Are you aware of any risks involved in going on the trip? Follow-up: do these concern you?
   
6. Why do other students choose not to go these trips? What are the barriers that keep students from participating?
   

Conclusion: students should be thanked and reminded that we will be talking about their experience when they return from the Dominican Republic.

Post-Trip Focus Group Questions
Introduction: remind participants of purpose (see above).

1. I want to begin by asking each of you to share an experience from the trip and why you chose this event.
   
2. How do you think you benefited from the trip?
   How has/will this trip affect you as a student?
   How has/will this trip affect the way you practice as a dentist?
   
3. What collaboration occurred with health professionals from the host country?
   What collaboration occurred with health professionals from UF?
   
4. Were there aspects of the trip that you would like to change?
   Were there problems or dilemmas? What did you do?
   What could be done to make the experience better?
   
5. Would you recommend this experience to someone else? Why?
   What would you say to recommend this experience to someone else?
   
6. Has this experience made you different from your classmates who have not been on a cross-cultural medical trip? In what ways?
   

	Author Information

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 
Dr. Bimstein is Professor, Department of Pediatric Dentistry, University of Florida College of Dentistry; Mr. Gardner is a Dental Student, University of Florida College of Dentistry; Dr. Riley is Associate Professor, Department of Community Dentistry and Behavioral Sciences, University of Florida College of Dentistry; and Dr. Gibson is Associate Professor, Department of Occupational Therapy, Medical College of Georgia. Direct correspondence and requests for reprints to Dr. Enrique Bimstein, Department of Pediatric Dentistry, College of Dentistry, University of Florida, P.O. Box 100426, Gainesville, FL 32610-0426; 352-273-7631 phone; 352-392-8195 fax; ebimstein{at}dental.ufl.edu.

Support for this research was provided in part by the University of Florida College of Dentistry Summer Research Program for Incoming Students.

	REFERENCES

Top Author information Abstract Methods Results Discussion Appendix i Appendix ii References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bimstein, E. Articles by Gibson, R. W. Search for Related Content PubMed PubMed Citation Articles by Bimstein, E. Articles by Gibson, R. W.