Preclinical Experiential Global Health Leads to Transformative Learning and Long‑term Impact

About AMPATH and the slemenda scholars program

The Academic Model Providing Access to Healthcare (AMPATH) is a partnership between a consortium of North American and European universities and Moi University in Kenya with over 30 years’ history in global health development [24, 25]. AMPATH’s long‑term commitment with faculty from member institutions serving multi‑year commitments in‑country, bilateral exchanging of trainees and faculty, and championing local experts and host‑led initiatives align with best practice guidelines for sending institutions.

The Slemenda Scholars (SS) program at Indiana University (IU) School of Medicine provides select preclinical medical students a fully funded opportunity for global health exposure through AMPATH. Started in 1998, the program honors Dr. Charles Slemenda, an IU epidemiologist committed to global health and reducing health disparities. Selection is competitive, involving a written application and interview. Scholars spend 8–10 weeks in Kenya between their first and second years of medical school, engaging in clinical shadowing, program development, didactics, case‑based discussions, education with clinical students concurrently on clerkships, and diverse global health initiatives [24]. They join Kenyan‑led teams for bidirectional learning and build long‑term relationships with guidance from IU faculty based in Kenya. Educational scaffolding is robust; these scholars complete cultural training before travel, are encouraged to take Swahili lessons, have constant support in Kenya, and have structured debriefings upon return. Philanthropy through AMPATH and IU funds the program. The SS program follows an experiential, constructivist learning model, which understands learners’ individualized learning experiences that involve action, emotion, and reflection through individual and group processing, as well as varying identities and social factors that influence their learning outcomes [26].

Study design

This mixed‑methods study sought to analyze qualitative and quantitative data on the Slemenda Scholars program. This study was submitted to and approved by the corresponding author’s Ethics Institutional Review Board as an exempt project.

Quantitative analysis

The quantitative data were collected through a cross‑sectional digital survey administered to past participants of the SS program. The survey was distributed via e‑mail, with an initial e‑mail and a reminder in January and February 2023, and a final reminder in November 2023 to increase the response rate prior to final analyses. The survey included questions about demographics, previous global health experiences, and personal and professional outcomes related to the SS program. The survey included one optional open‑ended question: “Please provide any other feedback about your Slemenda Scholars experience. Feel free to include best parts, worst parts, or any other thoughts.”

Analytic methods

Descriptive statistics were performed on demographic data and categorical question responses. Means and standard deviations were calculated for each of the Likert‑style survey questions, with “1” being “strongly disagree” and “5” being “strongly agree.”

Qualitative analysis

The qualitative analysis involved reading publicly available narratives about the SS program, including published essays and blog posts, as well as open‑ended survey responses obtained during this study. Writing narrative reflections was recommended but not required for scholars completing the program. Using the constant comparative method, all qualitative data were jointly coded and analyzed, enabling iterative theme generation [27]. Researchers met to discuss and finalize themes, with consensus from ≥ 2 researchers required for inclusion. All articles were read and coded twice, with three meetings to refine consensus themes. Descriptive statistics determined the relative prevalence of each theme in the narratives and responses.

Quantitative analysis

Surveys were emailed to 72 of the 77 alumni of the SS program as of 2023. Three SS alumni (MG, DR, and MV) are the authors of this study and were excluded. Two SS alumni were excluded owing to their having no contact information available. Of the 72 contacted, 6 e‑mails failed to deliver owing to inactive addresses. Fifty‑four responses were received (81.8% response rate; 54/66 successful contacts). After excluding responses that were more than half incomplete, 45 were included in the final analyses (68.1%). Twenty‑five respondents provided narrative responses to the survey’s open‑ended question. See Table 1 for an overview of survey demographics and select data.

The median respondent age was 35.5 years (range 23–54), and the majority of respondents were female (66%; 29/44). Although the average age of a Slemenda Scholar varies on the basis of their career path prior to medical school, most are in their mid‑to‑late twenties during the program. Over 80% of respondents were above the age of 30 years, with 38% being over the age of 40 years – suggesting decades of time had elapsed since their participation in the program for most survey respondents. Nearly one‑half reported they had GH experience prior to the SS experience; given where the Slemenda Scholars opportunity fits into the medical school timeline, almost all prior experiences were before matriculation into medical school. A quarter of these prior GH experiences were longer than 12 weeks, and most were clinical or community‑based.

Respondents used a Likert scale from strongly disagree (1) to strongly agree (5) to indicate agreement with statements. Higher scores equated to a more positive experience. One respondent was excluded from this analysis owing to a suspected entry error. The excluded respondent answered “strongly disagree” to all questions, despite writing a positive review about their Slemenda experience in the open‑ended response. As seen in Table 2, respondents indicated that they enjoyed participating in the program and learned more about themselves, global health, and the field of medicine.

The Slemenda Scholars program was also beneficial for knowledge dissemination. Nearly half of respondents reported conducting oral presentations related to their SS projects after the program (60%), and many presented posters (47%). Respondents self‑reported improvements in cultural humility (100%), personal resilience (86%), interpersonal connection (79.1%), patient/family health education (62.8%), physical exam skills (39.5%), research skills (34.9%), and professional writing skills (27.9%) (Figure 1).

Figure 1

Survey respondents reported a high level of continuation in a career in global health (70%). The survey did not have a specific prompt to describe what GH career paths physicians chose. However, in the open‑ended response, some respondents elaborated with the following quotes, demonstrating diverse career involvement:

• “working during the Ebola epidemic in 2014”;

• “been back to Moi University to help in Anesthesia”;

• “[my Kenyan] research mentor ended up shaping my career, leading to additional fellowships”;

• “I was able to host a student when the Kenyans came to the US.”

For the respondents who have not continued careers in global health, the most common barriers reported were clinical/professional obligations (67%), travel and professional costs for GH (50%), family obligations (50%), time (33%), and other (33%) – which included coronavirus disease 2019 (COVID‑19) and lack of institutional support. Of the physicians currently working in GH, all respondents indicated that the Slemenda Scholars program had a moderate (34%) or strong (66%) influence on their decision to pursue a career in GH.

Qualitative analysis

A total of 35 publicly available narratives were reviewed. Ultimately, 25 narratives were included in final analyses, after exclusion for content not relevant to Slemenda Scholars program or not written by a Slemenda Scholar. All 25 open‑ended survey responses were also included in the final quantitative analysis (Figure 2).

Figure 2

On the basis of qualitative analyses, two major themes emerged. Impactful experiences captured scholars’ accounts of the curricular components of their SS experiences. The four subthemes within impactful experiences include experiential learning, didactic learning, professional development, and cross‑cultural interactions. Transformative learning included reflections on intangible themes or values instilled through the SS Program. The five subthemes within transformative learning are expanding perspectives, motivation for a service‑oriented career, interpersonal skills, innovation, and adaptability.

Impactful experiences

See Table 3 for full definitions of each subtheme within impactful experiences. Of note, the incidence of each theme is stratified by personal narrative versus open‑ended survey response owing to the differences in data. The narratives were written directly after the SS program, with emphasis on detailed reflection as part of the debriefing, whereas the survey responses were collected 1–30 years after the completion of the program and may suffer from recall bias or dilution of detail. This difference in detail is reflected in different proportions of themes.

The most prevalent subtheme in impactful experiences was experiential learning. Respondents mentioned clinical experiences and community outreach as methods of experiential learning. Cross‑cultural interactions, both professional and personal; didactic learning; and professional development were nearly evenly represented. Professional development captured SS reflections on their career exploration while in Kenya and building their professional network through interactions with AMPATH and Moi University mentors. Didactic learning included descriptions of seminars about global health or the Kenyan healthcare system, as well as formal education on AMPATH.

Notably, cross‑cultural interactions were written about in rich detail and with more prevalence in the longer personal narratives than in the survey responses, which may be attributed to the educational slant of the preceding questions in the survey influencing the content of survey responses.

Collectively, the impactful experiences themes demonstrate that, despite the variability over decades of the SS Program, key components of the curriculum connect the experiences of former participants: formal instruction on the Kenyan healthcare system and global health, collaborative work and leisure with Kenyan colleagues, and exposure to clinical and community‑based AMPATH projects.

Transformative learning

Participants’ introspection on the abstract takeaways from the SS program produced multiple subthemes within transformative learning. See Table 4 for all subthemes with definitions.

The most prevalent subtheme was expanding perspectives, represented by more than half of scholars who reflected on an experience that strengthened or changed their world view. Types of perspective or paradigm shifts identified included ethical global health, health equity, impactful patient experiences, and cultural humility. Narratives demonstrated prevalent motivation for pursuing a service‑oriented career in medicine, whether in global health or other underserved communities. One respondent wrote:

The theme of interpersonal skills‑building highlighted how SS built relationships and collaborated with their Kenyan counterparts. Less prominent but still notable themes were adaptability and innovation. Examples of adaptability include the opportunities SS had to find creative solutions or build resilience in a resource‑ or language‑limited setting, such as one student working with a local butcher to obtain meat as practice materials for a surgery workshop. The innovation theme underlined how scholars saw opportunities to learn from the Kenyan healthcare system and proposed ideas to reciprocally implement or build upon them, for example:

While each scholar’s experiences were diverse, spanning time and changes to the SS program, the transformative learning themes that emerged were stable over time. The bilateral exchange of ideas, culture, and relationships in the SS program continues to shift trainees’ worldviews, ignite passion for health equity and global health, and build self‑efficacy for their future roles in the field. Table 5 contains illustrative quotes of the themes in transformative learning.

Limitations of this study

The publicly available nature of online narratives describing the SS program may influence their content, though the content of the public narratives did not differ substantially from the anonymous open‑ended responses in the survey. Several authors’ (MG, DR, and MVM) own narrative reflections were excluded from the analysis, but it is possible that their personal experiences as Slemenda Scholars could have unconsciously influenced emergent themes. Retrospective design includes a risk of recall bias, especially for participants who completed the program years ago. Selection bias may also be present, given that those scholars who had more positive experiences were more likely to voluntarily fill out the survey. Researchers noted verbiage from survey questions appeared in some open‑ended question responses, which suggests possible question‑order bias.

Over the 25+ years of its existence, the SS program has evolved and the exact composition of didactics, experiential opportunities, availability of other learners that might facilitate or hinder group processing, and emphasis on scholarly output have varied over time and for each participant. Thus, data from decades of participants may be heterogeneous, and cumulative analysis may not best characterize the salience of certain themes for certain time periods.

Future directions

Much has been written about how to create ethical STEGHs, and as demand for these experiences grows among medical students, there is an increasing need for best practices in evaluating the quality of existing programs’ ethics, outputs, and impacts. Moreover, there is an urgent need to creatively consider how to increase the capacity of preclinical global health programs to reach more learners who would benefit; virtual and domestic “local–global” experiences are being explored. While there is a robust educational exchange of residents, faculty, and students in their clinical years between IU, Moi University of Kenya, and other AMPATH consortium schools, opportunities for Kenyan preclinical students to rotate in the United States are currently unavailable. Exploring a reciprocal program for the exchange of preclinical Kenyan medical students to the United States is a goal and priority.