Current Practices in Global/International Advanced Pharmacy Practice Experiences: Home/Host Country or Site/Institution Considerations

Abstract

International outreach by schools and colleges of pharmacy is increasing. In this paper, we provide current practice guidelines to establish and maintain successful global/international advanced pharmacy practice experiences (G/I APPEs) with specific recommendations for home/host country and host site/institution. The paper is based on a literature review (2000-2014) in databases and Internet searches with specific keywords or terms. Educational documents such as syllabi and memoranda of understanding (MoUs) from pharmacy programs were also examined. In addition, a preliminary draft was developed and the findings and recommendations were reviewed in a 90-minute roundtable discussion at the 2014 American Association of Colleges of Pharmacy Annual Meeting. Recommendations for the host country include travel considerations (eg, passport, visa, air travel), safety, housing, transportation, travel alerts and warnings, health issues, and financial considerations. For the home country, considerations for establishment of G/I APPE site (eg, vetting process, MoU, site expectations) are described. The paper is a resource for development of new G/I APPEs and provides guidance for continuous quality improvement of partnerships focusing on G/I pharmacy education.

INTRODUCTION

International outreach by schools and colleges of pharmacy is increasing. Students and educators are participating in exchange programs and practice experiences with formal and informal agreements between institutions and individuals.¹ Standard 14.6 of the Accreditation Council for Pharmacy Education (ACPE) 2016 Standards recommends: “Schools or colleges of pharmacy may offer elective advanced pharmacy practice experiences outside the United States and its territories and possessions, provided that they support the development of the competencies required of the graduate, and the pharmacy programs implement policies and procedures to ensure the quality of the site(s) and preceptor(s).”²

In addition to enhancing clinical skills, health science students engaged in international opportunities are more likely to care for diverse patient populations and to demonstrate increased interest in volunteerism, humanitarianism, and public health.^3-8 Further, such experiences can be enriching, advance students’ professional development, and instill an appreciation and respect for other cultures, health care systems, and common problems.^9,10 At the country or institution level, establishing such endeavors can result in strong and sustainable relationships among people and further address mechanisms to meet the needs of the parties involved.

In response to the expansion of international education, the American Association of Colleges of Pharmacy’s (AACP) Strategic Plan includes goal 1.4.1: “coordinate the development of a best practices model for Advanced Pharmacy Practice Experience (APPE) international experiential rotations.”¹¹ The AACP Global Pharmacy Education Special Interest Group (GPE SIG) was charged in 2011 with developing this goal and an ad hoc committee was established to address current practices for global/international advanced pharmacy practice experiences (G/I APPEs). Initial meetings of the ad hoc committee identified five areas for consideration: home/host country, home institution, host site/institution, faculty members and preceptors, and student issues.

A report was submitted to the AACP Board of Directors in September 2013 to solicit more discussion among academy stakeholders regarding practices for G/I APPEs. This paper builds on that report and provides an in-depth description of the first three identified areas. It also includes specific recommendations based on a review of the literature and the collective experience of several pharmacy educators involved in G/I outreach with an emphasis on pharmacy education. A second paper will focus on preceptor and student qualifications and learning outcomes for G/I APPEs. A third paper will address hosting non-US students for G/I pharmacy education experiences/training at US institutions.

Most importantly, pharmacy-related G/I APPEs should maintain high quality of all associated activities. This commitment starts with each pharmacy program developing a culture of appreciation of the importance of G/I education and outreach as part of the curriculum. Some of the key planning goals to foster G/I education and training are listed in Appendix 1.

While the emphasis in this paper is focused on the experiences of US-based institutions seeking G/I APPEs, many of the considerations and recommendations apply to any institution sending their pharmacy students abroad. Also, to increase understanding of the context of discussed topics and how they pertain to different stakeholders including pharmacy institutions and students in the United States or in other countries, operational definitions of frequently used terms in this paper are provided in Appendix 2.

METHODS

This paper was developed using different methodologies. An extensive literature review was conducted using PubMed, Google Scholar, and IPA databases. The search was expanded to include the fields of nursing, medicine, public health, physical therapy, and veterinary medicine using the following keywords or terms: global rotations or experiential experiences; international rotations; home or host country; home or host institution; standards; site establishment; global medicine; international global health experiences; international clinical rotation site; education abroad; and specifically related topics (eg, visas, passports). The search was limited to publications between 2000 and 2014. Governmental and other official websites were also reviewed and referenced for pertinent information. Websites were considered reliable by assessment of the currency, depth and accuracy of the information, validity by the coauthors, who are content experts. In addition, educational documents such as syllabi and memoranda of understanding (MoU) from several pharmacy programs were reviewed.

Further, preliminary findings and recommendations were reviewed at the 2014 AACP Annual Meeting during a 90-minute roundtable discussion. The five key areas for G/I APPE development were divided among working groups of 5-8 each, representing a total of 40 pharmacy educators. A facilitator assigned to each topic area documented the input from the discussion which, in turn, was compiled, analyzed, and included here.

HOST COUNTRY CONSIDERATIONS

Students and faculty members should be well informed about the host country for the G/I APPE. The US Department of State - Bureau of Consular Affairs website¹² provides valuable information, and. the official website for the host country is another source of helpful information. The following topics, summarized in Appendix 3, should be addressed to assure legal, safe, and healthy educational experiences. Students and faculty members should be oriented to the country with a general awareness of the history, politics, socioeconomics, health care system, vaccination requirements, currency, language, etiquette, culture issues, food, weather, clothing, communication options with family or friends, transportation, and tourist attractions. Such information can be developed as part of an orientation package or can be retrieved online from the official website of each country and/or city hosting the educational experience. The US Department of State - Bureau of Consular Affairs is an additional source useful for country-specific materials.¹³ Seeking first-hand information from those familiar with the country and culture, such as someone who has lived in (exchange student/faculty, immigrants, expatriates), visited (faculty members, students) or provided services (eg, community organizations), provides practical insights that can be hard to glean from official websites and publications.

Students should be encouraged to learn the native spoken language of the host location. Some programs may require students to take a course before travel. Alternatively, students may consider attending secondary/junior college evening or online courses, as well as purchasing or borrowing library CDs and tapes, and downloading various phone language applications. Basic knowledge of the language will make the experience richer and allow for direct communication with patients, health care providers, and people from local community (eg, bus drivers, store clerks, policeman, maids, or bank personnel).

Other important information for students and faculty members to investigate includes government ordered policies, such as gender-specific customs, limitations on website availability (eg, Google, CNN, Gmail) and restrictions related to verbal or written comments about the leader of the country or the religion which may be perceived as insulting.

Communications

Students and faculty members should investigate all available communication options (eg, Skype, Viber, and WhatsApp software, phone cards, and international wireless plans). Access to Wi-Fi, electricity, and working telephones should also be assessed. In addition, knowledge about communication infrastructure in the host country should be researched prior to travel. Many countries have Global System for Mobiles (GSM)-based wireless networks that may support US-based cell phones depending on the carrier or phone type. Global System for Mobiles phones used in the United States may accept host-country SIM cards allowing the students and faculty members to use local cell phone networks and minimize communication costs to others in the host country. AT&T and T-Mobile use the GSM network in the United States, thus many of these phones can accept a host country SIM card which can be “loaded” with minutes. Additional technical considerations include SIM card size as most smartphones now incorporate micro or nano-SIMs, which may be more expensive or unavailable in host countries. If students and faculty members have Verizon or Sprint service or are not interested in changing SIM cards, they may want to contact their cellular company to determine if international data service options are available. In some cases, it may be easiest to purchase inexpensive cellphones in the host country and load the SIM card with minutes as needed. In some cases the cost of an international call from the host country may be less than if a US-based phone with an enabled international plan is used.

If Wi-Fi or broadband Internet access is not available at the host site, many countries have Internet cafes that allow access to Internet-based communication. Many countries also have USB-based cellular broadband access cards that can be used for Internet access on personal computers. These cards can be loaded with a certain amount of data, similar to a US-based data plan. Many US-based smartphones now run apps in the background that access data without the user’s knowledge. Using data internationally may be costly, and the students and faculty members should consider turning off their smartphone data capabilities while traveling if this is a concern. More information can be found by contacting cell phone providers.

Passport Requirements

Students and faculty members need a passport, which is often required before obtaining a visa. The US Department of State - Bureau of Consular Affairs website provides detailed information on obtaining or renewing passports, as well as country-specific requirements.¹⁴ Passports should be valid and should not expire during travel. Some countries require passports to be valid for 3-6 months beyond the date of departure to the host country and to have at least one or more blank pages. Students and faculty members should keep a copy of the passport in their carry-on luggage. Copies should be given to a family member or friend not traveling with them and potentially with the exchange coordinators in both the home and host country in case the passport is lost or stolen. Additionally, a scanned copy of the passport could be kept in an online accessible file. If the passport is stolen or lost, students and faculty members must secure a replacement from the US embassy, which will be needed before traveling outside of the country or back to the United States. The students and faculty members should identify the location, hours of operation, and contact information of the host country’s US embassy prior to departure.

Visa Requirements

Visa requirements vary among countries; but when required, are essential for ensuring valid entry into and exit from the host country. In addition to the specific destination, visa requirements vary based on the country of origin of the passport. Students and faculty members with dual citizenships should investigate the expense of entry and/or exit based on the origin of the passport used for travel. Visas may be required prior to departure from the United States or upon arrival in the host country. Because visa requirements vary, students and faculty members should explore requirements at least 2-3 months prior to G/I APPEs. The visa processing may take up to two months or more, sometimes requiring mailing the passport itself, which may impact the travel schedule.

International visa requirements for US passport holders are detailed on the US Passports and International Travel website or on the Henley & Partners website.^14,15 Educational or student visas may be free or have an associated cost. As of 2014, holders of a US passport could visit 174 countries and territories without a visa or with a visa on arrival.¹⁴ International students enrolled in a US pharmacy program should review the host country’s specific visa requirements. The country-specific embassy or consulates can be a helpful resource in the visa process for both US students and students from other countries.¹⁶ In addition, a country’s border agency website provides valuable information related to visiting students, including the visa application. Organizations such as the Association of International Educators¹⁷ and Study Abroad¹⁸ also maintain websites with helpful information. Finally, students and faculty members should check if their school has an international office, which generally establishes working relationships with visa offices that monitor policy changes regularly. Such expertise will be helpful to ensure compliance with visa requirements.

The majority of countries (166) allow US passport holders to visit without a visa for 90 or more days, which should be sufficient to conduct a G/I APPE.^16,17 However, some countries allow a stay of 30 days only (eg, Dominican Republic, Jordan, Qatar, United Arab Emirates). While some countries, such as Russia, India, and the Republic of China, require a visa to be issued prior to departure; others are much less restricted. Jordan, for example, allows US citizens to apply for a 30-day visa at the port of entry and for visa renewal by visiting a police station.¹⁹ Students and faculty members should take the time to review the most current country’s visa requirements well in advance to avoid frustration and delays.

International US based students as well as permanent residents (green card holders) attending US schools and participating in a G/I APPE may encounter travel restrictions, requiring additional time for processing before and during the G/I APPE. Pharmacy programs should consult regularly with the office responsible for international students.

Additional documents are often required for all students obtaining a visa, such as a letter from the sponsoring institution on official letterhead specifying duration of study, a letter from the student’s banking agency certifying that financial resources are available for tuition costs and living expenses, fingerprints, passport information, and photos. The application can be completed by mail or online; but in some cases, an in-person visit is required. Some commercial services such as Global Visas²⁰ and professional travel agents can process visas for a fee.

Besides entry visas, several countries have specific requirements on arrival and before departure, including registration with the local police agency, completion of health screenings via the ministry of health, and proof of immunizations. Students and faculty members who intend to visit outside of the host country before, during, or after the G/I APPE should investigate the requirements for an additional visa. In some countries, pre-approval for such travel is required. Several countries have restricted visas that allow one entry and one exit only. Some countries allow extension of visas while in the country whereas others do not. Thus, requirements for educational visas should be monitored closely before, during, and after the experience, since violations can result in extensive fines.

Home and host institutions should designate knowledgeable individuals to be responsible for processing and overseeing all visa applications, including review of passports, predeparture visa processing and fees, arrival visa finalization and follow up, and review of exit visa. The latter is important since there may be changes to visa requirements during the experience that need to be addressed by the host site’s representative.

Airline Travel

The cost of airline tickets can be burdensome for students and faculty members. Coordination with the school’s travel agency, if one exists, is important to receive discounts, especially if several students and educators are traveling. Airfare discount websites for students and faculty members, such as Student Universe²¹ sometimes offer discount for the desired dates of travel. Exploration of potential discounts with the host country airline in coordination with the host institution/site should also be pursued.

Rules and restrictions vary widely regarding checked luggage and carry-on allowance and other limitations, such as quantity of liquid allowed. Some airlines offer baggage waivers for international humanitarian trips (eg, Delta) and should be explored prior to purchase of tickets. Thus, airline-specific requirements should be known prior to the travel date. Students and faculty members should carry a copy of such requirements as a reference for airline staff at local airports in case they are not familiar with the specific airline rules and restrictions or no restrictions for international travel (eg, no charges for a second bag or for a bag weight up to 70 pounds).

International Student Identity Card

Students may elect or be required to obtain an international student identification card,²² which is useful as it allows the student to receive discounts on travel, shopping, tourism, transportation, student food services, and other items. The international identification card is also available for educators; however, some countries place an age limit on its acceptance.

Point of Contact in Host Country

Appointing an official contact person in the host country and coordinating with the host site/institution are vital to the success of a G/I APPE. The contact person is preferably the coordinating preceptor at the practice experience site. The contact person should be able to address any problems or issues that might arise. As international practice experiences demand support beyond the academic requirements, the contact person should be familiar with the local environment and essential infrastructure. In addition, this person could also be called upon to give advice on everyday life issues, and to coordinate between students and local preceptors/advisors. Some pharmacy programs have agreements with host preceptors to lead the practice experience and to serve as the contact person. Providing recognition to the host institution’s local contact with select privileges (eg, online library access) and/or formal title (eg, Country Liaison, Adjunct Faculty) can be beneficial as they serve an important role in ensuring the success of a G/I APPE.

Safety

Student and faculty safety must be a high priority for any international learning experience. Safety may be simply defined as freedom from the occurrence or risk of injury, danger, or loss. Perceptions of safety can differ from student to educator, provider to patient, and from home institution to host institution. Safety risks can vary widely depending on the area of the country/city/village or time of day.²³ Necessary measures must be employed so that expectations regarding safety are clearly communicated between the partnering institutions as well as among the students and faculty participating in G/I APPE. A central record and verification sheet or checklist of all predeparture orientation criteria, including safety, should be maintained at the home and host sites/institutions.

Among useful safety resources is the Council for International Exchange of Scholars- Fulbright Scholar Program, which has a mandatory pre-departure orientation program.²⁴ Safety steps include educating the students and faculty members in the following areas: identifying unsafe situations, identifying emergency contacts and institutions /agencies in the host country, avoiding becoming a target, and reporting unsafe travel conditions. The Fulbright Scholar Program has general and region-specific safety orientations that can be helpful for all travelling students and faculty members. Programs offering international experiences should establish a communication chain for emergency situations. A 24-hour emergency contact number should be provided within the home and host country.²³

Overall, basic requirements for a safe G/I APPE include appropriate selection of a host site, predeparture orientation for traveling students and faculty members, post-departure follow up and contingencies for emergencies with established plans should travel circumstances change. The roles of institution and students in a safe practice experience should be clarified before the start of the educational experience. In addition to general travel recommendations, institutions must ensure the student’s and faculty member’s personal safety in the practice setting. Students and faculty members should be educated on proper etiquette and personal behaviors in the host country, road safety, sexual harassment, psychological support, insurance, and relevant local laws.²⁵ The Center for Global Education has a handbook on travel health and safety, which addresses many of the above issues.²⁶

In general, the student and the international program coordinators in both the home and host country should be in constant contact regarding changing safety concerns in the host country and surrounding area. Furthermore, students and faculty members should be aware of and strongly adhere to the US Department of State warnings regarding travel to the region. A safe G/I APPE should emphatically include a predeparture orientation and postpractice experience debriefing with personal safety and comfort included as key parameters for practice experience evaluation.

Housing and In-Country Transportation

Preparation for personal safety should include evaluation of housing and transportation.²⁷ Safe and affordable housing should be within close proximity to the practice site and reasonably accessible either on foot or via usual means of transportation. Housing should be secured by the host site/institution or by the students and faculty members in coordination with the site institution. In addition, international organizations such as the Rotary International²⁸ and the Lions Club²⁹ may be helpful in coordinating housing, especially in rural areas. Arranging housing with a host family or local pharmacy student would be ideal.

The G/I APPE and host country coordinators should prepare detailed information regarding in-country transport. This information should include expected routes and means of travel (eg, buses, trains, taxis), and costs between the site and residence, local shops, and common tourist destinations. Students and faculty members should determine if the host country recognizes their national driver’s license or if an international driver’s license, which can be obtained through the American Automobile Association, is required.³⁰ Because of auto insurance issues, cost of renting cars, different driving rules, and varying road conditions, car rentals are not recommended during the educational experience. The G/I APPE coordinator could consider adding car rental policies to practice experience syllabus.

Travel Alerts and Warnings

The US Department of State routinely issues travel alerts and warnings.³¹ The alerts are issued for short-term events that may be specific to the country or the geographic region as a whole; those alerts are quickly removed when the event has passed or is no longer of concern. Reasons for issuing a travel alert can include an election season that is bound to lead to strikes, demonstrations, or other disturbances; a health alert like a disease outbreak; or evidence of an elevated risk of terrorist attacks.

Alternatively, travel warnings are issued when a long-term conflict exists and renders the country unstable or even dangerous. Reasons for issuing a warning can include unstable government, civil war, ongoing intense crime or violence, or frequent terrorist attacks.³¹ Warnings are targeted at informing travelers to properly weigh benefits and risks of travel or even to strongly consider not traveling to the destination at all. Warnings remain in place until the situation is resolved and this can take years. Travel warnings can result in embassy or consulate closures, which impedes the home government’s abilities to intervene on behalf of its citizens.

The US Department of State urges its citizens traveling abroad to follow its recommendations regarding travel warnings. It also urges US citizens living overseas or planning to travel abroad to register in the Smart Traveler Enrollment Program to receive important safety and security announcements and updates.³² Further, it has specific recommendations and advice for students traveling abroad.³³ Many universities require special approval for student travel or have policies that prevent students from traveling to countries that have posted travel warnings.

Approvals for travel should be received from the pharmacy experiential education office in coordination with appropriate university offices such as the General Counsel and the Office of International Students, which not only monitor the program’s safety but also have safety information and other resources. On campuses where an international exchange office does not exist, the school should use offices of local or regional health organizations (eg, Pan American Health Organization), and/or the US embassy in that country or the US Department of State website for safety verification.^34,35

Health-Related Issues

Health-related issues for each country need to be identified. Appropriate vaccinations and precautions (eg, food and water safety, eating at restaurants, brushing teeth, or drinking tap water) are important aspects of a healthy and safe experience. While all countries can have general vaccination requirements (eg, tetanus, typhoid, infectious hepatitis) and recommendations, students participating in health-related activities may have additional requirements (eg, guidelines relevant to dengue fever, diarrhea, malaria).¹²Students and faculty members should be oriented by qualified professional personnel at both the home and host country regarding such issues. The websites for the United States Centers for Disease Control (CDC) and Prevention,³⁶ the World Health Organization (WHO),³⁸ and the US Department of State - Bureau of Consular Affairs¹² are excellent resources regarding health-related issues including vaccinations. In addition, a list of local or regional travel clinics or pharmacies with travel services can be created to facilitate evaluation and acquisition of necessary vaccinations and medications.

A travel or immunization clinic should be visited well in advance of travel (>1 month) to allow development of adequate immunity prior to exposure in the host country. A comprehensive travel clinic should focus on identifying prior vaccinations through review of the “Yellow Card” or vaccination card. The potential student and faculty member should discuss with the clinic the risk factors and prevalent diseases in the host country during the expected duration of the G/I APPE and any additional tourism based on the most recent CDC (or the equivalent agency in the respective country) guidelines specific to the region and city of the intended G/I APPE.³⁶ The students and faculty members should learn the characteristics of the diseases and modes of transmission, immunizations and their side effects, protective measures, and preventive strategies.

Comprehensive travel information (ie, embassy contact information, destination description, entry and exit visa requirements, climate, travel and transportation information, region-specific safety and security information, local laws and special health information, details on each prevailing disease in the country, medical insurance, necessary nondrug items, and how to keep in touch with family and business) should be conveniently assembled in a travel packet prepared just for the travelling students and faculty members.³⁸

Prior to and during learning experiences, students and faculty members should acquire: appropriate prescription medications, recommended nonprescription medications such as antidiarrheal and cold medications, lozenges, antacids, athlete’s foot spray/powder, triple antibiotic ointment, multivitamins, antihistamines, sunscreen and sunburn lotions, rehydration products, and first aid/travel kit items; education on disease prevention strategies such as use of insect repellents, malaria prevention medications, mosquito nets, avoidance of certain foods and drinks, recommended outerwear and shoes, and instructions on what to do in case of illness.

Personal prescription containers should be properly labeled and packed in the carry-on luggage with the drugs kept in their original packaging. A letter from the student’s or faculty member’s physician confirming legitimacy of the medications is recommended. Since not all medications are available outside the student’s and faculty member’s own country and, in some cases, the quality of available prescription drugs can be questionable, students should carry the necessary supply of prescription and nonprescription medications for the entire duration of the trip, along with an additional one month refill. Several countries do not allow entry of controlled substances, so this must be considered when selecting students for a G/I APPE. A comprehensive file of the student’s health status should be maintained by the home institution and available to the host site/institution.

In most cases, students and faculty members should obtain health insurance with coverage of international health services and emergency medical evacuation, which can be costly (over $100,000). Some universities have their own policies, but if not, students and faculty members can get international travel insurance from organizations such as Cultural Insurance Services International.³⁹ The international health insurance costs are generally low (eg, currently as low as $1.20 daily). Students and faculty members should investigate and be familiar with their individual insurance policies regarding coverage, which should also be disclosed to the host site/institution. They should also understand documentation requirements for health care received in the host country. A list of health care facilities, including providers and pharmacies in the host country, should be compiled to enable them to obtain quick service in the event of a health need or emergency. A provider should be designated and coordinated through the host site. Several countries will delay departure from the country until all bills, including health-related bills, have been satisfactorily resolved. Therefore, providers of emergency health care must have an expedient protocol to ensure reimbursement for any incurred bills.

Prior to departure, the home institution and the students should have clearly defined parameters for discontinuation of the G/I APPE should a health incident arise. Certain health conditions may preclude a student from participating in a G/I APPE. These conditions should be explicitly conveyed and ascertained during the student recruitment.

Financial Considerations

Students and faculty members should be familiar with the amount of funds needed for the educational experience and additional travel, which can be estimated from feedback provided by past participants. Besides travel costs, student and faculty members need to pay for entry/exit visas (where required), accommodations, meals, local transportation, communications, entertainment, emergency funds (eg, a medical visit), and other expenses. Cash usually can be exchanged for the destination country’s currency prior to travel at major banks or at the airport. Since rates and services vary considerably, a list of trusted currency exchangers in the host country can be helpful and must be available before or immediately after arrival. Carrying excess amount of cash should be avoided; this might not be allowed by customs authorities and also can be unsafe.

For students and faculty members who must carry US currency, it is important to check with the host country to determine whether banks may not accept certain US bills. This is important since the United States has been phasing in new bills to combat counterfeiting. Thus, some banks outside the United States may reject currency that was issued before a certain year. Such information may be found on websites of major banks, or that of the central bank of the host country.

Major credit cards (Master Card, Visa, and American Express) and bank or credit union debit cards are useful and honored in most counties; however there may be differences in security requirements (eg, need for chips in debit cards or a 6-digit pin) and type of card. Students and faculty members should check with the credit/debit card providers for the best exchange conversion and processing fees. These providers should also be notified of the international travel dates as accounts can be frozen if unexpected activity occurs. It is also advisable to extend return dates in case of travel delays.

Although traveler’s checks can be used in some countries, they are no longer generally recommended since many businesses decline to accept them because of fraud. Learning from previous students’ or faculty members’ experiences is helpful in finding the best monetary practices. The international or experiential education office can connect new and returning students, and archive advice through the years.

Host Country Recommendations

AACP, the GPE SIG, and pharmacy programs in general can support activities at the host country level. The association can do so by creating a G/I pharmacy liaison(s) list for each host country that has an established relationship with an AACP member school of pharmacy. These liaisons can facilitate building pharmacy program-specific relationships and provide expert advice on the country/region to pharmacy programs interested in fostering international exchanges in that country/region. The GPE SIG in coordination with AACP, can develop guidelines for supporting institutions in their quest to establish an international education program. Pharmacy programs (if not already in place) can: (1) develop the infrastructure needed to address all the logistical aspects of a G/I APPE including visa and passport requirements, financial considerations and other pertinent practical aspects related to travel; (2) establish standardized recruitment and orientation processes that include all aspects of the areas above, especially student and faculty member’s safety; (3) create and maintain a list of organizations that provide international health insurance and encourage the students and faculty members to review individual insurance plans for coverage and limitations; and (4) require an on-site contact person, preferably the local coordinating preceptor, whom the student can easily access to ensure that quality and accountability throughout the rotation are met.

G/I APPE SITE/INSTITUTION ESTABLISHMENT CONSIDERATIONS

While sites and institutions are identified as two separate entities, in general, most of the considerations are applicable to both. The standards articulated by ACPE are expected to be applied and embedded in the considerations in G/I APPE site establishment. For example, Standard 13.7 addresses the need to establish a quality assurance procedure for all pharmacy practice experiences.² Thus, several considerations for site development were identified keeping in mind the guidelines articulated by ACPE as well as the outcomes of the literature review strategies. The key areas identified include vetting process, development and maintenance of site description, and identification of site expectations and quality indicators.

Vetting Process

A key priority for identifying a host site is to have vetted representatives on both sides. The home institution and the host site/institution should designate a faculty member or other representative who can adequately communicate student educational needs and learning outcomes and detect potential safety “red flags.” Each potential host site/institution and faculty member or other representative should be authenticated before sending any students, unless the host site/institution has a significant history of exchanges (eg, US-Thai Consortium).⁴⁰ Authentication is less critical for joint connections with other established organizations with a reputation for excellence and safety (eg, The United States President’s Emergency Plan for AIDS Relief⁴¹ or the Joint United Nations Program on HIV/AIDS).⁴² Site vetting may include consideration of the geopolitical status of the host country, general attributes of the site such as housing (security safeguards, lodging, safety of food and water), ability to communicate, and sponsorship of in-country monitoring and collaboration. Other issues related to the vetting process include an agreement on the primary purpose of the experience, mutual expectations and responsibilities, identifying and addressing local needs/benefits for both sides, especially regarding patients and other stakeholders, and determining how costs are distributed equally.²⁷ When feasible, development of relationships with ministries of health may help to enhance successful vetting of sites.^24,43

In addition to a first visit to authenticate the site, an on-going process of quality assurance assessment of site-specific educational resources needs and overall quality is necessary to ensure a site is still meeting the outcomes expected for the experience. This evaluation can be accomplished by soliciting student and preceptor feedback during and after the practice experience. Key questions to answer regarding the experience include what the goals and objectives are of the experience and what the individual student’s goals are. Given that these global pharmacy experiences can only be elective courses for US-based students, as stipulated by ACPE, a student’s choice and motivation for the G/I APPE is paramount. For a good learning experience, having the student understand the culture and the community can be just as important as learning about therapeutics. Engaging ACPE and pharmacy programs in the process of identifying and vetting sites is also helpful considering the outreach ACPE currently has with some international institutions.⁴⁴

A major purpose of site/institution vetting is to ensure continuity of the partnership. Development of an ongoing and mutually beneficial relationship with the site is essential for the success of the practice experience. These relationships can have financial, educational, and training overlap.⁴⁵ Thus, transparency about the purpose of the partnership (eg, educational outcomes, faculty exchange) and processes to detect any potential conflict(s) of interest and resolve them are important.²⁵ Development of relationships should also include consideration of the ability to mutually complement the mission and strategic plan of both the home/host site/institutions.⁴⁶ A systematic and consistent process of evaluation should occur to document fulfillment of expectations and outcomes sought by the home and host institutions. Documentation should also describe all modifications made over the years based on collected evidence.

Records of site evaluations should be maintained and be an integral part of the quality assurance process. Experiences gained through the G/I APPE can be shared with the school’s student international exchange program office to assist with planning other experiences at the same host site/institution. When possible, after a site is vetted and experience is gained, the information could be shared among the AACP institution members. For example, in the Pharmobility Program programs funded by the partners in the Funds for the Improvement of Post-Secondary Education (FIPSE) have a priority in exchange activities; but, when a site was available, FIPSE entertained applications from other pharmacy programs.⁴⁷ In this case, the sharing of good or bad experiences helped each partner. Policies and procedures adopted by pharmacy programs offering G/I APPEs, such as educational outcomes, curriculum, scope of practice for students, assessment tools, and other related materials, could be shared with other programs to improve consistency and assist with the development and evaluation of other G/I APPEs.

Standard Description of Site/Institution

Before committing to an international placement, the home institution should provide students with a clear and detailed description of the host site/institution for each G/I APPE. Such a description should include name of the site, location, setting (rural vs urban), affiliation (for example, private, government, military, profit, or nonprofit), history and size, associated health care infrastructure and facilities, services provided (inpatient or outpatient), personal and professional data (credentials and licensure) of the individuals with whom the student is expected to interact, site expectations of the student, and language and other pertinent cultural requirements including dress code and interactions with the professional staff.⁴⁸

Other aspects in the site description should include size of city or town, available facilities/services including images when available and demographics of the site’s surrounding areas. Variables such as cost of living, personal safety/liability concerns, and time away/abroad should also be included.⁴⁹ For sites offering opportunity for direct patient care experiences, it can be advantageous to describe orientation procedures aimed toward integrating the student in the site, schedules for clinical work, problem identification and feedback provision, involvement of site personnel in evaluations, and type of activities such as community public health or medical care activities, and health education provision.⁵⁰

Site Expectations

Expectations from the site vary depending on the G/I APPE’s expected learning outcomes (described in greater detail by Dornblaser and colleagues⁵¹), as well as on the personal goals and expectations of the student. The aim is not to homogenize the experiences and frame them in a single mold. The expectations of the home institution and the host site/institution must be communicated clearly and frequently. Sites should meet the programmatic requirements, facilitate relationships in the community for the purpose of meeting the core learning outcomes of the experience, and ensure adequate fulfillment of the student expectations, clinical and otherwise. Furthermore, the home institution may wish to provide an ongoing input relevant to the site needs and resources. It is essential that any input for quality improvement provided by the home institution benefits both the host site and the student. Coupling student expectations with awareness of site expectations and quality concerns may be enhanced through offering pre-departure travel orientation programs that cover site description and preparation for exposure to it.⁵²

Quality Indicators

The home and host institution should establish quality indicators for the entire experience; many aspects have been discussed above. The sites should be approved by the school’s experiential office based on established criteria (eg, meeting educational outcomes, qualified/experienced preceptors, direct supervision, direct patient contact, appropriate site and preceptor licensure, evaluation rubrics). A well thought out MoU between the home and host institutions and/or course syllabus can help ensure a quality experience to meet the goals on both sides and meet educational expectations. Participant evaluation of the experience and the host site/institution input are both critical to ensure a continuing quality improvement. Further, a biannual evaluation of the site/institution by the experiential office is critical to ensure that the site continues to meet established indicators of quality.

Establishment of Memorandum of Understanding (MoU)

Developing an MoU can assume many forms and degrees of complexity. Administrative support, including legal oversight at the highest university level, is a prerequisite for success. Universities with programs involved in international experiences may consider MoUs that cover many different types of students or may investigate expanding existing MoUs to include student pharmacists. For example, the University of Pittsburgh School of Medicine has MoUs with other partner sites for medical education purposes. In this case, the pharmacy program is included under the medical school’s MoU. Approval by the experiential office in the United States and other school offices as required, based on established criteria, should be obtained.

Although MoUs are important aspects of these relationships, their content is highly individualized based on site experience, university, and legal counsel requirements. Common components of an MoU to consider are purpose and history of the partnership, roles and responsibilities of the two parties and of specific individuals, resources to be provided and by whom, partnership details to cover associated costs of the experience, establishment of expected number of days prior to the start the experience for confirmation of continued participation, a minimum or maximum number of students/educators, the site’s/institution’s desired involvement with the selection process, assigning a contact individual, facilities and services that will be used or accessed by the APPE, description of relationships with various health care providers and their involvement regarding decisions to withdraw students, input in student pharmacist evaluations, liability clauses, insurance coverage, and statement of financial obligations on both sides. Other specific components of a MoU can include the relative scope of the agreement and its duration, timelines for planning and management of the site, funding sources, nondiscrimination clauses, and processes for modification of the existing agreement.

In the absence of a specific MoU, a more general version can provide more flexibility. In this case, more specific details can be a component of the course syllabus or of other documents such as a code of conduct agreed on by the home/host sites/institutions. The syllabus can serve as another critical component for establishment of a quality experience and articulation of expectations. It can specify activities needed to accomplish the learning objectives. A detailed review of learning outcomes is provided in Dornblaser et al.⁵¹ Course syllabi should also provide detailed instructional methods and activities feasible to offer and accomplish at the site. Grading criteria and rubrics should be specified to ensure fair and appropriate evaluation of the learning experience, preceptors, and site. Further, required or recommended readings should be selected carefully to ensure they address key educational aspects with sensitivity towards local values and beliefs. Finally, any pertinent site/institution policies can also be added or referenced. A code of conduct, as part of the syllabus, can address issues related to assuming professional, academic, and personal integrity, respecting and promoting the dignity of all persons concerned, and adhering to specific policies of the home/host site/institution.

Site/Institution Recommendations

In coordination with the GPE SIG, ACPE, AACP, and pharmacy programs can advance activities related to the site/institution. The council can do so by addressing international sites more specifically in its guidelines for G/I APPE in context of requirements of US-based sites. In coordination with the GPE SIG, AACP can: (1) create guidelines for establishing sites or relationships with international institutions. A checklist could be provided to enable new programs to have a starting point as they evaluate new sites. Furthermore, creation of additional resources could assist in providing pharmacy programs and universities with awareness and recognition of previously vetted sites; (2) compile a list of the types of acceptable/approved APPE sites (eg, pharmacies, hospitals, clinics, drug companies, governmental and private organizations) that are already vetted; (3) Explore opportunities and mechanisms for US- based institutions to facilitate the exchange of information on vetted sites that might accept students from different institutions; (4) Collect and make available a repository of course syllabi for G/I APPEs; and (5) compile exemplary policies and procedures regarding G/I APPEs including the scope of practice for student pharmacists abroad. The GPE SIG can: (1) Establish a subcommittee to review MoUs from a variety of pharmacy programs and provide a template of an exemplary MoU that includes all important aspects. The subcommittee should also address any differences in MoUs in relation to governmental, private or public sites or institutions; (2) compile examples of program evaluations and create a checklist of quality indicators for various types of G/I APPEs; (3) establish a dynamic “frequently asked questions” document on the GPE SIG website; and (4) create a forum for dialogue amongst its members to discuss different aspects of G/I APPEs, including development, expansion, and improvement. Pharmacy programs (if not already in place) can: (1) collate a description for each G/I APPE site, which would include a detailed summary of the key information described above; (2) establish a standardized checklist of logistical considerations for traveling students and faculty; and (3) develop and maintain a site quality checklist based on established criteria from experiential offices, Center for the Advancement of Pharmacy Education (CAPE) Outcomes,⁵³ and ACPE Standards.

CONCLUSION

Pharmacy programs have made great strides in the development and delivery of G/I APPEs. Development of new G/I APPEs and expansion of current programs are likely to continue. Careful attention to considerations and recommendations relevant to student and or faculty readiness and the host country site/institution are paramount for successful and rewarding G/I education and training, including APPEs. Pharmacy programs can build on these considerations and recommendations to make them both country and institution specific.

Appendix 1. Key Planning Goals for Global Education

• 1. Develop a vision and mission for global/international education and training opportunities

• 2. Adopt global/international training education as part of the institution’s strategic plan

• 3. Identify champion(s) and leadership (eg, director/assistant dean of international outreach)

• 4. Embed opportunities to promote understanding of global citizenship, global health issues, and cultural competency into the curriculum

• 5. Identify concisely how global/international training education meet standards developed by ACPE,² the Center for Advancement of Pharmacy Education (CAPE),^53,54 or respective professional bodies in the home country

• 6. Collaborate with university offices in charge of international studies

• 7. Establish a continuous quality improvement program for global/international training pharmacy education initiatives

• 8. Celebrate and highlight the programmatic outcomes of global/international educational initiatives

Appendix 2. Definitions of Operational Terms

Global/International Advanced Pharmacy Practice Experiences (G/I APPEs): an elective practice experience that US students and international US-based students studying in a pharmacy program in the United States can complete across national borders.

Global APPEs: practice experiences of students or educators across borders that address training related to global health.

Global/International Education and Training: an experience that non-US students studying in a pharmacy program outside the United States can complete across national borders.

Global Health: “An area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”⁵⁰

International APPEs: practice experiences of students and/or educators outside United States borders that might not involve global health issues; practice experiences with more emphasis on pharmacy practice, systems of health care, and cultural sensitivity.

International Students: non-US citizens who are enrolled in US-based pharmacy programs.

Institution: Governmental or private universities or organizations that accept US or non-US students and/or educators.

Memorandum of Understanding (MoU): a bilateral or multilateral agreement between two or more parties, usually the home/host institution or university, that delineates reciprocal obligations and goals for an international exchange.

Non-US Student/Educator: full-time students or educators in a pharmacy program outside the United States.

Pharmacy Programs: Used interchangeably for schools or colleges of pharmacy.

Site: governmental or nongovernmental or private training locations that accept US or non-US students/travelers for a G/I APPE.

US Student: full-time students in an accredited US-based pharmacy program who are engaged in G/I APPEs.

Appendix 3. Important Aspects to International/Global Education Planning and Student Education

Home Country/Institution Specific Pre-trip Issues

Safety Orientation

Travel Considerations: passports and visa requirements; airline travel cost, rules and restrictions; acquiring international student identity card; awareness of travel alerts and warnings to the host country

Home country embassy contact information and location in the host country

Health related issues: vaccinations; general health considerations; medications [prescriptions, over the counter]; medical insurance

Detailed description of the host country/site

Knowledge of native spoken language

Host country general description

Host country policies and restrictions: educational experience specific issues

Vetting process/Authentication of the site

Development of a memorandum of understanding

Development of a course syllabi and code of conduct

Development of site expectations

Establishment of quality indicators for the experience

Host Country/Site Specific Issues

Designated point of contact

Safety and housing

Safety and transportation

Financial considerations: currency exchange; use of credit/debit cards; traveler checks

Identifying communication options