Table 3.

Thematic coding categories and examples.

CODE	DESCRIPTION	EXAMPLE(S)
Positive
Comprehension	Expression of new material understanding based on case content.	“This case helped me increase awareness of cultural differences in different countries.”
		“’Anticipate, ask act’ was a helpful strategy for the person featured in the vignette to react, and it will be helpful for me too.”
Novelty	Expression that case content or theme were new to the respondent.	“A lot of these issues were things I have never thought about and am thankful for learning about.”
		“I was not aware of some of the procedures you should consider…and thought they are of great help in understanding consent from other cultures.”
Relevance	Content reported to be relevant to respondent interests, travel plans, or educational goals.	“…excellently illustrated a common issue that many travelers may not fully comprehend when attempting research. It helped to frame the issue appropriately, and provide effective strategies for potential issues.”
		“I actually thought this was really relevant and would not have thought about these issues.”
Succinct	Cases and content reported as concise, succinct, etc.	“Brief and to the point. It got the message across in just a few minutes. Wouldn’t change it.”
Negative
Basic	Content and themes considered too basic or rudimentary to be of educational benefit.	“Substantively it was too basic.”
		“This case is too easy to be of any benefit to anyone.”
Lack of Relevance	Content lacks relevance to the travel activities or interest of the respondent.	“Case was fine. I will not be conducting research, so feels less relevant.”
		“Not relevant to my plans.”
Case Content
Actionability	Statement and degree to which respondents felt case theme was actionable within their learning or experience.	“I like the practical vignette; such a situation could arise in several parts of the world and it gave me tools to better prepare and deal with if encountered in the future.” “The topic is important and perhaps broad but I did not glean any insightful next steps or action items should I find myself if any of the situations discussed in the case.”
Ambiguity	Unclear or contradictory content within the case.	“The topic is important and perhaps broad but I did not glean any insightful next steps or action items should I find myself if any of the situations discussed in the case.”
		“This case was not well elaborated…the representation of the issue needs to be better explained. I found it somewhat confusing.”
		“I have no idea how distributive justice has anything to do with donating property. That should be explained better.”
Burden of Responsibility	Comment on distribution of responsibility and/or accountability among trainees and institutions.	“I feel that the program sending trainees abroad should have a more direct role in these situations. Higher ups in the programs in developed countries should be talking with their colleagues about situations like this before hand. Trainees are relatively disempowered on the ground in such situations.”
		“I knew my host institution would be sponsoring meals for us and I was concerned about causing burden. Thinking about this ahead of time helps and I hope that in speaking with my advisers, we ensure an equitable balance between giving and receiving.”
Complexity	Comment of the level of complexity of the case material.	“I feel that this module may be too simple. Maybe more detail and/or complex cases would make it more of a challenging assignment.”
		“The case as presented was over simplified version of this complex issue…and did not necessarily deal with all the issues on the most practical or realistic way.”
Cultural Competency	Comment about need for/lack of/appropriate level of cultural competency or awareness within the case of for people in similar situations.	“It was a great example of telling the truth across different cultures. It just emphasizes the importance of understanding local culture before working there.”
		“Cultural competence should be a requirement for all medical student traveling to study in another country. This mandate would better prepare students on how to handle critical situation that would also prevent them from being looked down upon by the locals.”
Gender Roles	Participant points out specifics within case content regarding character gender or gender norms.	“I disliked the fact that this focused on the females as the “violators” of the cultural norms as it is also equally the responsibility of the male [characters].”
		“Navigating different expectations for male and female behavior in the host culture is part of this exercise, however the questions focused only on the conduct of the female visiting students. [Male character] is also an ambassador of the training program and the larger school community, and the training questions could explore his role as well.”
Previous Exposure to Topic	Respondent comment that topic of the case has been encountered or experienced previously.	“The only reason I personally did not find it beneficial is because I have had experience navigating different cultures therefore it was not new to me.”
		“This exact issue has come up during a past experience, so I was pleased to see it presented as part of this course.”
		“Even though I do have a great deal of experience working overseas and with students, this reinforced and reminded me of how important it is to practice what we know to be safe measures. It is all too easy to forget these when you are in resource poor areas but that is no excuse.”
Resource Limitations	Respondent comment regarding location resource or capacity limitations.	“It would be nice to see a discussion about why the clinic is so poorly supplied – and the ways in which people living in other countries with more resources can improve access to essential medicines such as antibiotics.”
		“This specific case didn’t give many actual recommendations or examples of how to handle resources in resource-scarce settings. More information regarding program sustainability would also be useful.”
Stakeholder Input	Comment on need for/example of/case content regarding stakeholder evaluation or eliciting community input.	“I really liked the answers that involved asking for the locals’ feedback. It demonstrates thoughtfulness and care.”
		“The idea of involving the local community in decision making is great, but making this happen is often quite challenging. Who makes up the ‘local representation’, how is the decision on who to include in that process made?”
User Disagreement	Respondent expresses disagreement with a detail, theme, or conclusion from the case content.	“I think it is unrealistic to say that you can always temporarily excuse yourself from a patient encounter to consult a local advisor. Some decisions have to be made on the spot and local advisors aren’t always available.”
		“I disagree about the discussion whether the student should explain that she is “not a doctor.” I feel that that [sic] term in some countries is used as health care workers…as such would be more meaningful in describing her role than student.”
Suggestions	Respondent provides specific suggestion for improvement or alteration of the case content or theme.	“Please elaborate the scenarios by including other cultural differences, e.g. dress code, mannerisms, tone and volume of conversations (Americans tend to be more boisterous than European and Asian and it is often misunderstood for arrogance and rudeness).”
		“I was most interested in this case because I am a surgeon who has worked extensively in Africa and still struggle with the concept of consent. I wish you would add on a module dealing with consent only done by husbands or head of families for operations such as amputation, tubal ligation, C section this is often the case.”
		“I would appreciate recommendations for LGBTQI+ individuals travelling to areas where non-heterosexuality is not “culturally appropriate” or even illegal. At what point does adhering to cultural norms violate personal expression and self-identity? How should personal safety be handled?”