Reflections from the Field: The Importance of Reflective Learning

As liberal educators, we provide our students with not just concepts but also a learning process that fosters their engagement in complex global challenges. As global health educators, we share with our students a passion to fight against global and transgenerational inequities. Organizations such as the Association of American Colleges and Universities (AAC&U) promote global learning as part of their mission to advance quality liberal education. According to AAC&U’s Global Learning VALUE (Valid Assessment of Learning in Undergraduate Education) Rubric, “global learning is a critical analysis of and an engagement with complex, interdependent global systems and legacies (such as natural, physical, social, cultural, economic, and political) and their implications for people’s lives and the earth’s sustainability” (2014). Global learning also includes the capacity to understand the consequences of one’s actions in an interconnected world (Hovland 2009).

As suggested by AAC&U, another key element of global learning is reflective practice (Kuh and O’Donnell 2013). Within the literature on experiential learning opportunities, reflection is often understood as a means to enhance the acquisition of knowledge and skills (Glass 2015; Hope 2009). In this essay, I want to showcase my own path as a global health educator—and the critical role of reflection in shaping my own understanding of my work and my involvement with different communities in my home country of Costa Rica. I have learned nearly as much from such reflection as from my years of higher education and training as a physician. Today, having made a career transition from clinical practitioner to global health educator, I work closely with faculty and students from around the world. I use these critical reflective practices to help my students increase the impact of their experiential learning beyond just the facts they acquire on our site visits.

First Contact

My first contact with global health was as a medical student in Costa Rica. I did not even recognize this experience as global health at the time—it was not spelled out with this language—but it is something that I have identified in hindsight.

At first glance, Costa Rica is a success story. It is the oldest democracy in Latin America, considered a peaceful and stable society. It boasts development indices well above expected when compared with countries that have similar income levels. In health and well-being indicators, Costa Rica also outperforms other countries with similar economic conditions. A life expectancy of 80.2 years exceeds that of many OECD (Organisation for Economic Co-operation and Development) countries, most of which have high-income economies. Costa Rican citizens have almost universal access to health services within the nation’s primary health care system. Catastrophic expenses in health are almost nonexistent, and Costa Rica’s progressive funding scheme allows for pension funds that cover sickness, maternity care, and death (Pesec et al. 2017). The Social Guarantees Law of 1943 created a social safety net well before many other nations, and the latter half of the twentieth century saw a surge of institutions designed to increase access to essential services such as water, electricity, and sanitation (de la Cruz 2004).

Having trained and lived almost all my life in urban, middle-class Costa Rica, I saw no reason to doubt this narrative. Yet when I spent twelve weeks at the end of my medical training in a rural, lagging region of the country, I began to understand that the actual story of Costa Rica and the health of its people was far more complex. During this time, I engaged with the minority indigenous population close to Costa Rica’s southern border with Panama. As I knew very little about the population beforehand, my mentor pointed me to critical readings that emphasized the systemic oppression, historic marginalization, and structural violence that have shaped this community.

While I did not enroll in a formal “global health” experience, that twelve-week residency with this indigenous population, and my subsequent professional opportunities to work with indigenous people and migrant populations, provided the core elements of global health experiential learning. In many ways, my journey resembled those of learners from the Global North who come to Costa Rica as part of a service-learning experience. Like a global health learner traveling internationally, I encountered cultural barriers, a massive power differential, disparate interpretations of history, and contrasting views of the universe in my work with this indigenous population in my own country.

Similar to many of the students with whom I currently work, I lacked the capacity to assess how extensively historical, political, cultural, and environmental contexts influence health outcomes. Even more challenging, I lacked the knowledge, or perhaps the willingness, to look beyond my comfort zone. That comfort zone was created by my medical training in quiet classrooms, sterile hospital rooms, and standard patient-provider interactions, all of which I took for granted and understood to be the basic components of a biomedical approach to health. After weeks of exposure to the “alternate” realities within my country, I began to learn more about the situations in southern Costa Rica, and equally important, I learned more about myself, my values, and my vocation. I started to question the assumptions that had been part of my formal education.

As part of this process, I also began to examine the formal and informal institutions of which I had become a part, as well as the underlying schemes and paradigms upon which knowledge is created, used, and reinforced in the Western biomedical approach to health. My profession, my place of work, my socioeconomic status, and even the color of my skin were but a few of the defining characteristics that influenced my thoughts and actions. I realized that I could never undo or lose those defining characteristics, but I could be aware of them and acknowledge their essential role in shaping the lenses through which I see the world.

Reflection and Career Redirection

From that “uncomfortable” truth stemmed my desire to create in Costa Rica an educational project that could engage students in intentional, deep reflection on global health through experiential learning opportunities (ELOs). ELOs have enormous potential to help leapfrog student understanding and growth in complex areas such as global health (Ash and Clayton 2004), but student growth is not maximized until students can engage thoughtfully in deeper reflection and contextual analysis (Eyler 2002). And sadly, despite the lip service given to the value of reflection, it is the area most frequently ignored or glossed over in the rush to complete the work of ELOs. Therefore, I sought to specifically construct ELOs with reflection in mind at the outset. These ELOs would enable learners to unpack and explore these “hidden” truths and gain a more expansive contextual understanding of health. I acknowledge that helping others to have a more critical understanding of health is only a single step toward addressing these inequities, but it is an important one.

This idea to create ELOs centered around reflection grew into work to build a regional hub that could champion high-quality, ethically sound experiential learning, as well as foster collaborative approaches to health and development. After an iterative and inclusive design process, Centro Interamericano para la Salud Global—InterAmerican Center for Global Health (CISG) was born. At CISG, our primary role is to serve as an academic interface to create ethical and transformative global health educational experiences. Our educational model is driven by health equity as we attempt to prepare future leaders with the competencies they need to contextualize health and partner with communities to develop sustainable and just solutions to global and local health challenges.

Despite universal health care, social inequities between Costa Rica’s majority nonindigenous population and indigenous groups regrettably remain today (ten years later), with clear educational, health, and socioeconomic gaps. Neonatal mortality among indigenous groups is still higher than the national mean (Comisión Económica para América Latina y el Caribe 2017). Malnutrition in children is more prevalent in indigenous populations (Ministerio de Educación 2017), and infectious diseases like tuberculosis disproportionally affect indigenous people of all ages more than any other minority in Costa Rica (Solís Ramírez 2019). But with the growing prominence of global health education in colleges and universities around the world, more students may be exposed to experiential and reflective learning, and more professionals and practitioners may emerge who begin from a place of cultural humility and a recognition of history and privilege as they work toward creating a more equitable and just world.

Experiential settings may be the most important spaces for students as they learn to reflect on their position in an intentional manner and in mentored settings. These more structured opportunities can provide them with the skills to reflect on their own positionality within their work and within communities, as well as the impacts and implications of their engagement.

Reflective Learning to Strengthen ELOs

Reflective learning refers to a wide range of activities that demand that individuals critically position themselves within specific geographical and sociopolitical contexts. In relation to global health, reflective learning allows individuals to explore power structures, not just the biomedical structures that frame health issues. Reflective learning builds on the extensive literature of service learning (Eyler 2002; Felten and Clayton 2011; Glass 2015; Hope 2009) and is foundational to effective ELOs in global health education.

The need for reflective learning can be seen most clearly in its absence. I have recognized two types of students who have difficulty reflecting on their work. I’ve encountered one type in my experience over the past decade working with students who have traveled to experience health in Costa Rica. It not uncommon to find learners who can describe their experiences but struggle to create the links and engage in the metacognitive process that reflection can enable. They tend to accumulate experiences (similar to knowledge in a book or a classroom) without creating new understandings of these experiences. The competitive nature of Western professional training and academic preparation is so demanding that faculty may dismiss this step when time is limited, and students may perceive time to be “wasted” if it is spent on reflection after the completion of an experience instead of engaging in other “new” activities. This perception diminishes students’ ability to learn from their experiences. Conventional educational structures therefore may actually facilitate more shallow learning.

The second type of students participate in ELOs but are unmentored, or have field experiences that reflect colonial views and constructs of engagement for global health (such as assuming that in areas of “need” there must necessarily be a lack of health infrastructure, and therefore any assistance is better than no assistance at all). In these instances, global health experiences will not yield the anticipated benefits of intercultural knowledge or increased understanding of global processes. Rather, such experiences might even reinforce undesired attitudes and narratives, cementing a simplistic and flawed view of complex global challenges (Duffy et al. 2005; Richards and Doorenbos 2016; Smith-Paríolá and Gòkè-Paríolá 2006). Learners might not be able to recognize causes of dissonance and might miss opportunities for challenging their preconceived ideas of the world (Eyler 2002; Felten and Clayton 2011; Mezirow 1992).

Challenges to Implementation

Despite its value, incorporating reflective learning effectively into a curriculum can be challenging. These challenges can relate to the operationalization of reflective learning and to gaps in knowledge on reflective learning. Overall, clear structures for successful reflective learning seem to be lacking at all institutional levels (Ash and Clayton 2009). Educators’ lack of familiarity with reflective practices and theories can hinder their efficacy in implementing them (Landy et al., n.d.; Mann, Gordon, and MacLeod 2009). There are also gaps regarding the evaluation of the quality of reflective practice (Eyler 2002) and how to assess student outcomes (Ash and Clayton 2004). The rapid growth of short-term ELOs in global health highlight that longer experiences may not be possible due to time constraints—and by default, reflective practices could be jettisoned for more “active” engagement given limited time. ELOs that do not intentionally build in reflection will absolutely fail to reap the benefits of deep learning from short exposures. This is further complicated when academic structures require faculty to fulfill a minimum of didactic contact hours with learners (Glass 2015).

It has now been over a decade since my first exposure to “global health.” A lot around me and about me has changed, giving me a different vantage point that allows me to better see the larger picture, understand the dynamic context around me, and connect the dots. And as the expansive circles of my and CISG’s actions widen, a new generation of global health practitioners is emerging equipped with the agency required to enact change.

Much work remains to be done, but one way forward is for us as educators to model the reflective practices we hope to cultivate in our students. It is often difficult to understand the possibilities of critical reflection when one has never seen or heard anyone engage in such practices or witnessed their impacts. In intentionally planned ELOs with structured reflective learning, we might be able to find an approach to overcome barriers that limit sought-after transformations in our students and in the social systems of our communities.

References

Ash, Sarah L., and Patti H. Clayton. 2004. “The Articulated Learning: An Approach to Guided Reflection and Assessment.” Innovative Higher Education 29 (2): 137–54.

———. 2009. “Generating, Deepening, and Documenting Learning: The Power of Critical Reflection in Applied Learning.” Journal of Applied Learning in Higher Education 1: 25–48.

Association of American Colleges and Universities. 2014. “Global Learning VALUE Rubric.” https://www.aacu.org/value/rubrics/global-learning.

Comisión Económica para América Latina y el Caribe (CEPAL). 2017. Mortalidad Materna en Pueblos Indígenas y Fuentes de Datos: Alcances y Desafíos para su Medición en Países de América Latina. Santiago, Chile: CEPAL.

de la Cruz, Vladimir. 2004. Las Luchas Sociales en Costa Rica, 1870–1930. San José, Costa Rica: Editorial de la Universidad de Costa Rica.

Duffy, Mary E., Suzette Farmer, Patricia Kay McArthur Ravert, and Liisa Huittinen. 2005. “International Community Health Networking Project: Two Year Follow-Up of Graduates.” International Nursing Review 52 (1): 24–31.

Eyler, Janet. 2002. “Reflection: Linking Service and Learning—Linking Students and Communities.” Journal of Social Issues 58 (3): 517–34.

Felten, Peter, and Patti H. Clayton. 2011. “Service-Learning.” New Directions for Teaching and Learning 2011 (128): 75–84.

Glass, Michael R. 2015. “Teaching Critical Reflexivity in Short-Term International Field Courses: Practices and Problems.” Journal of Geography in Higher Education 39 (4): 554–67.

Hope, Max. 2009. “The Importance of Direct Experience: A Philosophical Defence of Fieldwork in Human Geography.” Journal of Geography in Higher Education 33 (2): 169–82.

Hovland, Kevin. 2009. “Global Learning: What Is It? Who Is Responsible for It?” Peer Review 11 (4): 4–7. https://www.aacu.org/peerreview/2009/fall/hovland.

Kuh, George D., and Ken O’Donnell. 2013. Ensuring Quality and Taking High-Impact Practices to Scale. Washington, DC: Association of American Colleges and Universities.

Landy, Rachel, Cathy Cameron, Anson Au, Deb Cameron, Kelly K. O’Brien, Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O’Hearn, Brent Oliver, and Stephanie Nixon. n.d. “Educational Strategies to Enhance Reflexivity among Clinicians and Health Professional Students: A Scoping Study.” Forum: Qualitative Social Research 17 (3). http://www.qualitative-research.net/index.php/fqs/article/view/2573.

Mann, Karen, Jill Gordon, and Anna MacLeod. 2009. “Reflection and Reflective Practice in Health Professions Education: A Systematic Review.” Advances in Health Sciences Education 14 (4): 595–621.

Mezirow, Jack. 1992. “Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning.” The Canadian Journal for the Study of Adult Education 6 (1): 86–89.

Ministerio de Educación. 2017. Censo Escolar Peso y Talla. San José, Costa Rica: Ministerio de Educación.

Pesec, Madeline, Hannah L. Ratcliffe, Ami Karlage, Lisa R. Hirschhorn, Atul Gawande, and Asaf Bitton. 2017. “Primary Health Care that Works: The Costa Rican Experience.” Health Affairs 36 (3): 531–38.

Richards, Claire A., and Ardith Z. Doorenbos. 2016. “Intercultural Competency Development of Health Professions Students during Study Abroad in India.” Journal of Nursing Education and Practice 6 (12). https://doi.org/10.5430/jnep.v6n12p89.

Smith-Paríolá, Jennie, and Abíódún Gòkè-Paríolá. 2006. “Expanding the Parameters of Service Learning: A Case Study.” Journal of Studies in International Education 10 (1): 71–86.

Solís Ramírez, María Isabel. 2019. “Costa Rica Obligada a Reducir Incidencia de Tuberculosis.” CCSS Noticias, March 21, 2019. Caja Costarricense de Seguro Social. https://www.ccss.sa.cr/noticias/salud_noticia?costa-rica-obligada-a-reducir-incidencia-de-tuberculosis.


Carlos A. Faerron Guzmán is Director of Centro Interamericano para la Salud Global—InterAmerican Center for Global Health (CISG).

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