Abstract
Globalization calls for future generations of occupational therapists to effectively engage with culturally diverse client populations (Horton, 2009). Effective engagement with clients from multicultural backgrounds is what education scholars label international and intercultural competencies (Nagarajan & McAllister, 2015). International competence refers to adoption of a global perspective (e.g., on health care systems and policies; Knight, 2004). Health professionals with a global perspective are able to consider how various issues affect people in different parts of the world (Nagarajan & McAllister, 2015).
Intercultural competence is defined as a sense of relationship with other cultures (Knight, 2004) and entails curiosity, general openness and respect for other cultures, and cultural awareness and knowledge (Deardorff, 2006). According to Deardorff (2006), intercultural competence is an outcome of internationalization. Development of intercultural competence is a lifelong process and may be done in various ways, including international experiences such as study abroad programs, didactic course work, and on-campus interactions with students from different cultural backgrounds at the undergraduate level (Leask, 2009). Understanding the cultural contexts of people’s occupational worlds is significant in occupational science and occupational therapy (Hasselkus, 2011). To broaden perspectives of human occupation and to understand the role of culture in occupation, occupational science and occupational therapy students must be given opportunities to explore their sense of cultural selves and raise their awareness of personal biases, preferences, and choices (Baptiste, 2003) through education and exposure to other cultures (Humbert, Burket, Deveny, & Kennedy, 2012).
Internationalization of courses has become a necessity to build intercultural competencies (Horton, 2009; Nagarajan & McAllister, 2015). In occupational therapy education, these competencies have been built through two streams of internationalization: internationalization of the curriculum (IoC) and internationalization at home (IaH; Ilott et al., 2013). Leask (2009) defined IoC as the “incorporation of international and intercultural dimensions into the content of the curriculum as well as the teaching, learning and assessment arrangements and support services of a program of study” (p. 209); IoC includes study abroad opportunities and involves student mobility (Ilott et al., 2013).
Nilsson (2003) and Knight (2004) introduced IaH as an alternative to internationalization abroad; IaH integrates the same themes as in the formal and informal curricula but is made available to all students in the home campus (Beelen & Jones, 2015). Leask and Carroll (2011) highlighted creating new situations, in and out of the classroom, that foster cross-cultural interactions to promote inclusion and student engagement. Examples of IaH strategies include using international case studies in teaching, learning, and assessment; immersing oneself in local cultural and ethnic communities (Knight, 2006); and designing extracurricular activities that facilitate interactions between home and international students (Leask, 2009).
Existing research on internationalization in occupational therapy education has shown a positive impact on student learning. For example, Suarez-Balcazar, Hammel, Mayo, Inwald, and Sen (2013) reported that intercultural experiences helped develop students’ creative and collaborative skills during international fieldwork experiences. Mu, Coppard, Bracciano, Doll, and Matthews (2010) identified cultural competence, clinical reasoning, and leadership as learning outcomes of international outreach programs. Personal and professional development, such as the acquisition of adaptability, flexibility, cultural sensitivity, and awareness, were outcomes of international cross-cultural experiences (Barker, Kinsella, & Bossers, 2010; Humbert, Burket, Deveney, & Kennedy, 2012). Grajo and Aldrich (2016) found that intercultural learning experiences can be part of teaching foundational concepts in occupational therapy so that students have a more global understanding of occupation and people’s engagement in it. International learning experiences, however, are available only to students with financial resources and come with safety, risk, and sustainability challenges (Shimmell et al., 2016).
Learning outcomes achieved through IaH initiatives are still underexplored in the literature (Nagarajan & McAllister, 2015). IaH efforts have relied on virtual interactions. For example, nursing and science students from Canada and the United Kingdom used web-based technology for communication and understanding of international perspectives (Garrett & Cutting, 2012). In occupational therapy, Aldrich and Johansson (2015) and Sood and colleagues (2014) described using a web-based program in which they designed international, cross-cultural interactive sessions in the classroom, and they reported increased exposure of students to other cultures and increased knowledge about occupational therapy practices in other countries.
Research on internationalization efforts, both abroad and at home, has focused on learning outcomes related to knowledge of international occupational therapy practices and cultural competence (e.g., Barker et al., 2010; Sood et al., 2014; Suarez-Balcazar et al., 2013). However, articles describing these studies often do not provide details about how the IaH programs were designed or the specific outcomes that were measured or explored. This study aimed to address this gap in the literature. By exploring an IaH program, we sought to increase understanding of international and intercultural contexts of occupations among students in two occupational therapy programs, one in the United States and the other in the Philippines.
The aim of the IaH initiative was to understand perspectives on human occupation and the influence of culture on occupation among students of two universities. The design of this IaH initiative is grounded in a cross-cultural engagement model developed by Leask and Carroll (2011) that espouses the value of small-scale but carefully planned learning activities to promote student experiences of inclusion and engagement. Leask and Carroll’s model suggests the value of providing opportunities to engage in meaningful cross-cultural interactions and reflection and combining these with other pedagogies (didactics and discussions). The purpose of this study was to explore students’ perspectives on how an IaH initiative (web-based cross-cultural conversations) used in occupational therapy and occupational science courses in two universities, one in the United States (Saint Louis University) and one in the Philippines (University of the Philippines Manila), helped students develop an international and intercultural understanding of human occupation. In this study, we explored two questions:
How did the IaH initiative foster understanding of the international and intercultural nature of human occupation among students of the two collaborating universities?
What formal and informal teaching–learning strategies did students find most and least useful in developing an understanding of the international and intercultural nature of human occupation?
Method
Design
We used a collective case study design (Creswell, 2013) to answer our research questions. Our rationale for the use of this design is based on our aim to obtain in-depth understanding of an overall narrative of student perceptions about the intercultural learning experiences and the concepts they learned from the collaboration. By analyzing individual themes from each cohort of students and then reanalyzing the individual themes collectively, we sought to identify common patterns of perceptions about the potential impact of the IaH experience on student learning of concepts in occupation. Student responses from our questionnaires were treated as individual cases that were then collectively analyzed as responses for each cohort of U.S. and Philippine students. The institutional review and research ethics boards of both universities approved this study.
Collaborating Programs
Faculty members from the Philippines (Cabatan) and United States (Grajo) collaborated to develop the IaH initiative. The collaboration evolved from an existing mentoring relationship that developed between the two authors and initially aimed at finding ways for the two university programs to develop mutually beneficial teaching–learning experiences. Over a period of 10 mo before the pilot run, the authors met using video conferencing to discuss courses they teach, delineate shared learning objectives, and brainstorm ways to develop cross-cultural learning experiences for their students.
Teaching–Learning Experiences
Two cohorts of students from the two programs participated in active and experiential learning activities through online and virtual collaborations in the fall or first semester of 2014 and 2015. Table 1 shows the IaH learning activities for Cohorts 1 and 2 with enhancements done after receiving feedback from the initial run. Two courses provided the context of the teaching–learning collaboration: OT 122, Occupational Therapy Theory (Philippine undergraduate course) and OCS 3220, Contexts of Occupation (U.S. undergraduate course). The first author was co-coordinator of OT 122 in the first run and was involved in teaching the course for the second run. The second author was primary instructor of OCS 3220. OT 122 highlights theoretical perspectives on occupation and engagement and participation as factors in understanding humans as occupational beings. OCS 3220 focuses on understanding the influence of temporal, physical, social, cultural, personal, and virtual contexts in people’s choices of and participation in occupations.
Internationalization at Home Teaching–Learning Activities
Participant Recruitment
All students enrolled in OT 122 and OCS 3220 in 2014 and 2015 participated in the collaboration. Both cohorts were invited to participate in the study through an emailed recruitment statement and orientation sessions about the collaboration at the start of classes. Participation in the research study was optional. Completion and submission of the survey form signified the students’ consent to participate. The Philippine cohorts consisted of 58 (Cohort 1, n = 25; Cohort 2, n = 33) undergraduate occupational therapy students. The U.S. cohorts consisted of 102 (Cohort 1, n = 50; Cohort 2, n = 52) undergraduate occupational science students. Philippine students who were younger than age 18 yr at the time of data collection were asked to provide assent and parental consent.
Data Collection
For the full study, we developed an eight-item questionnaire that included five open-ended questions (Table 2) to assess student perceptions about the benefits of the collaboration. Although the entire questionnaire was administered, the focus of this study was on the responses to the five open-ended questions. The items in the questionnaire were formulated on the basis of discussions and analysis of the learning objectives of the two courses in the collaboration and essential concepts in occupational science (e.g., form, function, and meaning of occupations; impact of context in occupational participation) covered by these two courses.
Open-Ended Questions From the Survey and Reflection Prompts From the Analysis Papers
We administered the questionnaire anonymously (SurveyMonkey [Palo Alto, CA] for Cohort 1 Philippine students; Qualtrics [Provo, UT] for U.S. students) at the end of the semester for Cohorts 1 and 2. A paper-based version of the questionnaire was administered to Cohort 2 Philippine students. We also collected the reflection sections of the written analysis papers completed by the students (Table 2 provides a brief description of the reflection prompts). Sixty-five students (86%) from Cohort 1 (Philippines, n = 15; United States, n = 50) and 84 students (98%) from Cohort 2 (Philippines, n = 32; United States, n = 52) completed the questionnaire. For the purposes of this study, we analyzed only the responses from the open-ended questions of the survey and the student reflections. All students were informed that analysis of written reflections would commence after submission of grades at the end of the semester.
Data Analysis
We deidentified and lifted the reflection sections from the full analysis papers submitted by the students. We stored the reflections in a separate document from the responses to the open-ended questions for analysis. Data from the Philippine cohort were analyzed manually and electronically using Microsoft Word (Redmond, WA). Data from the U.S. cohort were analyzed through a qualitative coding software (Atlas.ti, Version 7.3; Scientific Software Development, Berlin, Germany).
We analyzed the data using categorical aggregation (Stake, 1995). We analyzed individual statements from each cohort of students for direct meaning and intent and aggregated similar statements and reflections to form common themes across cohorts. To establish trustworthiness and rigor, we used three methods: peer review, member checking, and documentation with research memos (Creswell, 2013). We independently analyzed data from our respective institutions and then exchanged data, codes, and themes to allow for verification and validation. Disagreements were resolved through discussions using video-conferencing and email. For member checking, we sent the initial themes back to the participants for feedback. The students confirmed the veracity of the themes and supporting quotes. We also created research memos to elucidate our thinking and decision processes during the analysis phase to establish an audit trail. Verbatim expressions are included in the Results section to illustrate the themes.
Results
Analysis of the reflection papers and responses to the open-ended questions support the overall positive and favorable feedback about gaining international and intercultural understanding of the nature of human occupation. Three main themes emerged from the analysis: (1) perception of increased knowledge and learning about human occupation and the influence of culture, (2) identification of teaching–learning aspects that facilitated intercultural learning, and (3) identification of factors that were enablers of and barriers to learning.
Increased Knowledge and Learning About Occupation and Culture
Three themes emerged regarding what students learned about the cultural context of occupational performance after participating in the IaH program: global nature of occupations, personal nature of occupations, and the power of culture in understanding occupations.
Global Nature of Occupations.
Participants from both cohorts stated that they found shared experiences in how occupations were chosen and performed in terms of activities, time use, value and meaning, and the ways performance was entwined in people’s lives regardless of culture:
I have learned that the occupations I engage in are very similar to the occupations teenagers across the world engage in.
It was amazing to learn how similar we actually are. A lot of times, you think about how different someone’s lives may be when they live on the other side of the globe, but this experience has just proved notions of the human condition through broadening our personal cultural competency.
As students, I realize that we were doing almost the same things—studying for exams, writing papers, finding time to balance studies and leisure, participating in extracurricular activities.
Personal Nature of Occupations.
Participants reflected on their subjective experiences of occupations. These experiences provided perspectives regarding the meanings of engaging in and performing occupations. Common reflections included how occupations contributed to participants’ personal growth and identity and transformed their worldview and sense of self, sense of control, and purpose:
I have become more aware of my strengths and weaknesses in academics. My sense of identity is changing.
Although we engaged in similar occupations, the way we performed each one made it unique for each one of us. . . . Even if we had shared occupations, its meaning and purpose for me and them differed. . . . There was always a difference in how, why, and where we do it.
I had never really considered why I do the things I do, but now I have learned to question whether the meaning behind my and others’ occupations comes from culture, my family, or myself.
I have learned that occupation is unique to the individual. To one person, it may hold a certain meaning, while it may not to the other.
Power of Culture in Understanding Occupation.
Three subthemes constituted the theme of the power of culture in understanding occupation: cultural awareness, cultural competence, and culture as a driving force for occupational participation. Cultural awareness was evident when participants reflected on modification of previously held stereotypes. Participants also reported having better knowledge and appreciation of their own and the other person’s culture. The experience of another culture, although mainly through virtual means, promoted the value of respect and openness. Participants also articulated how an intercultural perspective could be used as a tool for relationship building in occupational therapy practice. Related to culture as a driving force for occupational participation, participants reflected that they engaged in occupations to meet family and societal expectations and that their way of living influenced their choice and performance of occupations. The following statements from participants illustrate these subthemes:
Stereotypes exist among all people and countries, and the best way to debunk them is to get to know someone from that community.
I had to be consciously sensitive and open-minded during the interactions.
Our shared experiences can be used to have better understanding and relationships.
Discussing daily habits, routines, and rituals allowed me to learn and understand more of the Filipino culture, making me more competent.
I have learned that no matter what culture or setting that we grow up in, we each have a different sense of the human occupation because it is all about personal experience.
I have learned how everything from cultural values to family structure influences the occupations we do every day.
Identification of Teaching–Learning Aspects That Facilitated Learning
Three subthemes underlie the theme of teaching–learning aspects of the IaH program that promoted learning concepts about the international and intercultural nature of human occupation: learning through socialization, design and planning of teaching–learning activities, and learning from reflection.
Learning Through Socialization.
The subtheme of learning through socialization refers to the transformation of knowledge or skills gained from cross-cultural conversations with peers, including a better grasp of another culture and a perceived sense of personal growth in terms of improved communication and use of language:
The interactions improved my communication and social skills, even my use of the English language.
I think having questions to ask them about their different contexts helped me learn about them in a diverse way and kept the conversation interesting.
Being able to put the cultural, social, and virtual contexts into application with our Filipino partner via Skype allowed a real understanding and application of concepts we memorized for class exams and papers.
Designing and Planning Teaching–Learning Activities.
The participants reported that introductory activities and resources, such as faculty lectures, interaction guidelines, conversation topics, orientation to the other culture, and assignment of partners, promoted learning of international and intercultural perspectives about human occupation:
The types of questions provided helped guide us in meaningful conversations, but also led the way to other interesting conversations that we were interested in talking about and helped me to gain a larger understanding of my partner.
I found the lecture from their professor to be helpful in learning about their culture. It was kind of a starting point for my group to actually get specific topics out on the table.
Learning From Reflection.
The participants expressed that thinking and writing about the experience allowed piecing together of concepts learned in the classroom:
I think that the context analysis paper was the most helpful in learning about human occupation and cultural competence. I believe that I learned a lot from the paper itself because I was applying all of what I learned [during] the semester into one cohesive piece.
I enjoyed all of the international collaboration project; however, I think everything came together for me when I wrote the paper.
I found writing and [researching] our context with our group helpful in learning about the culture. I found the idea of discussing and comparing our partners with others in the class [helped] me get more understanding of the collaboration.
Factors That Influenced Learning
Factors that influenced the teaching–learning process included enablers and barriers that students identified.
Enabling Factors.
Learning enablers consisted of individual characteristics of the participants and the use of social media platforms and other virtual communication tools. Personality and willingness to participate in the interactions and share views, openness, and previous exposure to other cultures with partners were other factors that facilitated learning:
My prior experiences with other cultures fostered my understanding and appreciation.
Being able to talk in real time face to face via Skype [and] having Facebook to ask quick questions [facilitated learning].
Barriers to Learning.
Identified barriers to learning included factors such as preference for other modes of learning, perceived mismatch of partners and of schedules, inflexible scheduling of interactions, time difference, and limited access to or poor Internet connectivity:
I am an introvert, so the activity was not a good fit.
I would have preferred other forms of learning and more freedom to schedule an extended period of collaboration.
The time difference and busy schedules made it difficult to schedule interactions.
Poor Internet connections made it hard to interact.
The subsequent iteration of the IaH project included modifying some of the learning conditions. Suggestions for future runs included adding more class time interactions, monitoring interactions, exploring a partner matching scheme or self-selection of partners, 1:1 pairings, debriefing, and feedback from partners.
Discussion
This study illustrated the use of IaH as a teaching–learning strategy. Results from the qualitative analysis indicate that participants had positive perceptions about the cross-cultural learning experience. The experience enhanced students’ understanding of cultural influences on human occupation. Teaching–learning aspects and enablers and barriers to learning were identified.
Participants reported a deeper understanding of the entwined links of human occupation and culture. Several statements from participants emphasized that they found culture to be a driving force in choice, patterns of performance, and participation in occupations. This finding was consistent with Horton’s (2009) assertion that exposure to other cultures through international education programs brings about broader understanding of occupation and factors that influence it. Reflecting on their conversations with partners from a different culture facilitated participants’ integration of classroom learning, highlighting Leask and Carroll’s (2011) contention that relating cross-cultural experience to subject content makes learning more meaningful. Suarez-Balcazar and colleagues (2013) reflected on the transformative power of international interactions on student learning. Students in this study described the experience as an effective way to integrate and synthesize various concepts learned in class.
Virtual cultural experiences are an alternative means of cultural exposure. The findings from our study support the conclusions of Aldrich and Johansson (2015) and Aldrich and Grajo (2017) that a virtual platform may be an effective means for collaborating cross-culturally; learning concepts in occupation and components of intercultural competence, such as respect and openness; and increasing critical cultural consciousness.
The majority of the students reported positive experiences about being part of the IaH project, but there were challenges. Some students interacted and collaborated only to complete course requirements. It is reasonable to state that using virtual cross-cultural collaboration is not for everyone. This finding appears to be congruent with those of Leask and Carroll (2011), who noted that cross-cultural engagement is uncomfortable, time consuming, and effortful for some students. For the second cohort, we modified the teaching–learning collaboration in terms of giving topics of conversation to guide the conversations and a schedule of weekly interactions in consideration of the time difference between countries. Some students found the structure to be enabling, whereas others preferred more freedom.
This IaH initiative was born out of the involved faculty members’ professional relationship. Relationships with international partners create opportunities for international education at home and abroad (Shimmell et al., 2016). From the two iterations of this collaboration, we have learned a lot, particularly about planning, implementing, and sustaining this type of collaboration. We learned to build and strengthen the support structure for such activities.
Findings from this study suggest that IaH is a viable approach to enhance learning outcomes related to gaining perspectives on human occupation and intercultural competence in occupational science and occupational therapy education. Virtual cross-cultural conversation can be an appropriate milieu for IaH initiatives. However, a single learning experience may not be sufficient to develop international and intercultural competencies (Leask, 2009). Cross-cultural experiences need to be threaded into different stages of a student’s program of study to build these competencies.
Limitations
This study is a pilot application of an IaH initiative. It focused on students’ qualitative perceptions of the outcomes of cross-cultural experiences embedded in two courses of an occupational science and an occupational therapy program. There were no measurements of outcomes at pretest and posttest using standardized assessments to objectively assess intercultural competence. The cross-cultural experience was designed to last a limited period, and participants interacted with only one or two students from a different culture; these constraints may have influenced the overall results. Although students were informed that analysis of the reflection would commence after submission of grades, the knowledge that this was part of the grade could have influenced their responses. Our involvement in the teaching of the courses and assumption that learning would occur as a result of the collaboration, as reflected in our first research question, may reflect an inherent bias that may have influenced analysis and interpretation of the responses in the study.
Implications for Occupational Therapy Education
This study aimed to explore the pedagogical utility of internationalization in an occupational science and an occupational therapy curriculum without the need for mobility. Implications for use of IaH as a teaching and learning model in occupational science and occupational therapy education are as follows:
Students may be able to develop globalized perspectives of human occupation and intercultural competence without mobility using virtual technologies. Such pedagogical innovations may be time intensive because of the need for careful planning and implementation but reduce cost and safety risks for students and faculty. Increased and sustained interactions with students from different cultures at different stages of the curriculum can be used as a model for planning similar IaH initiatives.
Socialization, design of teaching–learning structures, and reflection are processes that facilitated learning after participation in an IaH initiative. These strategies can be essential components of various internationalization teaching and learning collaborations.
Learning outcomes and activities for international and intercultural competence can be systematically contextualized to promote inclusion and cross-cultural engagement. Educators need to engage in careful and thoughtful analysis of course content and curricular objectives to embed components of intercultural competence in their programs.
Use and further development of standardized measures of intercultural competence and learning can be useful for educators to allow triangulation of qualitative and quantitative data.
Footnotes
Acknowledgments
The authors thank the faculty and students of the University of the Philippines Manila (UPM) and Saint Louis University for their participation in and support for the collaboration. We also acknowledge the technical assistance provided by Faith Deanne Caube of UPM.
Note. Each issue of the 2017 volume of the American Journal of Occupational Therapy features a special Centennial Topics section containing several articles related to a specific theme; this issue highlights occupational therapy’s role internationally. The goal is to help occupational therapy professionals take stock of how far the profession has come and spark interest in the many exciting paths for the future. For more information, see the editorial in the January/February issue, 
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