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Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 223-229

Impact of a cross-cultural, inter-professional, ocular disease themed international elective for australian optometry students – A pilot study

Department of Ophthalmology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission30-Jun-2021
Date of Decision28-Aug-2021
Date of Acceptance02-Sep-2021
Date of Web Publication07-Dec-2021

Correspondence Address:
Dr. Jeyanth Suresh Rose
Department of Ophthalmology, Christian Medical College, Vellore - 632 002, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_67_21

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Background: International electives provide students an opportunity to experience diversity in educational content and the impact of social settings on health-care delivery. Primary eye care provided by optometrists is a crucial aspect of the ocular health chain. Optometrists play a large role in the early diagnosis and prevention of ocular diseases. Knowledge and skill acquisition in ocular diagnostics involving a spectrum of diseases that students have fairly limited exposure to in Urban Australian settings would go a long way in ensuring the wholeness of the optometry curriculum. Methods: The International Elective in Tropical Eye Disease and Community Eye care (TEDCE), based in a tertiary teaching eye hospital in South India, intended to impart this body of knowledge. This study is an educational-program evaluation study that assessed the change in knowledge, skills, and attitude of 10 International Optometry Students before and after TEDCE. Knowledge and skill were measured using multiple choice questions (MCQS) and objectively structured clinical examination (OSCE). Attitude OSCEs was quantified using the the readiness for inter-professional learning scale questionnaire. Results: The pretest MCQ showed a mean score of 44.40 ± 6.22 and posttest MCQ improved to 51.80 ± 3.85. Similarly, the pretest OSCE showed a mean score of 7.10 ± 1.52 and posttest OSCE improved to 12.05 ± 2.58. Qualitative questionnaire analysis indicated that students had better chance to understand interprofessional benefits and limitations. Conclusion: The analysis of the results indicates a positive impact of intervention with respect to knowledge, skills, and attitude gained.

Keywords: Clinical knowledge, international electives, optometry education, quantitative assessment, readiness for inter-professional learning scale questionnaire, tropical eye disease

How to cite this article:
Roy P P, Devamani K, Joshua A, Joshua G, Slecer R A, Susan V S, Lalgudi S, Rose JS. Impact of a cross-cultural, inter-professional, ocular disease themed international elective for australian optometry students – A pilot study. Curr Med Issues 2021;19:223-9

How to cite this URL:
Roy P P, Devamani K, Joshua A, Joshua G, Slecer R A, Susan V S, Lalgudi S, Rose JS. Impact of a cross-cultural, inter-professional, ocular disease themed international elective for australian optometry students – A pilot study. Curr Med Issues [serial online] 2021 [cited 2023 May 29];19:223-9. Available from: https://www.cmijournal.org/text.asp?2021/19/4/223/331838

  Introduction Top

International elective programs are widely recognized and sought-after options for students of various educational fields including medicine, economics, and international relations, among others. The idea that individuals are a part of and contribute in a cumulative way to pressing global issues, draws to the need for more institutions to create opportunities for students to gain first-hand experience and awareness in the various fields of interest.

Global health has become the need of the hour, where countries aim to partner together to provide the best possible treatment options and care for patients. Whether through pharmaceutical or medical equipment trade, research or others, the medical field has studied the importance of making a global health elective an essential component in medical school training.[1] Studies have reported that International Health Electives provide educational benefits in advancing knowledge (tropical diseases, cross-cultural issues, health-care delivery, and others), skills, and fostering attitudes and values (community service, interest in serving underserved populations, and others).[2]

Despite a significant amount of literature available on international medical electives, there is much less information on international electives in the field of vision sciences.

Optometry and vision science are rapidly growing fields in health sciences pertaining to the understanding of the visual apparatus and its biology. The current COVID-19 pandemic has made the profession much more visible on a global scale than it ever was. Many of the research, recommendations, and sight-related policies made with respect to the usage of virtual platforms have relied heavily on bodies associated with optometry and vision science.[3],[4],[5] From the clinical perspective, optometrists are primary eye care providers, dedicated to the early diagnosis and identification of ocular disease. Educational approaches of such professionals have a special relevance when viewed in the perspective of globalization. Early exposure and training beyond the boundaries of geographic location assumes great relevance in the present age.

In order to understand the attitude toward interprofessional education (IPE), some studies have been conducted among medical colleges and much less among the allied health professions. In 2004, a study was done to measure a student's perception of interprofessional health-care services postinterprofessional rural training. Regardless of the duration of the training, a significant change in attitude and perception was found, with a higher positive attitude for those in the long-term training.[6]

In 2014, a study was conducted where the attitude and perception of two groups of health professionals on IPE were compared, with one group having no exposure to IPE.[7] Both groups were required to complete two questionnaires, University of West England Interprofessional Questionnaire and readiness for interprofessional learning scale (RIPLS).[8] Results found that there were significant positive changes on both scales for the group that received the intervention of an IPE. The benefits, therefore, of an IPE on the mouldable personality of a student who wishes to work in the health care sector is immense. Students in an IPE system have the opportunity to learn skills that will equip them in the current demands of the work environment and also benefit them personally. Some of these skills include: Negotiation skills, leadership, teamwork, conflict management, improved self-confidence and competence in practice, developing mutual respect for other professions, improved delivery of care, and breaking down barriers of learning from others.[9]

  Methods Top

Study design

A prospective educational intervention study was designed at a tertiary eye care hospital in South India, to find the impact of an international elective in Tropical Eye Disease and Community Eye (TEDCE) care on Australian Optometry students.

Study setting

Prefinal year optometry students from Australia were offered a 3 week, carefully planned international elective in TEDCE. The curriculum focused on ocular diseases with a higher prevalence in the Tropics and how the health-care system offered approaches to combat them. The intention was to provide international students a clinical experience and logic health care model, possibly different from their practice back home.

Study development

The study was conducted according to the tenets of the declaration of Helsinki and received approval from the Institutional review board and Research ethics (IRB N0: 12313, dated: September 30, 2019)

Preparatory phase

Pre-final year optometry students from the University of Melbourne and Flinders University, Adelaide, were offered international electives at Christian Medical College, Vellore, a tertiary teaching medical institution in South India. Of the applicants, 10 students were selected to travel and take part in the elective which was called International elective in-TEDCE. The objectives of TEDCE were:

  1. To enhance the knowledge to diagnose, prevent and provide primary eye care for common tropical eye diseases
  2. To develop the skill to identify clinical signs on ocular examination that will lead to the correct diagnosis of the common tropical eye diseases
  3. To understand a model of inter-professional practice and cost-effective health-care delivery in the field of optometry
  4. To understand local customs, beliefs, and social determinants of eye health in communities.

A core curriculum consisting of tropical ocular diseases that have a significantly higher prevalence in the tropics was prepared by an expert panel [Table 1].
Table 1: The cluster module topics that were covered in the 3-week elective program

Click here to view

This study was a program evaluation study which was designed to assess if the objectives of the program had been achieved with respect to knowledge, skill, and attitude.

Execution phase


A pretest was conducted before starting TEDCE. Baseline knowledge, skill, and attitude of the students were assessed using the following tools.

The knowledge component was assessed using 70 multiple choice questions (MCQs). Distractors were critically reviewed to enhance the reliability of the test. The skill component was assessed using a patient-based Objectively Structured Clinical Examination (OSCE). All MCQs and OSCEs underwent a content and construct validity check by an expert panel. A validated and standardized questionnaire scale for attitude assessment-”The Readiness for Inter-professional Learning Scale” (RIPLS) was elicited from the students before the intervention. The RIPLS questionnaire is a 19-item tool that has been used among health-care students and professionals to assess the attitudes and perceptions of their readiness for interprofessional learning and change. It contains three subscales: Teamwork and collaboration, professional identity and roles and responsibilities, having an internal consistency of 0.9. It proposes to measure a change in attitudes, the effect of different interventions, and the effectiveness of these interventions on changing perceptions and attitudes.[10]


Clinical exposure

The daily routine of the elective ran as two sessions: morning session (AM) and noon session (PM)

Morning session (AM)

The students were exposed to bedside clinics/ward rounds (eye care in India is both inpatient and outpatient) for 1 h. They would observe presentations of patients admitted for various procedures in the eye hospital. Clinical findings would be demonstrated and a discussion on various aspects of diagnosis and management would follow. This session at the bedside, had a larger focus on ocular diseases that required surgical solutions. The students were also exposed to postsurgical care of the various ocular diseases that underwent surgery including cataract, vitreoretinal disease, keratoplasty, squint, and glaucoma. A 30 min lecture followed this session that covered the themes of the elective. Subsequently, students were posted in the outpatient consultation cubicles for 1.5 h in groups of 2. Students had access to slit lamps, ophthalmoscopes, and other tools needed for the examination. Clinical signs, documentation procedures, human resource management, and delivery of care were observed. This outpatient time had a richer spectrum of ocular diseases relevant to medical themes. The eye hospital also handles a large number of referrals from various other medical specialties such as rheumatology, neurology, and endocrinology. The students observed a spectrum of systemic diseases and their ocular manifestations. This was followed by small group clinics on patients with ocular diseases mentioned in [Table 1]. The patients were preselected by the investigators and informed consent was obtained for participation in the study protocol This small group clinic involved a detailed clinical work up by a group of students (two students on a day), followed by a presentation and detailed discussion on management options, social determinants and preventive care, customized for that patient. They were encouraged to justify their diagnosis, provide differentials, look at the patient holistically and talk about ways in which the health system did or did not achieve early diagnosis and treatment of the disease. Demonstrations were done with slit lamp cameras fixed to monitors to ensure easy visibility and time efficiency. The language barrier was overcome by ensuring that the small groups had both national and international optometry students.

Noon session (PM)

The postlunch session was divided into two parts:

A case-based learning module was housed in the college library which had access to an array of books, e-learning resources, and journals. There was a mentor who led the discussions and the students had a template for documenting their discussions and references.

The second half of the noon session consisted of reflective practice. The students were asked to free text any new/interesting fact/finding they had seen the same day. They were allowed to collect photographs of clinical findings if available from the hospital. This resource was shared with the larger group and the students were encouraged to discuss and ponder upon the differences in management of cases they were allotted. The intention was to get every small group (two students) to share their clinical experience spectrum to the larger group thereby providing maximum benefit for everyone.

Community exposure

The students also got to spend some time under the outreach department where they had a clinico-social case discussion of the patient's life aspects including clinical issues, visual rehabilitation, access issues, social issues, and financial issues. Students also had an opportunity to visit a leprosy home and peripheral eye outreach camp through one of the mobile outreach clinics.


After 3 weeks of clinical and community exposure, the students underwent a posttest. The posttest assessment of knowledge, skill, and attitude was done using MCQ's OSCE and RIPLS questionnaire (same as the pretest).

A qualitative questionnaire was added to the study to assess quality management issues, host friendliness, and logistic arrangements of the TEDCE program.

Statistical analysis

All the numeric data were entered into SPSS (version), and statistical analysis was done. Paired t-test and Wilcoxon signed rank was performed to look for significant differences between pre and posttest. Qualitative data from the qualitative questionnaire were analyzed by three researchers using thematic analysis, where data were coded and recurring themes were described and interpreted.

  Results Top

A total of 10 students participated in the study, of which three were male (30.0%) and seven were female students (70.0%). The age of the study population ranged from 21 to 26 years (mean age is 23.5 with an standard deviation of 1.7).

Quantification and comparison of knowledge scores

Knowledge was quantified by using 70 MCQs:

• The pretest MCQ scores ranged from 36 to 54 [Table 2]
Table 2: The individual pretest and posttest multiple choice questions and objectively structured clinical examination scores and percentages

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• The posttest MCQ scores after the intervention ranged from 48 to 61 [Table 2].

The MCQ score analysis using the Wilcoxon signed-rank test showed a statistically significant increase (P < 0.05), in the knowledge of tropical eye diseases [Figure 1].
Figure 1: Graph showing the Pre and Post-test comparison of MCQs result.

Click here to view

The overall mean assessment of pretest MCQs was 44.40 and posttest MCQs was 51.80 [Table 2].

Quantification and comparison of knowledge scores

Skill was quantified using OSCE with a maximum score of 20.

• The pretest OSCE scores ranged from 3.5 to 9 [Table 3]
Table 3: The comparison of pretest and posttest mean multiple choice questions and objectively structured clinical examination scores

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• The posttest OSCE scores after intervention ranged from 8 to 14.5 [Table 3].

The overall mean score of the pretest OSCE was 7.10 and posttest OSCE was 12.05 [Table 2]. Comparison of means using the Wilcoxon sign test showed a statistically significant increase (P < 0.05), in the pre and posttest OSCE score [Figure 2].
Figure 2: Graph showing the Pre and Post-test comparison of OSCE result.

Click here to view

Quantification of attitude

• The pre-RIPLS score ranged from 75 to 91

• The post-RIPLS score ranged from 63 to 91.

The comparison of pre-test and post-test mean Readiness for Inter-professional Learning Scale scores (attitude) is shown in [Table 4]
Table 4: The comparison of pretest and posttest mean Readiness for Inter-professional Learning Scale scores (attitude)

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Qualitative questionnaire result

On analysis of the qualitative survey from the interview data four main themes were identified as listed in [Table 5].
Table 5: Content themes and examples of evidence

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  Discussion Top

The international elective in TEDCE is a learner centered educational module that was developed to enhance knowledge, skill, and attitude of international optometry students in tropical eye diseases and community eye care. To the best of our knowledge, this is the first time an educational module with the above structure has been executed for optometry students. Although planned for 6 weeks, TEDCE was shortened by the COVID pandemic to 3 weeks. The investigators decided to perform the outcome measures at 3 weeks. This program evaluation study measures if TEDCE was effective in achieving its intended purpose and objectives. The objectives of TEDCE revolved around ocular diagnostics relevant to diseases with a significantly higher prevalence in the tropics and developing world. The spectrum of ocular disease in Australia is quite different from India.[11] However, all diseases are seen all over the world but in different proportions.

The core curriculum encompassed 10 themes that covered the most common tropical eye diseases that are seen in India. Objectives drawn from this curriculum included the first five hierarchical levels of Bloom's taxonomy-Remember, Understand, Apply, Analyze and Evaluate. The objectives were segregated into knowledge and skill separately. Assessment tools were aligned to the objectives and all measures were fine tuned to be construct and content valid by an expert panel. The pretest measures were done using MCQs and OSCE's which are common assessment tools used in medical pedagogy with a high validity and reliability.[12],[13] The clinical competence assessment encompassed the first 3 tiers of Millers pyramid of clinical competence-Knows, Knows how, and Shows how.

The mean MCQ pretest score which was 44.4, improved to 51.80, showing a 16.71% increase (P = 0.012). The mean OSCE pretest score of 7.10, improved to 12.05, showing a 69.71% increase in performance (P = 0.007). The change in knowledge and skills with respect to diagnosis of tropical eye diseases showed a statistically significant rise following the intervention. The more remarkable increase in skill score is a reflection of the experience and time spent with real patients that resulted in a learning that cannot be simulated in the absence of these real-time experiences.

In our study, the attitude toward interprofessional learning was assessed using a questionnaire RIPLS. The students however demonstrated “;readiness for interprofessional learning” prior to beginning the TEDCE program, which was evident from the high pretest scores. A study done among health-care students showed that students demonstrated readiness for interprofessional learning at the start of their training, with higher scores among those who had prior experience in health care.[14] The pretest data showed that students already possessed a high degree of positive attitudes toward inter-professional education, teamwork, collaboration, and professional identity. This might be attributed to a suitable student selection criterion that was employed for this program. In our study, there was no significant difference in the pre and posttest scores of the attitude of the students regarding interprofessional learning, (P = 0.20).
Figure 3: Graph showing the Pre and Post-test comparison of RIPLS result.

Click here to view

Several possible reasons could be given for the decrease in scores on the RIPLS posttest. Due to the COVID pandemic, several changes had to be made to the program. Students were anxious about whether they were to return before the 6 week program was complete, or to continue the program. It was during this time, the RIPLS posttest was conducted. Furthermore, as the community/rural aspect of the program was cancelled due to the time constraint, students were not able to experience that aspect of interprofessional learning. A study done by Mu et al.[6] showed a significant difference in attitude and perception on interprofessional learning, and students who participated in a longer training period reported more positive attitude on the posttest.

The study environment where the intervention was carried out possessed a unique work culture of holistic practice. Ophthalmologists, optometrists, opticians, orthoptists, nurses, administrative staff, and community health workers, worked under the same shelter to provide a one-stop solution to a myriad of eye problems. Inter-professional practice was therefore an integral part of the work ethic. The attitude of students toward inter-professional education remained positive postexposure.

In the qualitative survey, four main themes were identified from the responses to the open-ended questions, using thematic analysis.

Interprofessional education is important for better patient care

All participants expressed the need for inter-professional education in the field of vision science. All resounded that inter-professional education helps to better understand capabilities and limitations of each profession, and the knowledge that can be dispensed from Ophthalmologist to Optometrist, in giving a holistic view of patient's needs.

Cross-cultural community hospital experience is beneficial

Six participants expressed the need for optometrists to be available in the wider community. These participants detailed the critical role of the optometrist in reducing the morbidity of preventable blindness.

Exposure to patients with rarely seen eye diseases (in Australia) aided in consolidating learning

Six participants stated being able to observe many cases of diseases, which had either been read about or previously studied during their course in Australia but not been seen prior to their elective. Patients with end stage eye disease, avoidable blindness, corneal infections, Hansen's disease with vision problems, among others, were mentioned.

Challenges experienced during the international elective were expected; support received from faculty and students was invaluable

All participants were able to cope with the challenges arising from cultural differences, climate differences, and a packed schedule unlike experienced before.


Limitations of this study include the limited sample size and the short duration of follow-up that had to be done because of the COVID pandemic. However, the positive results obtained over a relatively short duration of time are encouraging.

  Conclusion Top

The international elective in TEDCE significantly improved knowledge and skill in tropical eye disease diagnostics among Australian Optometry students. The program model was well accepted and logistically operational. Cross-cultural differences and inter-professional education were appreciated.

Research quality and ethics statement

The study was conducted according to the tenets of the declaration of Helsinki and received approval from the Institutional review board and Research ethics (IRB N0: 12313, dated: 30/10/2019).

Financial support and sponsorship

This study was financially supported by Research Grant from Christian Medical College, Vellore.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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