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Gerontology & Geriatrics Education

ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: https://www.tandfonline.com/loi/wgge20

International fieldwork in the age of global aging:fostering intercultural competence throughstudent research and service provision in aresidential care facility for older Guatemalans

Margaret A. Perkinson

To cite this article: Margaret A. Perkinson (2019): International fieldwork in the age of globalaging: fostering intercultural competence through student research and service provision ina residential care facility for older Guatemalans, Gerontology & Geriatrics Education, DOI:10.1080/02701960.2018.1561445

To link to this article: https://doi.org/10.1080/02701960.2018.1561445

Published online: 07 Jan 2019.

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International fieldwork in the age of global aging: fosteringintercultural competence through student research and serviceprovision in a residential care facility for older GuatemalansMargaret A. Perkinson

Center on Aging, University of Hawaii at Manoa, Honolulu, HI, USA

ABSTRACTRepresenting one model of global aging education, internationalgerontological fieldwork placements provide opportunities to gainfirsthand knowledge of the impact of cultural contexts both on theexperience of aging and the provision of eldercare. The gerontologycomponent of the NAPA (National Association for the Practice ofAnthropology)-OT Field School in Antigua, Guatemala fostered inter-cultural competence through student engagement in eldercareresearch and service provision in a residential care facility for olderGuatemalans. Field trips to additional medical and gerontologicalcare settings expanded students’ perspectives of Guatemalan healthand aging networks. The process of implementing the internationalgerontological fieldwork model and issues involved in its day-to-dayenactment are described, including the development and initial yearof the program, its underlying theoretical framework of social andoccupational justice, the challenges involved, the trajectory of stu-dent involvement in the facility, social dynamics among students andresidents, and the final outcomes of our work.

KEYWORDSApplied anthropology;cultural competencetraining; occupationaltherapy; social justice;service learning

To address global aging issues in an increasingly interconnected world, the upcomingcohort of gerontologists must have a strong understanding of and sensitivity to culturaldiversity as it impacts later life experience and provision of eldercare (Jackson, 2008;Perkinson, 2013). The NAPA (National Association for the Practice of Anthropology) –OT (Occupational Therapy) Field School in Antigua, Guatemala was established to fosterintercultural competence through student engagement in health-related research andservice provision while contributing to the well-being of persons inhabiting the fieldsettings. This six-week intensive summer program offers cross-cultural service-learningexperiences for graduate students in anthropology and occupational therapy.

The gerontology component of the field school represents one model of global agingeducation (Perkinson, 2013). The immediate goals of that component reflected the generalgoals of the field school as realized within a gerontological setting and included: (1) trainstudents in anthropological research methods and the use of research data to inform OTpractice within a residential care facility (hogar) for older Guatemalans, (2) contribute tothe well-being of members of the field site and address issues of social and/or occupationaljustice within that setting, and (3) prepare students for future work with diverse popula-tions by fostering intercultural competence.

CONTACTMargaret A. Perkinson map3@hawaii.edu Center on Aging, University of Hawaii at Manoa, Honolulu, HI 96822This article has been republished with minor changes. These changes do not impact the academic content of the article.

GERONTOLOGY & GERIATRICS EDUCATIONhttps://doi.org/10.1080/02701960.2018.1561445

© 2019 Taylor & Francis Group, LLC

Impact of study abroad and international fieldwork placements

Impact on students: developing intercultural competence

Growing numbers of students are opting for international study. Studying abroad islinked to a number of positive outcomes, e.g., an expanded world-view, moresophisticated political and social perspectives, increased self-confidence and toleranceof ambiguity, and increased intercultural competence (Clarke, Flaherty, Wright, &McMillan, 2009; Giovanangeli & Oguro, 2016). Participation in international clinicalplacements results in similar benefits (Boggis, Kelly, Schumacher, Randt, & Erickson,2013; Suarez-Balcazar, Hammel, Mayo, Inwald, & Sen, 2012).

Intercultural competence, a concept central to the field school, is an ongoingprocess that involves several dimensions of understanding and action (Browne &Mokuau, 2008; Deardorff, 2006; Hill, 2006): cognitive (i.e., knowledge of one’s ownand other cultures), affective (i.e., empathy, respect, curiosity), and behavioral (i.e.,appropriate interactions in different cultural contexts) (Bennett, 2009 ; Lustig &Koester, 2006). This includes the ability to “gather, interpret, and act upon…radicallydifferent cues across cultural settings or in a multicultural situation” (Earley &Peterson, 2004, p. 105). Although multiple definitions of intercultural competenceexist, all include the ability to interact effectively and appropriately with personsfrom other cultures based on knowledge, attitudes, skills, and behaviors that reflectsensitivity to and appreciation of cultural differences. Intercultural competence goesbeyond a simple accumulation of facts and knowledge of a given culture. It entailsthe development of a critical cultural self-awareness and subjective exploration andcontemplation of other worldviews (Bennett, 2009; Perry & Southwell, 2011). It isbest achieved through experiential learning that entails both extended interactionwith individuals of other cultural backgrounds and empathy with their lived experi-ences (Kleinman & Benson, 2006; Perry & Southwell, 2011).

Intergroup contact theory explains how personal encounters with previously unfamiliarcustoms, environments, people, and/or languages, combined with thoughtful reflection onthose encounters, might lead to intercultural competence (Davies, Tropp, Aron, Pettigrew,& Wright, 2011; Perry & Southwell, 2011; Pettigrew, Tropp, Wagner, & Christ, 2011;Pöllman, 2013). Certain conditions increase the likelihood of attaining interculturalcompetence: (1) equal status among the groups in question, (2) common goals, (3)intergroup cooperation, and (4) support from social and/or institutional authorities(Allport, 1954; Brown & Hewstone, 2005; Pettigrew & Tropp, 2006). Underlying processesby which intergroup contact leads to increased intercultural competence include: (1)awareness, i.e., learning about the other group and alternate worldviews, cultural self-awareness (Bennett, 2009); (2) engagement, i.e., meaningful interactions with groupmembers, development of affective ties or empathy, and reappraisal of attitudes towardand perceptions of the group (Everett, 2013; Pettigrew, 1998; Tausch & Hewstone, 2010);and (3) “bringing knowledge home,” i.e., rethinking life choices, values, and beliefs(Giovanangeli & Oguro, 2016). The field school and its gerontology component offeredopportunities for extended personal encounters within various Guatemalan settings andfor individual and group reflections on those encounters with the intention of fosteringintercultural competence.

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Academic and social impact: intellectual foundations and praxis

The field school emerged as a response to parallel developments in both occupational therapyand anthropology. Leading OT scholars have urged colleagues to consider the larger socio-political and cultural issues in which their clients operate (Kronenberg, Algado, & Pollard,2005), recognizing that social and cultural factors can present barriers to participation in“occupations” (i.e., meaningful and valued activities, not limited towork-related roles) that arejust as daunting as barriers posed by physical or cognitive impairments. Occupationaltherapy’s definition of client has broadened in scope to include community-based interven-tions, as well as therapies targeting individuals (AOTA, 2014). This expanded vision of thefield requires additional knowledge and expertise of a distinctly anthropological nature, e.g.,sensitivity to the dynamics of social systems and cultural context, intercultural understandingsand collaborations, and the ability to conduct rapid assessments of community needs.

In a complementary disciplinary development, proponents of the growing subfield ofpublic anthropology (Clifford-Hall & Frank, 2012; Lamphere, 2004; Rylko-Bauer, Singer,& Van Willigen, 2006) acknowledge the moral mandate (and alternate employmentpossibilities) for a more applied and engaged stance in the field. In the subfield of medicalanthropology, this entails greater attention to structural inequalities that underlie healthdisparities (Scheper-Hughes & Lock, 1987).

Following these recent lines of intellectual convergence, the field school emerged asa conscious attempt to bridge the two disciplines of OT and anthropology and foster newmodes of collaborations. Employing a transdisciplinary approach, faculty and studentsexplore interconnections among anthropological and OT concepts, theories, methodolo-gies, bodies of knowledge, and approaches to action/practice within the context of variousGuatemalan healthcare settings. Espousing “advocacy education,” the field school operateswithin the conceptual framework of social and occupational justice, approaching health,healthcare, and access to meaningful activities as a human right, and strives to benefit bothstudents, the local community, and the field sites (Clifford-Hall & Frank, 2012; Pollard,Sakellariou, & Kronenberg, 2008).

The gerontology component of the field school extends the “transdisciplinary bridge”by incorporating theory and methods from both anthropology and occupational therapy/science to inform work with older Guatemalans and to reexamine basic gerontologicalconcepts (e.g., successful aging) within a different cultural context.

General background: location, structure, and curriculum of the field school

The country and its challenges

The field school’s orientation to social and occupational justice and human rights isespecially relevant in Guatemala, with its extreme social stratification and history of ethnicand class violence. Although the 1996 Peace Accords marked the official end of theGuatemalan Civil War, the aftermath of social disruption continues to haunt. Over halfof Guatemalan families (and 76% of Mayan families) live in poverty (Gragnolati & Marini,2003; Morgan-Taylor, 2008; PAHO, 2007; Perkinson, 2012). Extreme disparities in dis-tribution of land, wealth, and health resources make it one of the most socially andeconomically stratified countries in the Western Hemisphere (Gragnolati & Marini,2003). The government lacks resources and facilities to provide adequate geriatric care

GERONTOLOGY & GERIATRICS EDUCATION 3

(Avila et al., 2015). The few existing hogars are supported by religious groups or areprivately owned and have minimum regulatory oversight.

Organization of the field school

National organizational baseThe National Association for the Practice of Anthropology (NAPA), a national organiza-tion for applied anthropology and subunit of the American Anthropological Association(AAA), serves as the field school’s professional institutional organizational base. Fieldschool faculty members are medical and applied anthropologists and occupational thera-pists from an international array of universities.

Local organizational baseTecun Uman, a local Spanish language school, serves as a critical contact. In addition toproviding required language training, it arranges home stays for field school students andfaculty, provides reliable and safe long-distance transportation, and offers various culturalexcursions.

Structure and core curriculum of the field school

Fourteen students, six full-time faculty, and five part-time faculty participated in the fieldschool’s inaugural year. Faculty and students combined represented twelve differentuniversities from the U.S. and Guatemala.

After initial orientation to Guatemala and to Antigua, students began the core curriculum:12 hours per week of intensive, one-on-one training in Spanish atTecunUman and review of thepolitical and social history and contemporary culture of Guatemala and its healthcare systemsthroughweekly seminars, field trips, guest lectures, andfilms. Field trips targeted healthcare sites,(e.g., indigenous healers, rural government health posts, national hospitals, NGO clinics) andlocal programs (e.g., an indigenous weavers’ co-op, grassroots programs in community devel-opment, the founding meeting of an alliance of local NGOs), expanding students’ exposure toGuatemalan life and culture and to its social and health disparities. Living in home stays withlocal families reinforced language skills and understanding of Guatemalan culture. The groupseminars also included discussions and interpretation of students’ fieldwork experiences, pro-viding opportunities for reflection with student peers and faculty.

The gerontology fieldwork placement

The fieldwork placements represented the heart of the field school experience. Studentsworked in teams for 12–15 hours per week within one of three field sites: a pediatric wardwithin a residential hospital, a Center for Independent Living, or a residential care facilityfor older adults (hogar). The remainder of this article describes the gerontology fieldworkproject in its first year of operation to provide an in-depth account of its development. Toreiterate, the gerontology fieldwork goals were to: (1) train students in anthropologicalresearch methods and the use of research data to inform OT practice within a hogar, (2)contribute to the well-being of members of the field site, and (3) prepare students for futurework with diverse populations of older adults by fostering intercultural competence.

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Faculty accompanied students during fieldwork and responded to questions related tostudents’ observations (e.g., discussing the use of restraints in the hogar; providingguidance on increasing range of motion for a resident with Parkinson’s disease; givingfeedback on interviewing techniques).

The gerontology field team

The first year’s gerontology cohort consisted of five students, one full-time and two part-time faculty members (the gerontological OTs each worked three-week half sessions), anda full-time project translator. All five students, young women from the U.S., had workingknowledge of Spanish. Four were completing the second (final) year of their OT master’sdegree programs, the fifth was completing a degree in anthropology.

All faculty members had extensive experience in gerontological research and/or practice inresidential care. The two OT faculty members were licensed OTs, one with a PhD in publichealth, the other a PhD candidate in anthropology. The anthropologist had a PhD in humandevelopment and aging, specializing in medical anthropology. She directed the gerontologycomponent and supervised its research activities during the six-week period. The projecttranslator had a master’s degree in anthropology and native-level fluency.

The field site

History and physical layoutThe director and her brother founded the hogar as a group home for older Guatemalans inneed of residential care. After his untimely death, she continued on her own with limitedresources to fulfill their joint dream. In 2009, the first summer of our fieldwork, the hogarhoused 65 residents. The facility was a walled compound containing two main buildings.The first housed the reception and administration areas, kitchen, isolation room, andlaundry room. A gated area contained two bedrooms for men and two for women, eachwith five or six beds. When not in their rooms, residents congregated in the hallways,where they also dined. The second building was locked to prevent wandering. It containedtwo very large windowless bedrooms, segregated by gender. Mattresses lined the peri-meters of the rooms; each room accommodated approximately 20 residents. The bed-rooms opened unto a large enclosed courtyard, where all residents of this buildingcongregated, unless bedridden.

The residentsThe 65 residents ranged in age from 60 to 90+ years; most were in their mid-70’s.Residents came from a variety of backgrounds, e.g., school teachers, government officials(including a former mayor), a sports figure, a member of a prominent political family,domestic workers, migrant farm workers, a seamstress.

The 30 male residents represented 46% of the hogar’s population, in contrast to theU.S., where only 29.8% of older adults in residential care are male (Harris-Kojetinet al., 2016). The hogar’s male residents had fewer family visitors. Absence of familysupport may reflect general patterns in Guatemalan culture and family structure. Dueto limited job opportunities at home, younger Guatemalan men often leave theirfamilies for extended periods to participate in seasonal migrant work on southern

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plantations (fincas). In 2003 approximately 881,300 temporary workers migrated south.Poor health due to unwholesome living and work conditions, coupled with disruptionof education and attenuation of family ties from long periods of absence (in somecases, prompting establishment of a second family), diminish the ability of a significantnumber to contribute to the care of spouses, children, and older relatives. Such neglectplaces these men at risk for an old age bereft of family support (Perkinson, 2012;Varley & Blasco, 2000). One male resident confided that he had had two families in hisearlier years and was now abandoned by both. He noted many of the men in the hogarshared his situation.

Resident charts revealed a range of physical, cognitive, and psychiatric diagnoses,including diabetes, Parkinson’s disease, cancer, arthritis, heart disease, asthma, arthritis,epilepsy, injuries from accidents, deafness, stroke, depression, schizophrenia, and “oldage.” Twenty-three residents had some form of dementia; fourteen residents were labeledsimply as “well.” While some residents were placed in the facility by relatives unable tomaintain their care, others were either abandoned or placed there by court order (usuallyfor the protection of the older adult). Occasionally residents came to the hogar on theirown, hacer un regalo or “making a gift” of themselves to the facility’s director.

The staffThe facility employed approximately 25–27 employees, half of whom served as nurses ornurses’ aides, the other half did the cooking, laundry, housekeeping, maintenance, andadministration. Numbers fluctuated over time, due to staff turnover. All but two werewomen. Although staff were dedicated, heavy workloads allowed only basic custodial care.Nursing staff generally worked 12-hour shifts, with two nursing personnel in each of thetwo main buildings at all times. There were no recreational activity personnel.

VisitorsResident charts documented seven residents had frequent visitors. Seventeen residents(mostly men) had no visitors and were considered “abandoned.” Visitors were few andinfrequent; many residents had little contact with the outside world. The few structuredactivities (e.g., the rosary prayer group) took place during sporadic volunteer visits. Thehogar’s volunteers included students from the local private high school, university volun-teers, local church members, and persons leaving various donations of food or clothing.

Conducting anthropological fieldwork

Saint Louis University granted IRB approval. All students passed the CollaborativeInstitutional Training Initiatives (CITI) Program web-based training in research ethicsprior to arrival.

Gaining entryInitial encounters between gerontology team members and the hogar’s people set the stagefor subsequent fieldwork. Our introductions followed basic tenets of anthropological fieldmethods regarding gaining entry and developing rapport and adhered to IRB standardsensuring informed consent. The owner/director’s endorsement reinforced initial credibil-ity and legitimacy.

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Project introductions leading to informed consent proceeded in two stages: the firstwas conducted at the group level upon initial entry into the site; the second occurredone-on-one immediately prior to individual interviews. On our first day, we held threeseparate group meetings of introduction: one with staff and two with residents. Allwere invited to attend. We described the proposed fieldwork project, explaining ourgoals, our daily schedule of activities, the consent process, and length of the project.We explained that we wanted to understand what it was like to live and work in thehogar and would spend several days a week there, observing everyday activities andtalking with residents and staff. We would use what we learned to develop individual-and group-level programs and activities for residents that could improve their well-being. We would develop in-service training for staff, on topics such as fall preventionand safe transfers. Each member of the gerontology team introduced herself, providingbackground information and expressing interest and gratitude for being allowed toconduct the project within the facility.

In addition to conforming to basic tenets of research ethics, this introductory meeting was animportant “ice-breaker,” a critical first step in the opening of “communicative space” (Kemmis,2001) between the gerontology team and the hogar, in which we explicitly discussed andnegotiated our roles and personae within the setting. Avoiding identities as gerontology“experts,” we approached residents and staff as valued collaborators. As key informants, theywould contribute information and insights into the experience of growing older in Guatemala,specifically in a hogar. Maintaining that communicative space was an ongoing, consciousprocess, a critical prerequisite for enabling extended interpersonal interactions and the sinequa non for developing intercultural competence.

Residents were accustomed to encounters with visiting medical and mission teams, soour initial foray into the hogar elicited little surprise. What did surprise residents was ourcontinued return, daily, for weeks. The facility’s director quickly dismissed her initialrestrictions (e.g., limiting numbers of team members working within the facility at any onetime) when she witnessed the team’s dedication and the residents’ positive reactions tothem. In spite of language barriers, connections were made. By the end of our first week,the residents’ affectionate greetings, hugs, and kissing of hands were visible displays ofsuccessful rapport. The students eventually settled into granddaughter-type roles withmost residents and were accepted as part of the daily scene.

Ethnographic data collectionOur research goals were to identify and describe individual- and group-level resources thatmight facilitate “occupational engagement” (active involvement in activities meaningful toresidents) and resident needs and barriers to such engagement. Information on resourcesand needs of residents and, to a lesser extent, staff would inform students’ development ofindividual- and group-level activities and therapies.

Students learned ethnographic methods, including participant observation, writing fieldnotes, and conducting interviews. A three-stage strategy (Keith, 1986) guided data collection.With each succeeding stage, research grew more focused and structured, informed by dataderived from earlier stages.

Stage one: initial mapping of the site. Students conducted initial field observations ofpublic spaces at varying times of the day to develop a “map” of the facility. They identified

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the “who” (e.g., main categories of persons, social groups, social roles), “what” (e.g.,different types of activities), “when” (e.g., how time was divided, general and individualschedules for residents and staff), and “where” (e.g., how physical space was divided upand categorized, different “territories” within the facility, any barriers to accessibility).Stage One data collection thus entailed documentation of general daily observations.Analysis of data acquired during this initial stage of research provided an overall under-standing of the context in which residents conducted their everyday lives and wasintended to inform site-specific OT practice.

Given the lack of prior research on hogars, an exploratory, inductive approach, i.e., groundedtheory, was deemedmost appropriate for data collection and analysis (El Hussein, Hirst, Salyers,& Osuji, 2014; Strauss & Corbin, 1990). Students analyzed data individually and in small groupmeetings, reviewing specific observations in their field notes, proceeding to open-coding (i.e.,identifying similar segments of data and labeling them with appropriate terms or concepts) andaxial-coding (i.e., identifying underlying relationships, themes, or patterns among the opencodes).

Stage two: focused interviews. General mapping activities continued as needed, ata reduced level. Stage Two data collection shifted from documentation of general observa-tions of the field site and its inhabitants to more focused observations. Students alsoconducted informal, semi-structured interviews on daily life within the hogar, to identifyresources and needs of both residents and staff (Table 1).

Table 1. Open-ended questions used in stage two data collection.Topics Open-Ended Interview Questions

Medical & health- related resources & barriers(questions for administrator and staff)

How does the hogar track health-related information on individualresidents?Are medical charts maintained? If so, what information is included &who documents it?What work-related qualifications (e.g., training, experience, attitudestoward their work) do staff and volunteers possess?How does the hogar determine distribution and use of limitedresources?How are disruptive behaviors and depressed affect among residentsinterpreted and treated?

Social/interpersonal resources & barriers To what extent are “outsiders” (e.g., family members, volunteers)involved in the hogar ?What kinds of relationships exist between residents and staff?What kinds of relationships exist among residents themselves?Are any individuals isolated or marginalized?Do residents assume specific roles within the hogar ?

Activity resources & barriers Do residents engage in meaningful occupations/activities? If so, whodoes what?What factors support/discourage the continuity and expression ofpreviously valued occupations/activities and everyday life skills?Does the hogar encourage residents’ engagement in physical activityand affective experiences through music and dancing or routinehousehold tasks?

Cultural resources & barriers How is “normal aging” defined within the hogar?Who is considered to be an especially good example of “successful”aging?How do past lifestyles impact current life experiences and the agingprocess?Does this impact differ across class, ethnicity, and/or gender?

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Stage three: structured data collection. The final stage of data collection provided infor-mation on individual resident’s health and functional status, their daily schedules andtheir perceptions of life in the hogar, as well as favorite activities and ability to engage inthem. This information informed the development of client-based individual- and group-level activity interventions.

Residents identified by the director or staff as cognitively able and who consented to beinterviewed were further screened with a brief cognitive assessment, the AD8 (Galvinet al., 2005). Residents scoring 0–1 (“normal cognition”) received questions on their dailyactivities. They also were given a battery of scales, the Spanish versions of widely-usedmeasures of health, cognitive status, and functional ability, and the Guatemalan OlderAdult Interest Checklist (see below). Residents scoring 2 or above on the AD8 (indicatingprobable cognitive impairment) received only the interest checklist and a health assess-ment. Results from the AD8 cognitive assessments closely matched those provided by thedirector and staff.

We initially intended to administer the Canadian Occupational Performance Measure(COPM: Law et al., 1998), a semi-structured interview designed to detect change in self-perceptions of ability to perform specific meaningful activities. Administration of the COPMrequired the student interviewer and resident interviewee to identify activities within areas ofself-care, productivity, and leisure that the resident wanted, needed, or was expected toperform. Based on this information, the resident and student therapist would create client-centered goals for therapeutic interventions. Creators of the COPM warn the scale “may bemore difficult to use in cultures that are very hierarchical and where the health professions areseen as the unquestioned authority, or cultures where the notions of distinguishing self-care,productivity and leisure are antithetical” (Law et al., 2004). This proved to be the case duringa pilot interview with a resident recommended by the hogar’s director. The resident wasunable to identify areas of occupational performance (i.e., activities she wanted/needed to do),much less problems encountered in that performance, because (to paraphrase) she claimed,‘They don’t allow us to do things here. We cannot do things for ourselves; the staff does thingsfor us.’ In addition to using a complicated rating response set, basic assumptions underlyingthe COPM were contrary to the hogar’s cultural definitions of “good” care for residents. Weeventually learned that “good” care meant taking care of residents’ needs, as they passivelyallowed that care to take place. Residents were not encouraged to act on their own regardingself-care or initiating activities. As long as residents sat peacefully in place, all was deemed fine.This did not mean that all residents shirked from addressing their own personal care needs(e.g., dressing or grooming), assisting fellow residents (e.g., in eating or walking), or evenassuming quasi-staff roles (e.g., dishwashing). As long as they did not hurt themselves or eachother, residents were allowed to do what they wanted. However, for most that meant sitting inthe hogar’s public spaces and allowing staff to minister to them as needed.

In recognizing the COPM’s misfit, we learned an important lesson that guided sub-sequent attempts to make OT interventions site-specific and culturally appropriate. Forcedto re-examine prior assumptions regarding optimal activity levels and residents’ quality oflife, we adopted a more conscious and culturally-sensitive stance toward articulation offieldwork goals. Those goals were subsequently framed as negotiated processes, ratherthan formally-stated endpoints, regarding optimal resident participation.

Sensitized to hogar norms, we sought to further clarify our goals with the administratorand staff and to identify and negotiate possible areas of disagreement regarding resident

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care and engagement. While she did not oppose our plans for OT interventions, thedirector and, to a lesser extent, staff, were skeptical that residents would participate in ourproposed activities. Undaunted, we proceeded to develop a site-appropriate assessmenttool to identify activities meaningful to residents. Studies of cognitive aging indicate olderadults have greater ease with tasks of recognition compared to free recall (Craik &McDowd, 1987; Danckert & Craik, 2013). Rather than asking residents to recall preferredactivities/occupations in the manner of the COPM, we developed a checklist that namedpotential activities and required a simple “yes” or “no” response to indicate the resident’spast or current interest in participation. The list contained items from various activitypreference checklists for older adults (Carpenter, Van Haitsma, Ruckdeschel, & Lawton,2000; Teri & Logsdon, 1991) to which we added culturally- and age- appropriate items(e.g., making tortillas). After pre-testing and modifying as needed, we added theGuatemalan Older Adult Interest Checklist to our battery of assessments.

OT practice: developing and implementing interventions

Research melded into practice as students collaborated with staff and residents to identifyand prioritize their OT practice plans. Data from all three research stages informeddevelopment of resident- and site-specific OT programs. We identified optimal times(i.e., mornings) and spaces for group activities. We strategized how best to presentactivities and interventions and how to motivate residents to participate. We weresensitive to the various physical and cognitive limits identified in interviews and medicalcharts and planned accordingly, identifying individual residents who could benefit mostfrom individualized OT. Based on responses to the Guatemalan Older Adult InterestChecklist, we identified types of activities of greatest interest to residents.

Based on the research data and feedback from the team’s OT faculty, students developedand implemented group activities that included: exercising, painting, cooking, playing bingoand various other games, and working with beads and other crafts. Activities were tailoredto meet the needs and abilities of the greatest number of residents and allow safe andsuccessful engagement. For example, the exercise program was performed while seated.Students scheduled activities, invited and motivated residents to participate, provided clearand simple instructions and demonstrations, monitored for safety, and encouraged and gaveappropriate feedback throughout the duration of the activity.

Daily group activities continued for the remainder of the summer and were held inpublic spaces of each building. Numbers of participating residents grew over time.Participation took two forms: active engagement in designated activities and passiveengagement through observation of activities from afar. Those unable or unwilling to bephysically active still were interested in watching their neighbors perform exercise rou-tines. One severely depressed and isolated resident (whom we discovered was a formerbasketball player) was coaxed to emerge from her bedroom to engage in a ball tossinggame, which turned into a “basketball” game when a student circled her arms to simulatea basketball hoop. This first step led to the resident’s growing participation in exerciseprograms, and she eventually assumed the role of exercise group leader. The hogar’sadministrator and staff members observed the various individual activities and groupprograms and were pleasantly surprised at residents’ levels of participation.

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Each student also maintained a caseload of two or three residents, addressing theirphysical, cognitive, psychosocial, and/or occupational needs by developing individualized,client-based, one-on-one therapies. For example, two students chose to work with Dulce,a depressed, bedridden woman diagnosed with Parkinson’s disease, who spent her daysisolated and alone in her room. Dulce tearfully told the students that she felt ‘trapped inher own body.’ Under the supervision of the faculty OT, the two students developed a careplan and patiently worked with her, first engaging in passive range-of-motion exercises,progressing to standing, walking with assistance, and eventually playing a game of rollinga ball back and forth on a table. After she had made significant progress, Dulce surprised herdaughter during a visit by standing up and dancing with her, bringing the unsuspectingdaughter to tears.

With OT faculty oversight, students provided staff in-services on body mechanics topromote safe lifting and on fall prevention. They processed their experiences and plannedfuture activities through daily group discussions with the OT faculty supervisor andpersonal reflections on their work.

Students developed materials to support continuation of activities (e.g., a binder withinstructions for each group activity and a poster illustrating exercise routines). They alsoprovided in-service training to staff on all group programs.

At the end of our six weeks in the hogar we held a farewell party, attended byresidents from both buildings and the staff. Each student gave a brief speech to thegroup, expressing gratitude for the time spent with residents and staff. When onestudent, overcome with emotion, halted in her presentation, three residents in thefront row initiated chair exercises in a show of support. One resident, a former boxerof some repute, recited a poem to commemorate the occasion. We passed aroundcake and punch, which all enjoyed. In a relatively short time, the students clearlymade an impact on daily life in the hogar and developed strong bonds with many ofits residents. When the second-year field school’s gerontology team returned thefollowing summer to resume work in the hogar, the residents gave them an enthu-siastic welcome, asked about students from the previous summer by name, andseemed eager to resume the activities.

Results

Structured as a service-learning experience, the objectives of gerontology fieldworkwere multi-dimensional, with intended impact on both individual- and group-levels.Specific objectives included: developing students’ research and clinical skills whileworking with older adults of different cultural backgrounds; contributing to thehealth and well-being of hogar members while addressing issues of social andoccupational injustice; and preparing students for future work with diverse popula-tions by fostering intercultural competence. Preceding sections described activitiesdesigned to achieve those objectives. The following provides assessments of students’research and clinical activities and the extent to which those activities achieveddesignated objectives.

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Documentation and assessment of research and clinical skills

Evaluation of research skills in data collection and analysesThe anthropology faculty member conducted observational assessments of students’research skills, monitoring research interactions and reviewing field notes and analyses.Evaluation criteria included: mastery of the mechanics of field observations (e.g., deter-mining which components of a setting to observe, committing those observations tomemory for later write-up, writing descriptive field notes that document essential ele-ments of observations); informal and in-depth interview skills (e.g., ability to gaininformed consent, develop rapport, formulate appropriate questions, employ probeseffectively to elicit detailed responses, keep an interviewee “on target” and preventtangential remarks, document the interview in appropriate detail); clarity and detail offield notes and the coding and analyses of those notes; and appropriate use of data todirect follow-up field observations and interviews. All students successfully completedtheir assigned research tasks and made observable progress in developing research skills.

Evaluation of clinical skills in developing and executing individual and group interventionsThe OT faculty members based their mid-term and final assessments of students’clinical fieldwork on extensive observations of student engagement at the field siteand one-on-one evaluations with each student, using the Fieldwork ExperienceAssessment Tool (FEAT) (Atler et al., 2001). Endorsed by the AmericanOccupational Therapy Association (AOTA), FEAT is widely used to evaluate advancedOT internships. The instrument focuses on attitudes (e.g., the extent to which thestudent is an active learner, shows initiative, is non-judgmental, is flexible/tries alter-nate approaches) and on behaviors (e.g., the extent to which the student used knowl-edge and skills with clients, assumed responsibility as an OT, incorporated feedback,worked as a team member, reflected on fieldwork experiences). All students showedprogress between the time of the mid-term assessment and the final evaluation, and allreceived high marks in their final evaluations.

Contributions to the well-being of the field site and its members

Students’ work with residents through group activities and individualized therapies andwith staff through in-service training contributed to the well-being of members of thehogar. In addition to the direct impact on residents’ physical and mental health andincreased work-related knowledge and skill-building among staff, the students’ fieldworkhad subtle, but perhaps more long-ranging effects on attitudes toward participation inoccupations and rethinking residents’ potentials. At the start of our time at the hogar, boththe facility director and staff members expressed doubts that residents would engage in theproposed activities, and at least one resident expressed an inability to participate in theways we envisioned as a result of those doubts. The director and staff frequently watchedinteractions among students and residents from a distance and were surprised and pleasedto observe increased levels of engagement and positive responses of residents, even amongthose who typically avoided social contact.

12 M. A. PERKINSON

Interpersonal processes and developing intercultural competence

Fieldwork assignments were structured to maximize student engagement in interpersonalinteractions, activities, analyses, and reflections conducive to development of interculturalcompetence. While many standardized assessments of cultural competence exist (Gabrenya,Griffith, Moukarzel, Pomerance, & Reid, 2012; Griffith, Wolfeld, Armon, Rios, & Liu, 2016),we chose a qualitative approach to evaluation, i.e., in-field observations by gerontology facultyand self-assessment by students (Jackson, 2005). Gerontology faculty (as well as residents,director, and staff) acknowledged students’ sensitive and competent interactions with mem-bers of the site.

An exit survey, consisting of a 20-item scale and open-ended questions, providedstudent feedback on specific aspects of the field school (e.g., application process, orienta-tion, field trips, etc.) and their general evaluation of the program and its impact. Averagescores on select scale items are included in Table 2.

Because the survey was anonymous, scores listed in the table reflect averages of all 14 fieldschool students. Although this was the first year of operation, scores reflect a high level ofsatisfaction.

Some students chose to identify themselves as authors of their qualitative statements.With their permission, responses of gerontology students are included below:

“In participating in the field school, I have become more culturally aware and sensitive to thepeople I am working with… If you are passionate about making a difference in the world andlearning about other cultures, then this field school is for you.”“I really enjoy the School and I would do it again. But don’t go down there thinking you willmake a big change. It’s mostly you who changes, and if you better someone else’s life whileyou’re down there, that’s a bonus.”“The field school gave me insight about people, OT, life, and myself that cannot be taught ina classroom or learned by reading a book. I have a different perspective on life and cultureboth. I have connected with others that I normally would not have and can appreciate thepositive change the experience has provided me.”“Although it was different than what I expected, I appreciated the opportunity to learn andgrow both professionally and personally, i.e. increasing my cultural sensitivity, gainingknowledge of anthropology, working as a part of a multidisciplinary team.”“My ability to impact the quality of life of the population I worked with was a memorablepart of my learning experience. However, the impact they have made on me is difficult toarticulate. I will forever be changed.”

Table 2. Field school student quantitative evaluations (N = 14 unless otherwise noted).Item Average Score*

The field school provided a worthwhile learning experience: 9.4The field school has had a positive influence on my career goals: 9.5I would consider returning to the field school in the same or another fieldsite – as a student or part of the faculty or staff:

9.6

I would recommend this program to others in my department,graduate program, university, or profession:

9.4

I have grown personally and/or acquired new life skills as a result of participating in thefield school:

9.6

*On a scale from 1–10, with 10 indicating highest level of agreement.

GERONTOLOGY & GERIATRICS EDUCATION 13

Discussion

Intercultural competence entails the ability to interact effectively and appropriately with personsfrom other cultures, based on knowledge, attitudes, skills, and behaviors that reflect sensitivity toand appreciation of cultural differences. Awareness and appreciation of cultural differencesrequires effort. The ubiquitous nature of culture ensures that it seldom comes under consciousexamination. A frequently cited analogy, “Culture is to humans as water is to fish,” helps oneappreciate that “…it is hard to see your own culturewhen you are in themidst of it” (Pusch, 2009,p. 71). Extended and meaningful engagement with members of other cultures and intensivereflection on those interactions are crucial to the development of cultural self-awareness andintercultural competence (Giovanangeli &Oguro, 2016). Training in ethnography represents aneffectiveway to structure such encounters and reflections,maximizing the likelihoodof increasedsensitivity to cultural difference and ability to competently engage in a manner appropriate tolocal cultural norms (Kleinman & Benson, 2006; Ogden, 2006). Students’ ethnographic inter-views, participant observation, and therapeutic interventions required extensive engagement inthe everyday life of the setting and its participants. Through reflection on their experientialknowledge of the hogar, students attempted to understand the “local world” (Geertz, 1983) of thefield site from the perspective of its participants. Training in anthropological fieldwork and in theuse of research findings to informOT practice within the facility was designed to hone students’observational, analytic, clinical, and reflective skills and to facilitate processes (i.e., increasedawareness, engagement, and reflection) conducive to the development of interculturalcompetence.

Our initial interactions with residents and staff revealed basic differences in under-standings of “successful aging,” “quality of life for older adults,” and “good eldercare.”A general perception of later life as a “time to rest” and of older adults’ earned right torelax served as guiding principles for eldercare in the hogar. Whether this reflectedgenerally shared norms regarding old age in Guatemala or justification for staff’sprimary focus on custodial care due to excessive workloads is unclear. Residentsseemed to share this perspective. With a few striking exceptions (i.e., residents whoserved as “quasi-staff”), most spent their days seated in silence prior to student-initiated activities. While this situation may be seen as a combination of occupationalinjustices, e.g., “occupational deprivation” (denial of resources and opportunities toallow access to occupations), “occupational alienation” (having to participate in occu-pations that are personally meaningless and void of recognition or reward), “occupa-tional marginalization” (lack of power to exercise occupational choice), “occupationalimbalance” (being occupied too much or, in this case, too little to experience empow-erment and meaning), and/or “occupational apartheid” (segregation of a group on thebasis of a given criteria such as age or physical/mental functioning and denial of accessto meaningful participation in occupations as a result) (Barney & Perkinson, 2016;Kronenberg et al., 2005; Stadnyk, Townsend, & Wilcock, 2010), the gerontology teambegan work with caution. Respecting the cultural milieu of the hogar, we refrainedfrom using U.S.-based definitions of “successful” or “productive” aging to guide ourwork. Based on extensive ethnographic investigations (e.g., identifying preferred activ-ities of residents through the activity checklist, conducting in-depth resident inter-views), students worked within a client-centered framework, basing occupational goalson previously unacknowledged preferences of residents. Student-initiated activities

14 M. A. PERKINSON

provided opportunities to engage in occupations defined by residents as meaningful.Participation in such activities introduced new “occupational possibilities,” i.e., “waysand types of doing that come to be viewed as ideal and possible within a specificsociohistorical context,” the shared and taken-for-granted notions of what people thinkthey can and should do (Perkinson & Barney, 2016; Rudman, 2005, 2006).

Conclusion

Fieldwork in a residential care facility for older Guatemalans provided meaningful trans-disciplinary opportunities in both research and practice. Students made significant pro-gress developing skills in data collection and analysis, assessing institutional and personalresources within the facility, and developing and employing clinical skills to supportculturally sensitive, client-centered and community-based practice informed by theirresearch. The fieldwork placement provided opportunities to gain firsthand knowledgeof the impact of cultural context both on the experience of aging and provision ofeldercare. This placement also provided opportunities to make significant contributionsto the fieldwork site and its participants.

Benefits of the gerontology fieldwork placement extended beyond acquisition of research andclinical skills. Prolonged firsthand engagement with hogar residents provided exposure to andexperience of a life world in great contrast to that of the students. Continued encounters withpersons operating under culturally different assumptions forced students to re-examine theirown cultural assumptions and assume “an attitude of inquiry,” embracing the “underlying andcontinued challenge of living in the world as a question” (Marshall & Reason, 2008, p. 62;Wicks& Reason, 2009). Intensive immersion in a different cultural environment did not permita “business as usual” mentality to daily activities and encounters. It required a heightenedawareness that can be mentally and even physically exhausting.

Some proponents of international student fieldwork (Ouma & Dimaras, 2013) suggestthat meaningful measures of its impact should focus less on specific tasks completed andoutcomes achieved, and more on the interpersonal processes and personal developmentthat occurs among program participants. As reflected in their evaluations of the fieldschool experience, students were very aware of their changed perspectives, and acknowl-edged (sometimes with strong emotions) a fear that such perspectives might slip awayonce they left Guatemala.

It was clear that they left their mark on the hogar, transcending what is sometimes termed“student development tourism” (Clifford-Hall & Frank, 2012; Hudgins, 2010) that charac-terizes some student programs abroad. In our brief, but very intense, six-week encounter withthe world of the hogar, we could not expect to solve its varied problems. We did, however,develop significant relationships with residents and staff, offered them a glimpse of alternatepossibilities, and provided staff and select residents training and encouragement to pursue thecontinuation of at least some of our gerontological OT programs.

Acknowledgments

I wish to thank my fellow faculty members of the NAPA-OT Field School in Antigua,Guatemala: Gelya Frank, Devva Kasnitz, Nancie Furgang, Rachel Clifford-Hall, KeriBrownson; my first year gerontology students: Adrianne Jones, Abby Mell, Cathy Nunez,

GERONTOLOGY & GERIATRICS EDUCATION 15

Kaitlin Rooney, Lacy Yacko; the gerontological occupational therapists Karen F. Barney, JaneYatczak, Sue Coppola; my field assistant and translator: Ellen Ziegemeier; the residents, staff,and administrator of Casa Maria; and the administration of Common Hope.

Funding

Funding for the initial year of fieldwork was provided by the Ruth M. & Francis A. StrobleCharitable Foundation.

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