Abstract

Each year, more than 300,000 American students have an international experience to earn academic credit on a variety of programs ranging from two weeks to a full academic year. Education Abroad (EA) enables students to “experience new perspectives, learn how to navigate different cultures, work with diverse peers, and communicate in other languages” [1]. In nursing, studying abroad has been shown to help with cultural awareness, personal growth, cultural immersion, and networking. EA opportunities help nursing students to gain “diverse cultural perspectives, as well as global competence” [2] in a world where they will be providing care for an increasingly diverse population.

At a mid-size university in the American South, an associate professor in nursing who has previous EA experience, became interested in a health-related concept known as the Blue Zones, described below. She realized that this particular research area of interest could be applied to an opportunity for a health-related study abroad program for nursing students and other college students interested in the concept. In this article, the authors will describe the concept of Blue Zones, how an EA program focusing on the concept was developed, what was involved in the course connected with the program, and details of the experience.

Blue Zones

There are five areas of the world, known as Blue Zones, where the largest numbers of centenarians, or people living greater than 100 years, reside. (The current average life expectancy of people in the United States is 78.9 years) [3]. The regions of Sardinia, Italy; Loma Linda, California; Okinawa, Japan; Nicoya, Costa Rica; and Ikaria, Greece were studied in great detail by Dan Beuttner and National Geographic, following up on research by Poulain et al. [4], to determine why and how people living in these zones were able to live longer and healthier than those in other areas of the world. Nine similarities, dubbed the Power 9, were found among the Blue Zones including moving naturally, knowing one’s purpose, down shifting one’s life, surrounding oneself with a tribe of people, belonging to a religious group, putting one’s family first, having a glass of red wine at least once per day, including larger portions of vegetables, and eating only until 80 percent full [5].

Education Abroad Program Development

In 2014, a nursing professor became interested in the concept of the Blue Zones after reading about Buettner’s research online. The concept was intriguing to someone involved in healthcare because in the Blue Zone areas, people were living longer than in the United States at an astounding rate, and more importantly, they were living healthier. For example, in Ikaria, Greece, people on average live eight years longer than Americans and have 20% less cancer, half the rate of heart disease, and no dementia. In Loma Linda, California, residents outlive other Americans by a decade. In Sardinia, Italy, there are more male centenarians than anywhere on the globe. In Okinawa, Japan, the world’s longest-living females reside. And in Nicoya, Costa Rica, people are twice as likely as Americans to live to 90 years old [5]. When someone in healthcare learns about these statistics, many questions naturally arise: What are they doing differently? How do they do it? Could these lifestyles, behaviors, and routines be modelled by people in the U.S.?

Because of a desire for knowledge acquisition about all things related to living healthier, the professor decided that in addition to reading about these places, it would be valuable to visit these locations, observe and talk to the people, and learn about living healthier from some true experts. Additionally, she believed it would be of great value to take nursing students along so they could bring back the knowledge to their communities and patients. Upon further reflection, she realized that students other than just nursing could really benefit from this knowledge as well. She reached out to EA coordinators at her university and discussed the idea of taking students to these sites for true immersion and experiential learning.

EA coordinators were supportive of this experience and felt it had merit and value. In 2015, the professor completed the application process used by the university. Included in the application was a description of the program to the selected location of Sardinia, Italy, and a syllabus outlining course objectives and assignments (see next section). The program was approved for the Summer of 2017 based on rigor, recruitability, and educational value. She and the EA staff contacted education abroad providers and found an organization that would be willing and able to assist with the requested program and itinerary.

The next year consisted of recruitment efforts by the professor, other colleagues in her department, colleagues across campus, and EA representatives. She spoke to classes of students in each semester of the nursing program, including pre-nursing students but excluding senior students who would graduate prior to the travel date, and had a great deal of interest. Included in these visits was an explanation of what Blue Zones are, how the concepts are applicable for nurses and their patients, and why visiting the Blue Zone of Sardinia, Italy would be of value to nursing students. Details of the itinerary were shared as well as cost and course credit. She was able to recruit 17 nursing students, and it was decided among the professor, the EA coordinators, and the provider that that would be an adequate maximum number of students to take to Sardinia. Due to achieving this set capacity by recruiting in nursing, the professor was unable to recruit in other departments and disciplines, although there was interest from students in a variety of disciplines.

The Program and Course

Much thought, time, research, and reflection must go in to the development of an EA program and course. It is vital that courses abroad maintain an appropriate level of rigor, not only to uphold the reputation of EA, but also to maximize the learning experience for students while abroad [6]. When developing this particular program, the faculty member determined that the ultimate goals were for the students to learn about Blue Zone and bring the concepts back to families, peers, community members, and patients and also to engage in a research component. Below you will find details about the specifics of the program and course.

Course Description

For the course offered in conjunction with this travel experience, the focus was on exploring Italy’s Blue Zone in Sardinia with attention to sociocultural practices such as diet, activity, exercise, religion, and agriculture. The course also had a component where students investigated unique healthcare techniques and practices, including alternative treatments and therapies, university education, hospital structure, and healthcare systems throughout Italy. Because the group would be travelling to Italy, the professor planned stops in Florence and Rome on the way to the island of Sardinia.

Course Objectives

Upon completion of this course, the objectives were for the student to obtain an understanding of the current structure of the Italian healthcare system, explore sociocultural contributions to health and illness in the U.S. and Italy, compare health practices in the U.S. and Italy, and understand the Blue Zone concept as a research project. When taking nursing students abroad, it is always important to expose them to healthcare practices, procedures, and systems and allow them to compare the foreign practices to healthcare in the U.S. Additionally, the goal was for the students to understand what Blue Zones are, how residents live and behave, and how this knowledge can be disseminated.

Grading Procedures

In any EA course, as part of maintaining rigor and following course guidelines, grades must be assigned. For this particular course, the breakdown was as follows: Class Participation and Discussion (20%); International Reflective Journal (20%); Blue Zone presentation (30%); Class Presentation Murray (15%); and Class Presentation Italy (15%). Descriptions of these components are detailed below.

Course Activities

For this course, credit was given for a Spring 2017 class, based on University policy. It was considered a second-half semester course, so the professor met with the students weekly during the second half of the spring semester. In these class meetings, they discussed the plan for the course, analyzed Dan Buettner’s book The Blue Zones: Nine Lessons for Living Longer from People Who’ve Lived the Longest (2012), discussed interactions with Italian citizens, determined goals for Blue Zones research, and conducted and viewed presentations. Students were required to choose three presentation topics from lists provided. Some of the terms were non-nursing related locations that they would be visiting (such as the Pantheon or the Duomo), and some were nursing-related (such as Italian nursing education or thermal baths). These presentations could be done individually or in pairs. A maximum of seven minutes was suggested, a rubric was provided, and creativity was encouraged. For the nursing-related presentation, students were required to include information about similarities and differences between US and Italy. For non-nursing locations, they were required to include any connections to health care and information classmates might need to be aware of. At one class meeting, they each presented two topics, and in Italy, they presented the other.

At the class meeting prior to departure, students had to do Blue Zone presentations, with a partner or individually. It was recommended that they attend any Blue Zone speaking events in the community prior to this meeting, and there was one presentation in a nearby community that they could attend. They had to discuss what they had learned about Blue Zones (based on websites, speaking events, books, literature, etc.), what they hoped to learn about Blue Zones, and what they hoped to bring back to the community with regards to the Blue Zones. They were to include several specific things they would like to implement both individually and in the community.

Students were required to maintain a reflective journal throughout their experience that included the following: at least 2-3 pages per day, showing evidence of comparison of US and Italian culture, with emphasis on health care similarities and differences and Blue Zone ideals; a 2-3 page journal entry about specific encounter/conversation with an Italian citizen about health; a 3-4 page journal entry with an overall analysis of the visited Blue Zone. This journal was to show evidence of a depth of analysis of the culture as well as to document this EA experience for later reflection.

Schedule of Activities

The professor worked closely with the EA office and the provider to develop a one-of-a-kind, unique experience for the students. The itinerary was revised and edited throughout the planning process to best fit the needs of the students and to meet the objectives of the course. The final itinerary was as follows: included. However, students were asked if they voluntarily wanted to continue working on Blue Zone research upon their return. Half of the students engaged in work with the professor after their return from Italy. Some opportunities included website development and updating, Facebook page development and updating, presentations at the local, regional, and international level, and manuscript development.

Implications and Recommendations

Research describing the value of EA is abundant [2,7]. This particular program was of great value to nursing students, the professor, the university, the community, and many patients that those future nurses will interact with. (For more detail about personal student experiences, please see the article in-press by Naber, 2019.)

One specific component of this EA experience that makes it unique is sustainability. Since there are five documented Blue Zones, the plan is for the professor and her colleagues to apply and recruit students for programs that will travel to each of the other locations over the next several years. Additionally, students are still working with the professor on ideas for presentations and implementation of Blue Zone ideals into communities and with patients.

Conclusion

EA is a valuable experience for students in any discipline. Tailoring programs for students in a particular area can be done with collaboration among the university EA representatives, faculty members, and potentially providers, if desired. It is important to find a theme or focus for the EA program that is of interest to the faculty person and will be interesting and of value to potential students. Additionally, the course connected with the program needs to be rigorous and engaging while accomplishing the set objectives. If the program can also focus on something with a potential for future engagement, or even research opportunities, that can be of great benefit to students as well.

Conflict of interest

The authors declare no conflict of interest.

References

1. United States Department of State. (2019) Why study abroad? View

2. Mailloux CG (2017) Benefits of study abroad in nursing. J Nurs Patient Care 2.View

3. World Population Review (2019) Life expectancy by country.View

4. Poulain M, Pes G, Grasland C, Carru C, Ferrucci L, et al. (2004) Identification of a geographic area characterized by extreme longevity in the Sardinia island. Exp Gerontolo 39: 1423-29.View

5. Buettner D (2012) The Blue Zones: Nine lessons for living longer from the people who’ve lived the longest. National Geographic Society: Washington, D.C.View

6. University of Nicosia (2019) Standards of good practice for education abroad.View

7. International Student (2019) Ten benefits to studying abroad.View