Rethinking Education in Pakistan: Perceptions, Practices, and Possibilities

The book under review is titled ‘Rethinking Education in Pakistan: Perceptions, Practices, and Possibilities’ (2010), authored by Dr. Shahid Siddiqui and published by Paramount Publishers. This book highlights the revival of educational mindsets of all stakeholders in terms of policy issues pertaining to teacher and teacher education, curriculum, school, home support, language, research, and assessment to bring a vibrant change in our national education system. The author has critically analysed Pakistan’s overall education system and highlighted the root causes that have brought pedagogical experiences in a malfunction condition. The book is bent more on improving the quality of scholastic experiences within the paradigm of available national resources in order to re-strengthen the weak areas of such educational practices that de-limit the fruits of education in a nation. The objective of the book is contextually ideological with emphasis on the foundation of education, current practices, and their consequences.

Rethinking Education in Pakistan
Iqbal amalgamation of opinions, information, and suppositions and all these elements make a schema of each individual teacher. He further elaborates that teachers' repertoires support to participate in different activities through problem solving, questioning, discussion, hands-on-activities, and buzz group activities.
In the fourth section titled 'Teaching Practices', the author highlights the key factors to bring about a change in the teacher's expertise. Pakistan has an orthodox culture in teacher training programmes and the needs of the teachers are not considered. This is true for both the teachers as well as trainers in terms of inaccessibility and quality of teacher education. Constant upward move has been observed in informal teaching in Pakistan. Another dilemma is that trainers do not cater to the needs of the teachers. The basic aim of workshops is to enhance meaningful learning, but in Pakistan, programmatic approach has been followed over the years. Schools conduct workshops just as a formality to show the number of training in their Annual Service Report (ASR). Similarly, school workshops are conducted to utilize budgetary allocation at the end of the fiscal year. A strong follow-up system of workshops and trainings is highly required for success and true learning. As a result, lack of ownership and responsibility has been found among these teachers and the quality of teaching stands nowhere with respect to international standards. The author elaborates that private tuition syndrome has spread like a virus in Pakistan. Initially the purpose of tuition was to facilitate weak students in specific subjects, but now it is the need of all students to get good marks. Tuition academies are promoting their services at a very high price to attract students for passing different board examinations. This happens due to lack of quality teaching in schools. Even when schools employ good teach-ers, they earn extra money by luring their students to join the tuition centeres where they are working. The disadvantage of tuition culture is that students are unable to think out of the box and depend on academics and the role of regular teachers becomes redundant.
There is a dire need to rejuvenate the regular teacher's role and assessment system that should not be memory-based, which will curb the tuition system in existence.
In the fifth section titled 'Curriculum and Materials', the author focusses on the concept of curriculum as a continuum of development, but the policy makers forget that it is a complete implementation plan spread over the education system and the future of our generation depends on it. The writer mentions that a teacher is the key person to understand and develop curriculum for its effective implementation. He shares the philosophy of help-books which are useful and a short-cut to achieve the goals, but we need to find out authentic materials for meaningful learning.
In the sixth and the seventh sections of the book, the author discusses the school and the home environment. He elaborates the criteria of goodness of schools and shares that the schools should provide opportunities for holistic development of children.
There must be an equal ratio of academic development, physical development, social development, and moral development in schools. The school management should focus not only on visible, but also on invisible aspects of the process of change in schools.
Issues regarding corporal and physical punishment are also raised by the author. Teachers victimize the students by giving them physical punishment in different ways and place a negative tag on them. In the eighth section on 'Language Issues', the writer emphasises that there is a gradual increase in the number of incompetent English language teaching teachers across the nation in general, which is of concern. He reveals that language cannot be considered as a linguistic occurrence, but it is considered as a social and political fact which directly affects the economy as well. The author suggests that the two approaches The author shares that our educational assessment from primary to master's level is based on cramming of knowledge. No critical thinking and reflection is required to solve the papers. Students are bound to memorise long answers and get position in their respective classes because their parents expect them to get highest marks in the classes. If it does not happen, they consider their child as weak and slow in learning which causes low self-esteem in the child. He suggests that collaboration is required in the examination system among educational institutes, examination boards, and assessment experts to help make papers to enhance the higher order thinking skills of the students.

Critique
The book is based on issues and useful suggestions and recommendations for the educational system of Pakistan to achieve desired results. Star teachers could initiate to bring about a vibrant change in our society by following these suggestions. The crux of the entire review is that learning beyond schooling is the root of personality building, which starts from mother. To bring a fundamental change in the education landscape, this book highlights different scenarios of education system at all levels and tries to give applicable Rethinking Education in Pakistan suggestions, but from where we need to step-up would be decided by the individual teachers according to their context. The book is inclined more towards the quality of educational experiences within the standard of existing nationwide resources in order to reinforce the deteriorating areas of such educational practices that demarcate the fruits of education in a nation.
The author could have included few success stories for inspirational purpose to show that things are doable and efforts are successful even in forlorn scenarios. Positive and heart-warming stories from educators as well as students can perform as a catalyst to bring a gradual change in our education system at all levels. Such motivating stories could directly impact teacher-student relationship and student-student relationship both inside and outside the classroom. It has been observed by teachers that these stories help to increase respect, cooperation, motivation, and the ability to solve peer conflicts. In a nutshell, the book is a treasure which should be owned by all, who support the idea of quality education in Pakistan.


The distribution of information content in English sentences

Sentence is a basic linguistic unit, however, little is known about how information content is distributed across different positions of a sentence. Based on authentic language data of English, the present study calculated the entropy and other entropy-related statistics for different sentence positions. The statistics indicate a three-step staircase-shaped distribution pattern, with entropy in the initial position lower than the medial positions (positions other than the initial and final), the medial positions lower than the final position and the medial positions showing no significant difference. The results suggest that: (1) the hypotheses of Constant Entropy Rate and Uniform Information Density do not hold for the sentence-medial positions; (2) the context of a word in a sentence should not be simply defined as all the words preceding it in the same sentence; and (3) the contextual information content in a sentence does not accumulate incrementally but follows a pattern of"the whole is greater than the sum of parts".

sentence to reduce information density; conversely, they are more likely to omit words with little or no meaning or use reduced forms of words and phrases (e.g., info, you're) in less information-dense parts of sentence to increase information density (8)(9)(10)(11)(12). Moreover, the information content of a word has been found to be directly proportional to its length and thus a better predictor of the latter than word frequency (13,14). Cross-linguistic statistics have also revealed a negative correlation between information density and speech rate in communication (15). The number of bits conveyed per word is claimed to be a determinant of cognitive load measures including reading time (16). Of the six basic word orders of human language, the object-first languages are found to be the least optimized from the perspective of information density (17), which reasons why only less than 2% of the world's languages are of this type (18).
In an effort to explicate the above phenomena, theories have been proposed. Among them one is the Constant Entropy Rate (CER), claiming that speakers tend to keep the entropy rate of speech at a constant level (19); and the other is Uniform Information Density (UID) (8,9), supposing that the language-generating system prefers an even distribution of the intended message in the speech stream. The major tenet of these two theories consists with the conclusion of information theory, that is, the most efficient way of transmitting information through a noisy channel is at a constant rate close to the capacity of the channel (20). If the communicative properties of human language have already been optimized through evolution, human language would have a stable rate of information transmission. In other words, the uniformity of information density may be a constraint on the production and comprehension of natural language.
As a basic unit of natural language, sentence has always been an important subject of research in various disciplines. However, little is known about the role of information content (entropy) in sentence processing. In other words, we still lack a definite answer to such a basic question as how information content is distributed within a sentence. In addition to syntactic and semantic factors, information content may constitute another important constraint on sentence production and comprehension.
The intra-sentence distribution of information content (entropy) is not only relevant to various syntactic phenomena but also reflects the optimal efficiency of communication of the language system. Currently there exist two major lines of research related to the intra-sentence distribution of information content. One line holds that CER and UID can be considered as general principles in sentence processing, and based on them we may anticipate that the information content in sentence is distributed uniformly. The other line focuses on the intelligibility and predictability of words in different positions of a sentence. The main findings of the latter line suggest that the sentence-final position may carry more information content than the other positions (hereafter as the "sentence-final effect"). For instance, Behaghel (21) found that longer words tend to occur later in a German sentence and the same is true of important, less predictable words. Rubenstein and Pickett (22,23)  The current goal is to obtain a systematic and quantitative characterization of the intra-sentence distribution of information content based on a large body of authentic language data of modern English. We calculated a series of entropy-related statistics for different positions in English sentences, including the positional entropy (1-gram entropy), number of words (types), power-law exponent of the words' probability distribution, mean word length, mean word frequency, and proportions of different word-frequency classes. As sentences vary in length, the same position in different sentences may play different roles in their intra-sentence distributions of information content. Therefore, we calculated the statistics for sentences with a length (in the number of words) from 3 to 50, inclusive, respectively.

Results
We first calculated the 1-gram entropy (noted as H(X)) for different sentence positions. Basically, it is an out-of-context entropy, for it is dependent exclusively upon sentence positions without considering the specific context. This entropy signifies the mean information content of all the words occurring in a given sentence position, hence it is the conditional entropy given sentence positions in strict terms.
Here, we refer to this entropy as positional entropy.  Of studies concerning information content of human language, the most influential are perhaps the investigations of the correlation between information content and word length (24,25). It has been found that information content exhibits a strong positive correlation with word length (13,14), that is, longer words tend to transmit more information. Hence, it is anticipated that calculating the change of mean word length with sentence position can reflect the distribution of information content in a sentence.
Quite in line with our prediction, the relationship between mean word length and sentence position exhibits the same pattern as illustrated in Figure 1 (see supporting information for the results in detail).
Moreover, the mean word frequency for different sentence positions was also adopted as a statistic for the intra-sentence distribution of information content. As high-frequency words tend to be more predictable than the low-frequency ones and the latter constitute majority of the lexicon (see 'Materials and Methods' for information concerning the words' rank-frequency distribution in the language data of the present study), mean word frequency can be adopted as another indicator of information content in a given sentence position.  Besides, the intra-sentence distribution of information content can also be observed by means of word-class-related statistics. As high-frequency sequences and syntactic relations are more likely to be grammaticalzed (26)(27)(28)(29)(30)(31), high-frequency words tend to be function words. "[T]he roles of words and other linguistic phenomena such as morphology, phonology, and syntax are highly influenced by low, medium, or high frequency with which they occur" (26). Given this, certain word classes can be roughly distinguished from the others by their differences in word frequency. In the present study, we classified the words into three classes of frequency, namely high (the first 100 in the word frequency rank), low (the last 100 in the rank) and medium (the rest). High-frequency words are mostly function words, which carry less information content; while medium-and low-frequency words are generally content words, with more information content. The intelligibility of words at a given sentence position can be quantified as the ratio of contents words to function words (22).  As the frequency of a word is negatively correlated with its information content, the change of its frequency with respect to sentence position can also reflect the intra-sentence distribution of information content. The current statistics further reveal that for the sentence-medial positions, the frequency of some words (proportion = 50.15%) increases with sentence position while that of others (proportion = 49.85%) exhibits the reversed tendency (see supporting information for the results in detail).
The proportions of these two types of words exhibit no significant difference, as confirmed by the F-statistic 0.36 and the corresponding probability 0.5497. This indicates that the out-of-context information content does not fluctuate significantly in the sentence-medial positions.

Discussion
The present study investigated how information content is distributed across The notion of entropy is crucial to linguistic studies, for it is capable of measuring the difficulty of information processing. Theoretically, to achieve the optimal efficiency of communication, the entropy during language processing should be maintained at a constant level as postulated by the hypothesis of CER. As for the contextual information content I(X, C), up to now there have been no solid findings concerning how it is distributed within a sentence. A straightforward approach is that the contextual information available to a word in a sentence is mainly from the words preceding it. That is to say, the contextual information content in a sentence is supposed to increase with sentence position.
Our results, based on authentic language data and in light of Formula 2, help illuminate the relationship between contextual information content I(X, C) and conditional entropy H(X/C).
On the one hand, suppose that the entropy H(X/C) is constant in language processing as postulated in CER, our findings would mean that the contextual information content I(X, C) increases with sentence position with the same pattern as H(X). That is, I(X, C) in the sentence-initial position is less than the medial positions, the medial positions less than the final position, and the medial positions exhibit no significant difference. The stable level of I(X, C) in the medial positions means that a word does not get more contextual information than the words in the preceding positions. In other words, the context of a word in a sentence should not be simply defined as all the words preceding it in the same sentence.
In addition, if we assume that CER is valid, the uniform distribution of contextual information content in the sentence-medial positions and the notable increase of contextual information content in the final position would indicate that the contextual information content does not accumulate for the greater part of a sentence and follows a pattern of "the whole is greater than the sum of parts" during the course of the sentence, no matter how context is defined.
On the other hand, if the context of a word in a sentence is defined as all the words preceding it, then the more the preceding words, the greater I(X, C) is. Given the increase of I(X, C) and the relationship in Formula 2, it can be inferred that the entropy H(X/C) would decrease with the sentence-medial positions. However, our results have shown that H(X) maintains at a stable level in the sentence-medial positions, That is to say, CER does not hold for the sentence-medial positions, such that UID does not work in this case.
To note, the three-step staircase-shaped increase of positional entropy suggests that the conditional probability of a word occurring in a specific position in a sentence does not have "position" homogeneity.
With regard to the conflict, we are more inclined to assume the validity of CER (also UID) rather than model the context of a word in a sentence as all the words preceding it. For one thing, both CER and UID have a solid theoretical basis upon information theory (9,19). For another, assuming the validity of CER (also UID), our results will be consistent with a large number of research findings (21)(22)(23) and our intuition about language.
By assuming the validity of CER and UID, our results can be interpreted as follows. In the sentence-initial position, the sentence has only started to unfold and the contextual information available to this position is at its minimum. This explains why the initial position exhibits the least positional entropy, the smallest number of words (types) and the highest proportion of high-frequency words. It has been found that high-frequency words tend to be hubs of a linguistic system from a perspective of complex network (32,33) and are more easily accessed. In the sentence-final position, the whole sentence has virtually been completed and the words in the preceding positions provide contextual information and sufficient sentence structure information, such that words with greater out-of-context information content are used here to keep the in-context information content of words in this position consistent with the preceding words. As content words carry greater information content, they are predominant in the sentence-final position. Meanwhile, as the words preceding the sentence-final position are mostly medium-and high-frequency words, which usually do not have strong relevance to the sentence topic, words with stronger relevance to the sentence topic need to be filled in the final position to make the meaning of the whole sentence complete. Generally, the candidates for the final position are low-frequency, content words. As the range of sentence topics is infinite, the number of content words (types) that can occur in the final position is huge. This echoes what we have found in the current study, and is also consistent with the sentence-final effect (21) and the findings concerning the intelligibility and predictability of sentence-final words (22,23).
Our current findings about the relationship between contextual information and sentence positions can potentially contribute to modeling the context of words in sentences and push forward the understanding of the Markov model of context as widely-used at present.

Materials and Methods
The language data we used in the present study is part of the British National The current study adopts the positional entropy and other entropy-related statistics, instead of calculating information content directly. The reason for this is that the accurate calculation of information content is far from easy (35) due to two features.
On the one hand, it is difficult to quantify a word's contextual information (especially mean-related information), which is indeed essential to the calculation of information content. On the other hand, the information content estimates of sequences with long range correlations (including natural languages) converge very slowly with the sequence length (36,37).
As suggested by Ferrer-i-Cancho et al. (38), positional entropy is closely related with UID and CER. If UID holds for words in sentences and we assume that contextual information increases with sentence position, then the information content or entropy out of context should increase with sentence position. Therefore, we can examine whether information content has an even intra-sentence distribution based on the change of entropy out of context with respect to sentence position.
The positional entropy (1-gram) of a given sentence position is given by whereby H(X) is the 1-gram entropy of the position, the random variable X any possible word (type) that can occur in this position, pi the probability of X=word i.
This Formula is adapted from Formula (1) of Shannon's work (36) and H(X) of the former is equivalent to F1 of the latter. As seen from Formula 1, H(X) is an out-of-context entropy, for it is dependent exclusively upon sentence position instead of the specific context.
According to information theory, the relationship between positional entropy, contextual information content and conditional entropy is given by whereby H(X) represents the positional entropy of a given position, the random variable X any word (type) occurring in the position, the random variable C the context of X, H(X/C) the conditional entropy given context C (i.e., the entropy as in CER), and I(X, C) the mutual information between context C and the position.


Predictors of professional placement outcome: cultural background, English speaking and international student status

Placements provide opportunities for students to develop practice skills in professional settings. Learning in placements may be challenging for culturally and linguistically diverse (CALD) students, international students, or those without sufficient English proficiency for professional practice. This study investigated whether these factors, which are hypothesized to influence acculturation, predict poor placement outcome. Placement outcome data were collected for 854 students who completed 2747 placements. Placement outcome was categorized into ‘Pass’ or ‘At risk’ categories. Multilevel binomial regression analysis was used to determine whether being CALD, an international student, speaking ‘English as an additional language’, or a ‘Language other than English at home’ predicted placement outcome. In multiple multilevel analysis speaking English as an additional language and being an international student were significant predictors of ‘at risk’ placements, but other variables tested were not. Effect sizes were small indicating untested factors also influenced placement outcome. These results suggest that students’ English as an additional language or international student status influences success in placements. The extent of acculturation may explain the differences in placement outcome for the groups tested. This suggests that learning needs for placement may differ for students undertaking more acculturative adjustments. Further research is needed to understand this and to identify placement support strategies.

Introduction
Research conducted in Western contexts has found that students from culturally diverse and non-English-speaking backgrounds perform poorly in university degrees for health professionals compared with students from the dominant culture who speak English [1]. Such students may be domestic students from culturally and linguistically diverse (CALD) backgrounds or international students who are not residents of their country of study. In 2014, there were 4.5 million international students globally, and 53 % of these were from Asia [2,3]. In Australia, where this study was conducted, international students comprise 20 % of university students, but limited data exist about the par-ticipation of domestic CALD students in higher education [3]. Studies of health professional students have established that being CALD [1] and speaking English as an additional language [4,5] are predictors of poor academic performance, but the relationship for international students is unclear. Whilst previous studies have focussed on academic outcomes, little is known about the performance of these students in their professional placements.
Health professional education programmes require students to undertake placements situated within a range of health and community settings. These provide opportunities to work directly, and in an authentic way, with clients and situations related to the placement setting [6]. Placements facilitate opportunities for students to develop and practice professional knowledge, attitudes and skills, embedded within the sociocultural practices of their profession [7]. In many health professions, students are supervised in their placements by qualified practitioners who provide direct educational support and workplace based competency assessment during the placement [8,9]. Findings from qualitative studies suggest that in Western, English-speaking contexts CALD students, international students or those speaking English as an additional language may experience learning challenges in placements [10][11][12][13].
To succeed in these placements, international students [10,14] and domestic CALD students [13,15] must adjust to Western settings; manage culturally unfamiliar approaches to learning, assessment and supervision; and conduct their practice in English. Acculturation describes the process of cultural and psychological change that occurs following contact between individuals or groups from dissimilar cultures. This process of adjustment may influence learning outcomes for students in placements [16]. The extent of an individual's acculturation is influenced by several factors including their ethnic and cultural similarity to the receiving community, proficiency in the majority language, social supports, adaptation strategies, and the attitudes of the host culture [16][17][18]. Students who must undertake multiple or extensive adjustments may experience acculturative stress that affects their ability to cope with these changes [17] and impacts their academic performance [18]. In placements, all students must adjust for the context and practice of each setting. However, students who are also undertaking extensive acculturative adjustments may need to complete additional learning [10,18] and this may influence their placement learning outcomes.
Previous studies have used acculturation to explain educational, social, cultural and language adjustments made by international students, and how stress related to acculturation affects adaptation to learning at university, but have not investigated the critical learning environment in placements [18]. Acculturation may also affect domestic CALD students as these changes are known to continue for sev-eral generations following migration [17]. This suggests that acculturative factors may also impact educational outcomes for these students [18]. Studies identifying that international and domestic students who are CALD experience difficulties learning on placement and meeting performance expectations are small and preliminary in nature [11,13,15]. Students' placement success does relate to their English as this can impact communication with patients and health teams [12,14]. Speaking English as an additional language is an acculturative factor that has been identified to predict academic performance for health professional students [4,5,18]. However, speaking a language other than English at home (LOTEH) includes native English speakers, and is also a contextual variable that affects acculturation [17], but is rarely included in educational studies. Speaking English as an additional language or a LOTEH may be permutations of English language status that predict placement outcome. Factors related to students' cultural background or international student status may also hinder placement performance due to the process of acculturation, but little empirical data exist to support this [11,15].
Few studies have examined the predictive nature of CALD, being an international student, speaking English as an additional language and speaking a LOTEH together, and no previous research has investigated these for professional placement outcomes [1,4,19]. Investigating outcomes in placements is critical as they are key for the preparation of health professionals who can function competently in the workplace [6]. The placement context may pose additional acculturative challenges for students who are culturally and linguistically diverse [14]. This study aims to determine whether factors known to influence acculturation [17], including students' background or English status, predict their outcomes in professional placements.
We hypothesized the following: • English status categories ('English as an additional language' and 'LOTEH') and background status categories ('international students' and 'CALD') are separately predictive of poor placement outcome compared with English as first language, domestic or non-CALD students. • Interactions between background and English status variables will additionally predict 'at risk' placement outcome.

Context
This prospective cohort study was conducted with speechlanguage pathology students in Australia, an English dominant Western culture.

Participants
Students were recruited from five undergraduate and masters professional preparation speech-language pathology programmes at three universities in different cities. There were 854 students who consented, a consent rate of 82.2 %.

Data collection
Placement outcome data for any completed placements were collected from a staff member coordinating placement courses (placement coordinator) at each university. Data from six placements were excluded due to incompleteness; data from 2747 placements from 852 students were analyzed. Each university utilized the same standardized and validated assessment of speech-language pathology student competency development, which is conducted in the placement by the student's supervisor [20,21]. Continuous formative assessment of competency development occurs over the placement and a final summative assessment is recorded [9]. Placement outcome is determined by measuring competency development yielded by this assessment tool and qualitative appraisal by the supervisor. If the quantitative and qualitative judgments are not aligned with the required level of performance to pass, the placement outcome is determined via university mediation which also considers relevant contextual variables.
Placement outcome data were collected by the placement coordinator and one member of the research team and coded into one of four categories: • Pass: Student passed the placement. • Additional support: Student received additional learning support, such as mentoring or learning contracts during their placement due to competency development concerns, and subsequently passed the placement.  due to competency development concerns, and subsequently passed the placement. • Fail: Student failed the placement and was subsequently required to repeat.
The 'Pass' category comprised 2534 placements (92.2 %). Students in the remaining three categories had each been identified by their placement supervisor as being at risk of not meeting placement competency requirements and had received additional university support. These 'at risk' categories were small: 'Fail' had 71 placements (2.6 %), 'Supplementary placement' had 17 placements (0.6 %) and 'Additional support' had 125 placements (4.6 %). Initial modelling using these categories was not meaningful due to estimation problems and high standard error. Therefore, they were combined into a single 'at risk' category. This combined 'at risk' category defined poor placement outcome, and comprised 213 placements (7.8 %). The alternative placement outcome category was 'Pass'.
Students complete several placements during their speech-language pathology programme, and these occur across two or three years, depending on the university. This study captured placements over three consecutive years from 2011-2013, but during this period most students contributed data over one year (44.4 %) or two years (45.8 %). The mean number of placements for all students was 3.22 (SD = 1.6; range = 1-7). Unpaired T-tests revealed no significant differences between the mean number of placements for all students compared with the mean placements for each predictor. Each student was assigned a university identifier and a programme variable for undergraduate or masters enrolment.

Student background survey
A survey was constructed to collect students' cultural and linguistic characteristics using relevant standard questions recommended by the Australian Bureau of Statistics [22]. Acculturative factors were classified into five predictors shown in Table 1, and coded into binary 'yes/no' responses. These were defined as: 1. English language status: -English as an additional language: students for whom English is not their first language. -LOTEH: students who use a language other than English at home. 2. Background status: -'Defined CALD': students born outside of Australia who speak LOTEH [22]; -'Perceived CALD': Students identifying as CALD, including those Australian-born students perceiving as belonging to the cultural group/s of their family. -International students: students who are not Australian residents [2].
Students present in combinations of these groups, depending on their individual background and English status. For example, an international student may be a native English speaker, but have a CALD background.

Analysis
All data analyses were conducted in SPSS v22. Frequency data for each predictor were gathered to identify the proportion of placements with a 'Pass' or 'At risk' outcome, as shown in Table 2. Students' country of origin was also collated. Binomial logistic regression analysis was used to estimate the odds ratio for each predictor in relation to an 'At risk' placement outcome [23]. Multilevel modelling was applied using the Generalized Mixed Linear Models procedure as each student contributed data from multiple placements during the study, creating a nesting effect. This ensured findings were not artificially inflated by individual students' performance [23,24]. The predictors were tested for multicollinearity using polychoric correlation and variance inflation factor prior to analysis [25]. The 'defined CALD' variable had a collinear relationship with 'perceived CALD' (>0.9) and 'English as an additional language' variables, and was removed from analysis [23,26]. Table 3 shows the models of single and multiple predictors of 'At risk' placement outcome. University, programme and placement year variables were controlled in each iteration. The simple multilevel logistic model investigated the likelihood that the individual variables predicted 'at risk' placement. These predictors were then entered together using multiple logistic multilevel analysis in model 1. In model 2, interactions between 'international student', 'perceived CALD', 'English as an additional language' and 'LOTEH' variables suggested to impact placement performance [11,13] were entered with the single predictors from model 1. Non-significant student predictors were removed one-by-one via backwards elimination for the final model [26].

Results
The proportion of students for each predictor group are displayed in Table 1. The majority of international students were from countries in South-Eastern Asia 'Perceived CALD', 'defined CALD', 'international student', 'English as an additional language' and 'LOTEH' predictors had proportionately more 'at risk' placement outcomes than their alternative categories, as demonstrated in Table 2. Interactions between background and English status predictors had proportionately more 'at risk' placements than those from single predictors.
The unconditional model revealed that the odds of any student having an 'at risk' placement outcome was small but significant (OR = 0.07; p Ä 0.001), as shown in Table 3. All predictors tested in the simple multilevel model were significant. However, 'international student' and 'English as an additional language' were the only significant student predictors of 'at risk' placement outcome in the final multiple predictor model. In this model, international students were 1.83 times more likely to have an 'at risk' placement than domestic students (p < 0.05); and English as an additional language students were 2.38 times more likely than English as a first language students (p < 0.001). Interactions between background and English status predictors were tested in the multiple multilevel analysis, but 'perceived CALD and English as an additional language', 'Perceived CALD and LOTEH' and 'International student and LOTEH' interactions were eliminated due to estimation problems and high standard error. The remaining interaction between 'international student and English as an additional language' was not significant and did not enhance the model. University and programme variables used as controls were not significant, except for 'Year of placement' where students who completed a placement in 2012 were significantly more likely to have an 'at risk' placement in each model iteration, and 1.63 times in the final model (p < 0.01).
Atkinson's R was calculated to determine the importance of the 'international student' and 'English as an additional language' predictors to the placement outcome model. Although the 'international student' and 'English as an additional language' variables were significant predictors of 'at risk' placement, their R values of 0.02 and 0.03 respectively indicate that these cultural and linguistic characteristics have a small contribution to placement outcome overall [24]. The R value for 2012 placement year was 0.02.
The median odds ratio was calculated to determine the extent that the individual probability of an 'at risk' placement outcome was influenced by heterogeneity among students [27,28]. The median odds ratio value of 2.86 in the final model indicated that the residual heterogeneity among students was of greater relevance for placement outcome than 'international student' or 'English as an additional language' status.
CALD and international student groups are rarely delineated in previous studies, and differences between these variables in the multiple multilevel analysis prompted investigation of the proportion of 'perceived CALD' and international students who also spoke English as an additional language. Post-hoc analysis conducted using the 'N-1'chisquared test found no significant difference in the proportion of 'English as an additional language' students in the 'international student' and 'perceived CALD' groups (χ 2 = 0.150; p = 0.7) [29].

Discussion
In this study, acculturation theory was used as a lens to identify predictors of placement outcome for health professional students studying in a Western, English-speaking country. Specifically, background status variables of 'perceived CALD' or 'international student' and English status variables of 'English as an additional language' or 'LOTEH' were modelled to determine if they predicted poor placement outcome. We also investigated whether interactions between background and English status variables additionally predicted 'at risk' placement outcome. Interactions between 'international student and English as an additional language' were not significant in the multiple predictor model, but estimation of other interactions was limited.
In the simple multilevel logistic analysis, the single variables each significantly predicted 'at risk' placements.
However, only 'English as an additional language', 'international student' and 'placements in 2012' remained significant predictors in the final model which utilized a more powerful multiple multilevel logistic analysis [23,26]. Longitudinal data are required to determine if the variation in 'at risk' placement outcome in 2012 is more than anomalous. Whilst these variables were significant predictors of 'at risk' placement, their importance for the overall placement outcome was small, and the median odds ratio indicated that heterogeneity among individual students is also a relevant factor for placement outcome [27]. Placement outcome is likely to be predicted by many untested factors related to student academic performance, placement setting, supervision and assessment. This study did not intend to model a broad range of variables, but rather to determine whether the acculturative factors identified predicted placement outcome. The contribution of the 'international student' and 'English as an additional language' predictors in the multiple multilevel analysis indicates that these should be included in future studies. Individual acculturative factors such as personal attributes and values, sociodemographic status and coping strategies may also contribute to placement outcome [17,18], and should also be considered for future studies.
Students who speak English as an additional language were more likely to have an 'at risk' placement outcome but students speaking a LOTEH were not. This finding extends previous research linking speaking English as an additional language with poor academic performance [4,5] into the professional placement context and lends support to qualitative findings identifying English proficiency as influencing students' placement success [10,13,14]. Acculturation theory predicts that challenges associated with using English as an additional language result in stressors for students which inhibit their adjustment to new educational environments, even when their cultural background is constant [17]. Adjustments for language are likely to be greater for students who speak English as an additional language than students who speak a LOTEH, as this includes native English speakers. Adjustments may be intensified in placement settings, where the client focussed nature of services reduce opportunities to scaffold students' professional communication skills [6]. Whilst speaking English as an additional language has been linked with poor academic performance [4,5], it is not a direct measure of English proficiency. Measures of proficiency may better reflect communication challenges in placement settings as speaking English as an additional language does not reflect a students' application of English [11,13,15]. Further research is needed to examine the relationship between English as an additional language, English proficiency and placement outcome.
Previous studies have identified CALD students as having a greater risk of academic difficulties, but these studies have not clearly differentiated between CALD and international students or addressed placement outcomes [1]. In this study, being an international student was more predictive of 'at risk' placement outcome than belonging to 'perceived CALD'. As 'English as an additional language' also predicted 'at risk' placement outcome, differences in the proportion of English as an additional language speakers in the 'international student' and 'perceived CALD' groups may have assisted to explain their difference in placement outcome. However, they were not significantly different. These groups were distinguished by domestic students born in Australia, who comprised almost half of the 'perceived CALD' group. The identification of these Australian students as CALD may relate to the cultural background of their family. Domestic CALD students were also included in study cohorts of previous research that identified CALD as a factor predicting academic failure [1,19]. The factors that influence the extent of a student's acculturation to the receiving culture are likely to impact international students differently to domestic CALD students. These include their prior education experiences, cultural similarity with and fluency in the language of the host country [17]. This may account for the finding that being an international student predicted 'at risk' placement performance, but being 'perceived CALD' did not. The time limited and specific intentions of the international students' sojourn [18] or the greater acculturation of domestic CALD students to the home culture [17] may also influence outcomes.
Domestic CALD students have been noted to experience challenges in professional placements [13]. However, international students may need to undertake greater acculturative adjustment to operate successfully within these environments compared with those of their home culture. These factors may be independent of cultural or language background, as students from Western, English-speaking backgrounds also undertake adjustment to accommodate their learning in foreign professional placement settings [10]. International students may therefore find adjustment to the language, learning, cultural and/or organizational expectations of professional placements more challenging than their domestic peers, regardless of their background [10,11,14]. This may have a greater contribution to international students' placement outcomes than previously understood. Acculturative factors may therefore assist to explain differences in placement outcomes between the 'international student' and 'perceived CALD' groups; however, further research is needed to confirm this.
Frequency findings for interactions between 'international student and English as an additional language' predictors indicated that these students may be more likely to have an 'at risk' placement outcome than other student groups. International students who also speak English as an additional language may need to undertake more extensive acculturative adjustments than those represented in the other groups [16,18]. However, in the multiple multilevel analysis, interactions between 'international student and English as an additional language' were not significant. Therefore, students who are international students and speak English as an additional language are not more likely to have an 'at risk' placement outcome than students who are either international students or speak English as an additional language. This suggests that the 'international student' and 'English as an additional language' variables independently predict placement outcome, and both should be included in future studies of placement outcome.
These findings that suggest that international students and students who speak English as an additional language may require support for their learning and performance in placements. However, there is little empirical evidence of what strategies would be effective. Future research should clarify learning needs for these students and explore appropriate placement supports [10,13].

Limitations
The identity, background and placement outcome of students who did not consent for this study is unknown, so it is not possible to determine if the results represent speech-language pathology students from the participating universities. However, consent rates did not markedly differ across the three universities, and the proportion of international and domestic students within this study approximates that identified in previous speech-language pathology research [30].
There are likely to be many predictors of placement outcome including factors related to student, supervisor, placement context and the assessment of competency, but this study did not aim to include these in modelling. Future studies should include a broader range of predictors, including 'international student' and 'English as an additional language' to determine a model of placement outcome.
Backwards elimination was utilized to remove non-significant predictors from the modelling. While this potentially introduces bias, it is an accepted strategy where research does not aim to identify a causal model [26]. Multicollinearity limited modelling of students in the 'defined CALD' group, which constrained the analysis of CALD as a predictor. Estimation problems and standard error also precluded investigation of interactions between predictors in the multiple multilevel analysis.

Conclusion
This study aimed to identify if students' placement outcomes are predicted by being an international student, CALD or English-speaking status. 'English as an additional language' and 'international student' variables were significant predictors of 'at risk' placement outcome, but their relative contribution to overall placement outcome was small. Acculturation theory may be useful to advance understanding of factors that influence students' success in their professional placement programmes. Future research should clarify the impact of speaking English as an additional language or being an international student on placement outcomes, and strategies that contribute to placement success for these students.


Beyond Visas and Vaccines: Preparing Students for Domestic and Global Health Engagement

Dr. Adams From the D standing, D Abstract At campuses across the United States, scores of students are embarking on global health experiences in lowand middle-income countries. The desire to improve the health of poor communities while preparing for future health careers is often the main driver. The spotlight on domestic health issues also has fueled a resurgence of interest in underserved communities in the United States. Regardless of the destination, rigorous preparation is needed to ensure that the students’ presence benefits the communities they aim to serve.

I N T R O D U C T I O N
Global health has become a highly popular area of study for students in health-related fields at both the undergraduate and graduate levels. A growing attention to health disparities and a desire to improve the health of poor communities often are the main drivers of such student interest. Impassioned students and trainees are now clamoring for both additional global health coursework in their formal curricula and for opportunities for mentored overseas clinical, community health, and research experiences. For many considering future careers in health, a global health experience has become a presumed rite of passage for students, who now view a term, or summer, or year working in global health as requisite for admission to medical or graduate school. Many prospective applicants now include the option for international training or the presence of global health tracks as a criterion for ranking their colleges; medical, nursing, or public health schools; and residency programs. 1,2 In the constant competition to attract the best students, academic institutions across the country continue to expand global health programs to meet this growing demand. In 2010, 37% of medical schools reported offering global health content, and this number has grown every year. 3 At universities, global health programs feed into a growing trend of internationalization of the undergraduate curriculum and of experiential learning. 4 Recent attention to global health programs in the lay press, spurred by advocacy from various Hollywood celebrities, has pushed global health into mainstream media and discourse. Global health also responds to the desire of today's altruistic youth to take part in making the world a better place. As Dr. Mike Merson, a global health expert based at Duke University, observed "Global health, particularly because it brings to light such gross disparities between lowand high-income countries and populations within countries, is a natural channel for student compassion and action." 4 As a result of this confluence of factors, each year, scores of students embark on global health experiences in low-and middleincome countries (LMICs) across the world, predominantly in Africa and Asia, and to a lesser extent in Central and South America. Indeed, more than one-third of incoming medical students report having an international volunteer experience before entering medical school. 5 Applications for participation in these programs indicate how competitive they have become; in some cases, as much as 25% of the student body applies. 6  Although not always as popular among students, programs to address domestic health equity issues also are commonplace on academic campuses. 8 Some of these programs predate the global health movement by decades; at Dartmouth such programsdthen referred to as community service programsdhave been available to undergraduate and medical students since the 1980s. These programs range from clinics providing free care to medically indigent populations in urban and rural areas, to programs that provide assistance with the health care needs or health education of recently resettled refugee or at-risk immigrant populations, to public health campaigns in lower socioeconomic neighborhoods to reduce smoking, obesity, drug use, and other unhealthy lifestyle habits. Well-designed domestic programs offer students an opportunity to achieve similar experience in addressing complex health and public health issues as is available in international programs, and the added benefits of longitudinal, multiyear (vs. 4-12 weeks) involvement and, depending on the number and capacity of community partners, the potential for all interested students to participate. 9 For some students, these experiences lack the exotic appeal of a dramatically different culture and setting. Our experience has shown that both global health and domestic health equity work are extremely challenging and highly rewarding. In fact, we remind our students that there are more similarities than differences to working with underserved populations regardless of where they reside. The common themes of understanding context and culture, the challenges of working with underresourced services and systems, and of the need to work through strong community partnerships are foundational to both global and domestic health programming. In recognition of the important crossover in this work, many global health programs, ours included, have begun to offer domestic placements in Native American communities and organizations serving refugee populations.

The Effects Of Increased Demand: Taking Our
Partner's Perspective. The explosive growth of global health programs in the United States (US) and other high-income countries (HICs) has created parallel demand for new opportunities for work with partners in LMICs. Although many view this increase in demand among our students as a positive phenomenondreflecting more students desiring to work with underserved communities to tackle the many complex issues of health care delivery in these settingsdwe need to consider the effects of this demand on our international partners. As Kerry and colleagues noted, the growth that we have witnessed on the US side in the form of newly established centers, institutes, and programs for global and local health training and internships is not necessarily being matched by an increase in capacity within our international partner institutions and organizations. 1 Consequently, we may be placing an even greater burden than previously on our community partners and their ability to accommodate our students and trainees.
Many educators have underestimated the burden that sending our US students and trainees overseas imposes on our international partners. Through years of managing reciprocal exchanges, we have learned how time intensive it is to orient an incoming student to a new health care or public health system, a new professional culture and living environment (and the students coming to Dartmouth all have sufficient English-language ability, so there is no need for the use of translators, which may be an added task in other universities).
Yet when we send a US student overseas, too often the assumption is that the student, by providing "free labor," will be an overall asset to the partner. After all, isn't the student bringing needed skills, be they technical, analytical, organizational, or computer-based? Didn't we select the most confident, articulate, and organized applicants during the application and interview process whose success in our US academic system will carry over to this experience? Won't their abilities as bright, critical thinkers and active problem solvers allow them to successfully navigate their new environment in a low-income setting? After more than a decade selecting students for global health experiences, the answer to these questions is a resounding no.

Preparing
Students: Beyond Visas And Vaccines. Global health programs have been developed at a rapid rate with a focus on recruiting top student or residency candidates and accommodating their training needs. It is unclear if institutions have paid a similar level of attention to developing the necessary predeparture preparation for their students. Predeparture preparation should serve to: 1. Ensure that students are safe during their global health experiences; 2. Maintain academic rigor and optimal learning; and 3. Provide the student the most meaningful experience possible and an understanding of the "bigger picture" of the project or work in which they are engaged.
Furthermore, predeparture preparation can help to ensure that the experience is beneficial (and not burdensome) to the international partners hosting the student. Identifying projects and managing the logistics for such experiences can be quite time and labor intensive. However, if we focus only on the visas and vaccines associated with the global health experience, we miss important opportunities for global health education, partnership building, and project progress. And although this may be more obvious for international placements, we know that students engaging in domestic health programs also need and will benefit from similar preparation. Mistakenly, because such work does not require a visa or visit to travel clinic, these students are often not included in the pre-departure training offered to students embarking on global health experiences. It is time to close this gap.
The Consequences of Getting It Wrong: Risks to Students, Partners, and the Partnership. If something goes wrong in this work, the stakes are higher than we might imagine. Sending ill-prepared students to work with underserved populations can cause harm to both the sending and the receiving institution. For years, our colleagues in LMICs have graciously accepted our students despite the strain that hosting and supervising them can place on existing resources and the diversion of limited faculty and staff time toward orienting and bringing the students up to speed on the project or the workings of the public health or medical system in the country. Nearly half of respondents in a survey of hosts at clinical sites in Sub-Saharan Africa reported decreased efficiency when precepting foreign students. 10 Time spent teaching and training our students may be worthwhile for the individuals involved and affect their careers, but any time it replaces the teaching of local students and traineesdwho are likely to spend their careers working in that system, not just 1 or 2 monthsdthe overall value of the program must be questioned. In many LMICs with a high disease burden, medical faculty are already stretched to capacity and university faculty-tostudent ratios are well below those of their US partner institutions. 1 In such settings, time for teaching students is already a precious commodity. Stretching this capacity even further with additional students seems an unfair burden to place on them.
Although we may select the best and the brightest among our US student body for these experiences, rather than strengthening weak institutions, the presence of foreign students can disrupt fragile education and health care ecosystems by sidelining local professionals and residents. 11 US students sometimes experience the resource constraints for patient care as a lack of caring among the local health care team and, with the best of intentions, push for additional testing and an intensity of care that they believe their patients would receive in the United States but do so without knowledge of the effects on actual patient outcomes or healthcare delivery systems. Similarly, students engaged in public health and community outreach activities may seek solutions that do not take into account the broader national and community contexts. Examples include performing health education under the assumption that lack of knowledge is the only barrier to behavior change, or raising expectations for services that local institutions are unable to provide.
Unprepared students and trainees also can negatively affect institutional partnerships. International collaborations, like any professional relationship, require constant attention and good communication to ensure needs are being met on both sides. Partnerships between LMICs and HICs often carry the additional complications of a legacy of Western colonization and a power imbalance from an unequal distribution of resources. Sites receiving financial support from an international collaborator may feel an obligation to host its students or an inability to express concern with their performance. 12 Many cultures outside the United States demonstrate greater respect for hierarchies of age and professional standing. Students who are inadequately prepared for their experience may unknowingly show disrespect and offend their international supervisors or the local health care team. Some allowances are made to foreign students being unaware of local practices, but when a student prioritizes meeting his or her project goals over respecting and preserving professional relationships, it can jeopardize the whole partnership. Regrettably, on more than one occasion in the early days of our program, we had to intervene to remedy a threatened partnership from an overzealous student's efforts to achieve his or her project objectives. Of course, these kinds of misunderstandings and inappropriate approaches are not restricted to studentsdfaculty and staff who engage in global health programs can make the same missteps if not properly prepared. Program leaders have a responsibility to ensure that all involved in this work are given adequate training and an introduction to the context in which they will be working.
Ideally, these programs are structured to satisfy the needs of both the students and the populations and colleagues at the international partner sites. Most of the time, our international partners have not complained about the burden that receiving our students places on their staff or educational systemdeither because they have grown accustomed to being the training ground for foreign students who have the means to travel for a service project or overseas training, or because no one has ever asked them about it. A recent study conducted by Evert et al surveyed 35 faculty, staff, and community members from institutions and organizations in 17 countries that host visiting undergraduate and graduate students and trainees to better understand perspectives on competencies, learning objectives, and interactions with visitors. 13 Although the data are preliminary, hosts reported that only 20% of visiting students/trainees were well prepared, and 21% were evaluated as less than satisfactorily prepared. One-third of respondents suggested that 35% of trainees did not demonstrate an understanding of the realities of working and living in a lowresource setting. Additionally, one-third felt that students took away more than they could give to the community where they worked and very few (10%) felt that the student gave more to the community than they themselves gained. A study by Lukolyo and colleagues of preceptors of students engaged in short-term experiences at clinical sites in Sub-Saharan Africa reported similar findings. 10 Although preceptors generally regarded students favorably, respondents expressed concerns around some learners' professionalism, cross-cultural skills, and understanding of the local conditions. These findings are among the first formal reports from international hosts (a telling fact by itself) and provide a baseline against which to measure improvement in this area.
Students themselves can also suffer consequences from poor preparation before their global health experience. Student safety should always be a top priority. Accordingly, perhaps driven by liability concerns, student health and safety has been the mainstay of predeparture preparation for students heading overseas. But beyond the malaria prophylaxis and traveler's diarrhea precautions, the mental health and well-being of our students during their time overseas, and especially upon their return, has been underemphasized. Poorly designed programs may have adverse consequences on students, who struggle afterward to manage their stress. 14 We have observed the challenges of the "re-entry phenomenon" or reverse culture shock when students try to integrate back into campus life. Many find their friends and family have a hard time understanding exactly what they experienced, and the typical student quandaries and challenges seem superficial or insignificant in comparison to the true hardship they witnessed overseas. At the same time, inadequate preparation and post-return reflection may cause students to jump to conclusions about the root causes of the challenges they witnessed in the LMIC where they worked. Some programs are now focusing on this important part of the student experience to ensure a safe and healthy conclusion follows. 15,16 These programs can provide effective models to emulate.
Although this discussion focused on the risks encountered in international settings, we emphasize that they are no less serious in domestic health settings with similarly underserved and vulnerable populations. These local experiences do not require passports or prophylaxis but are no less fraught with the same institutional, social, and crosscultural challenges as those overseas. 17 Moreover, many students are increasingly interacting with the same populations they would have previously encountered abroad but now as newly arrived immigrants and refugees, often as they navigate a HIC health and social services system. Paradigm. Experts in global and domestic health programming have long recognized the importance of building durable partnerships in the communities where they work in order to be effective. However, achieving balanced and equitable collaborative relationships is complex and requires a paradigm shift in how global and local health programming is conceived and conducted. Under this new paradigm of making the partnership central, our health programs as well as the preparation for our students must be restructured to reflect this shift. In recent years, several global health experts have developed guidance to help program directors develop comprehensive predeparture programs to ensure ethical engagement of students and trainees. 11,18 The Working Group on Ethics Guidelines for Global Health (WEIGHT) established guidelines for best practices in global health programs based on their collective experience. 18 These guidelines urge sending and host institutions to organize programs in line with local host priorities to maximize benefits to the receiving institution. Beyond mutually beneficial collaborations, consensus is emerging on the need to situate student global health experiences within a broader agenda of building local LMIC capacity and health systems. This shift parallels a larger movement in global health away from vertical programs narrowly focused on a single disease and led by foreign partners to more locally driven initiatives to build and strengthen health systems. Cancedda and colleagues cited programs such as the Medical Education Training Partnership Initiative, the Nursing Training Partnership Initiative, the Rwanda Human Resources for Health Program, and the Global Health Service Program as examples that apply a more comprehensive approach to building health workforces in line with partner priorities and disease burdens. 19 This shift has forced a broader reexamination of academic partnerships and programs designed largely to benefit short-term trainees from high-income settings. Kerry and colleagues call for an approach to global health education that invests explicitly in in-country leadership, health systems, and research capacity. 1 Reflecting this trend, Melby et al proposed four guiding principles for the development of short-term experiences in global health: 1. skills building for participants in cross-cultural effectiveness and cultural humility; 2. bidirectional participatory relationships that create opportunities for both sending and host institutions; 3. local capacity building; and 4. long-term sustainability. 10 The WEIGHT guidelines challenge academic institutions from HICs to move beyond models limited to opportunities for their own students. A clear lesson from both global and domestic health is the centrality of longitudinal, institutional partnerships to lay the foundation for successful student experiences. 20 Global health experiences embedded in partnerships designed to address locally identified community and health system needs yield greater benefits to hosts and trainees alike. At our institution, student global health experiences are one component of broader partnerships that, based on local priorities and needs, often encompass capacity building and training in-country, faculty and student exchanges, and shared research activities. Situating student experiences within this existing framework of reciprocity allows closer alignment of student activities with partnership goals as well as more optimal use of resources at host institutions. Where possible, student projects are designed to fit within the scope of existing activities of the partnership. For example, students have served for many years as research assistants in ongoing clinical trials being conducted with our partners in Tanzania. Incorporating these students into formal partnership activities has shifted some of the burden of supervision to our own faculty while supporting our joint research goals.

Adams and Sosin
As firm believers in reciprocity at our institution, we have established bidirectional exchange programs of students and faculty as a core programmatic activity. Each year, we partially or fully fund and host roughly 7 to 10 students and trainees from 3 to 4 partner sites. Bidirectional exchanges, we have learned, take significant resources on the part of clinical costs and administrative staff. Early in our exchange program, faculty members lamented the additional work associated with hosting students unfamiliar with our medical system and training. Over time, these same faculty members have come to appreciate the burden that our students place on their hosts.
Identifying areas where students can support partnership or host priorities can mitigate many of the pitfalls of student global health experiences. Many students bring skillsdan ability to write effectively in English, knowledge of data analysis programs such as SPSS or STATA, and an ability to organize large amounts of informationdthat can provide significant value to their hosts without displacing local trainees. Students may assist with ongoing research collaboration, assist partners with manuscript or policy writing in English, or conduct background research. Students' ability to dedicate time to research and other projects can both help to advance programmatic goals and can contribute to career development for individual hosts. Through careful program design, academic institutions can align missions, goals and expectations of student global health programs to best serve all invested parties: local partners, students, faculty, and the communities where they will be working. Selecting and Preparing Students. Selection of qualified candidates who can fulfill supportive roles in their placement is critical to the success of collaborative partnerships. Matching student skills to project needs, rather than defining projects around student interests, is essential. Equally important is identifying candidates whose attitudes predispose them to thrive in a global health setting. Ventres and Wilson highlighted the critical importance of open mindedness, humility, generosity, patience, and excellence to the success of students' global health experiences. 21 Conversely, they identify attitudes reflecting arrogance, entitlement, and lack of sensitivity to institutional or cultural context as impediments to successful experiences. Programs can design the selection process to screen for these qualities. At our own institution, we include questions in our written and interview questions to assess cultural humility, flexibility, and emotional maturity. Students are asked to describe how they have negotiated academic or work issues in the past. Here, global health programs have much to learn from the domestic service learning community and social justice movements, which have long stressed the importance of participant attitude in approaching communities of difference. 22 Local hosts should have an important role to play in the selection of students, although they often are not consulted. Many can identify the skills and qualities that will be most useful on a project in a particular environment. Involving them in the selection process also helps to minimize feelings of being imposed on by the sending institution. In our program, we routinely solicit host input both in the development of candidate requirements and selection through participation in review of applications or interviews via video or teleconference with program finalists.
Critical to their effective functioning in a partnership, students must also be prepared for the ethical and cultural challenges they will face in their work and in their host country. Many universities have developed training programs in cultural competency and global health ethics, and resources such as the Ethical Challenges in Short-Term Global Health Training Course 23 are now available online. Equally important is the need to prepare these students for the realities of working and living in a low-resource setting. Paradoxically, many of the personal qualities that have positioned students well for these opportunitiesdassertiveness, efficiency, and a desire to servedtranslate poorly in institutional settings with strained resources, competing priorities, and complex hierarchies.
Even the best predeparture training, however, cannot prepare students for the myriad challenges they may encounter in their global health experiences. Instead, we must teach students to repeatedly eschew simple, quick solutions. Most of the problems that they will encounter are embedded in complex systems that they can only begin to grasp in their short time in-country. We must therefore impress on students that our expectation is not that they achieve visible results but rather that they learn to establish working relationships and understand how they fit within a broader ecosystem. This is equally true for students working in domestic health settings.

C O N C L U S I O N
It is time to shift the paradigm in global and domestic health programming to place the partnership and our partner's priorities at the center. Preparation for student and trainee engagement in these experiences should be developed from this perspective. Students working with underserved populations and in resource-constrained settings should undergo the same rigorous preparation regardless of whether their site is overseas or local. Just as negative experiences can have lasting negative consequences, the best ones can lead to strengthened partnerships, durable benefits for local and global communities, and optimal learning for students, their supervisors, and their hosts.


CHARACTERISTICS OF BARBELL TRAJECTORY IN SNATCH, FULFILLED BY ELITE FEMALE WEIGHT-LIFTERS

Purpose: to determine trajectories of elite female weight-lifters’ movements. Material: 137 elite sportswomen were tested. Analysis of sportswomen’s bio-kinematic actions was fulfilled with the help of Weight lifting analyzer 3.0 apparatus, Germany. Results: we found correlation of barbell snatch trajectory in respect to different weight categories of sportswomen. General characteristics of barbell trajectory are equal both for men and women. We determined indicators of barbell grip deviation from vertical axis. Optimal barbell trajectory depends on relative length values of body segments and other important factors. Conclusions: it was proved that execution of 2nd type trajectory of barbell horizontal movement is the most wide spread and effective. Such type of trajectory is the most often for high sport results off light weight categories (48-58 kg).

Introduction
The problem of sport movements' training and correction is a central one in theory and practice of sports спорту [4,10]. Sport movements' training and correction are the most effective if they are realized on the base of modern ideas about weight-lifting exercises' fulfillment [6, 8, 9, and 11]. One of such ideas is trajectory of barbell movement [1,22]. As on the present moment the way of technical characteristics obtaining, their information potential and objectiveness permit to detect mistakes rather quickly., Such mistakes can be effectively corrected at different stages of sportsmen's training. Reference models were received already in 70-s of 20 th century [3]. Such models represent three types of barbell movement trajectory with three kinds of each. They reflect characteristics of snatch and lifting barbell on chest (see fig.1). Since that time, scientists from different countries only have been proving their correctness [13,17]. Alongside with it searching of more effective trajectories (the most wide spread among weight-lifters) is remaining the permanent subject of their discussions. In some works trajectory (А) [16] is offered; in other -trajectory of B type [14,25]. In his turn Hiskia G. [18] came to conclusion that type C is the most wide-spread. Other scientists [24] also came to conclusion and recommended model C as the best trajectory.
It should be noted that till now scientists have not had commonly accepted opinion about usage of these trajectories. Their conclusions were received from studies, which involved little quantity of sportsmen or sportswomen far from being elite.
Hypothesis: it is assumed that analysis of great number of elite sportswomen will permit to more precisely show one of technical fitness sides (barbell horizontal movement in snatch). It may result in reviewing theoretical and practical principles of sportswomen's technical training.
The purpose of the work is to determine trajectories of elite female weight-lifters' movements.
Organization of the research: analysis of sportswomen's bio-kinematic motor actions was fulfilled with the help of modern apparatus complex, which works on principle of video-grams' automatic processing (Weight-lifting analyzer 3.0, Germany). Collection of these data was carried out at competitions of different levels (Championship of Europe, Budapest; Championship of Europe, Minsk; World Championship, Istanbul; World Championship, Wroclaw). In total we analyzed 238 successful snatches.
Statistical analysis was fulfilled with the help of Microsoft Excel 2010 programs.

Results of the researches
The received in our researches data permit to prove the fact that most of sportswomen practice second type (B) of barbell trajectory (see fig.2). . Evident prevalence of second type (B) application (44.53%), comparing with type A (24.82%) and type C (30.66%) was determined (see fig.3). As we can see in figure 3 sportswomen of 48 kg category mainly use trajectory B (69.23%). C-type takes only 23.08% and A-type -7.69%.
The same situation was observed in 53 kg category. The tendency of B-type prevalence in snatch (В, 58.33%) is remaining. Type C takes second place (25%) and type A -third (16.67%).
These data change a little in categories 58 and 63 kg. In these categories sportswomen lift barbell the most often by second type (В): 52.27% and 43.48% respectively. The second place is taken by trajectory A with percentage of 30.43% in both categories. Data analysis in category above 75 kg showed that sportswomen, mainly, apply third type (C) in snatch. I.e. from 22, 12 sportswomen lift barbell by third type of trajectory -C (54.55%).

Discussion
Analysis of successful attempts in snatch showed that mainly sportswomen apply type B for lifting barbell. It coincides with the data of other authors [3]. General characteristics of barbell trajectories are equal for men and women. It coincides with the data of other researches [15, 17, and 21].
The works of American scientists showed inconsistency in barbell snatch trajectories in weight category 69 kg. More over less that half of sportswomen lifted barbell by trajectory A. It was proved in our previous works [19].
In the whole, in fig. 2 we can notice certain tendency of movement trajectories' usage. The highest percentage of fulfillment of B type is observed in 48 kg weight category. This percentage gradually reduces with weight categories' increasing. Percentage of trajectories A and C fulfillment grows with weight categories' increasing. From this diagram we can see that in 69 kg category balance between trajectories types' fulfillment exists. With further growth of weight categories correlation again changes. Many scientists try to explain this phenomenon by influence of body anthropometric sizes [2, 12, and 23]. For example, Garhammer J. [16] found that optimal trajectory depends on relative lengths of body segments and other important factors. Specialists in other kinds of sports support the opinion that technique of exercises' fulfillment is influenced by constitutional and typological features of sportsmen's bodies [5,7]. Though, the role of anthropometric factors in determination of optimal barbell trajectory has not been cleared up yet [19].
It is necessary to pay attention to indicator of barbell deviation from vertical axis. By the data of authors [20] ineffective barbell lifting results in great energy losses. It is reflected in barbell excessive horizontal movements. In our opinion this characteristic has not been studied sufficiently. It opens prospects of further researches with paying attention to main three types of barbell trajectories.

Conclusions
We proved that usage of second type barbell horizontal movement (B) by sportswomen is the most widespread and effective for achievement high sport results.
Sportswomen of light weight categories (48-58 kg) use type B the most often. It was determined that many sportswomen of the heaviest weight category (+75kg) use C type of barbell trajectory.