Reconfiguring a One-Way Street: A Position Paper on Why and How to Improve Equity in Global Physician Training

Access, interest and equity considerations for virtual global health activities during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Global health activities (GHAs) reduce health disparities by promoting medical education, professional development, and resource sharing between high- and low- to middle-income countries (HICs and LMICs). Virtual global health activities facilitated continuity and bidirectionality in global health during the COVID-19 pandemic. While virtual engagement holds potential for promoting equity within partnerships, research on equitable access to and interest in virtual global health activities is limited.

METHODS

We conducted a cross-sectional, online, mixed-methods survey from January to February 2022 examining access to virtual activities before and during the pandemic across resource settings. Eligible participants were participants or facilitators of global health activities. Closed- and open-ended questions elicited participants' access to and interest in virtual global health engagement.

RESULTS

We analyzed 265 surveys from respondents in 45 countries (43.0% LMIC vs. HIC 57.0%). HIC respondents tended to report greater loss of in-person access due to the pandemic at their own institutions (16 of 17 queried GHAs), while LMIC respondents tended to report greater loss of in-person activities at another institution (9 of 17 queried GHAs). Respondents from LMICs were more likely to gain virtual access through another organization for all 17 queried VGHAs. HIC respondents had significantly more access to global health funding through their own organization (p < 0.01) and more flexibility for using funds. There were significant differences and trends between respondent groups in different resource environments in terms of accessibility to and interest in different virtual global health activities, both during and after the pandemic.

CONCLUSIONS

Our results highlight the need to examine accessibility to virtual global health activities within partnerships between high- and low- to middle-income countries. While virtual activities may bridge existing gaps in global health education and partnerships, further study on priorities and agenda setting for such initiatives, with special attention to power dynamics and structural barriers, are necessary to ensure meaningful virtual global health engagement moving forward.

Lifting all boats: strategies to promote equitable bidirectional research training opportunities to enhance global health reciprocal innovation

Inequities in global health research are well documented. For example, training opportunities for US investigators to conduct research in low-income and middle-income countries (LMIC) have exceeded opportunities for LMIC investigators to train and conduct research in high-income countries. Reciprocal innovation addresses these inequities through collaborative research across diverse global settings.The Fogarty International Center of the US National Institutes of Health (NIH) promotes research capacity building in LMICs. Fogarty K-grants for mentored career development in global health are available for both US and LMIC investigators, whereas the D43 is the standard grant to support institutional training programmes in LMIC. Other NIH institutes fund T32 training grants to support biomedical research training in the USA, but very few have any global health component. Most global health training partnerships have historically focused on research conducted solely in LMIC, with few examples of bidirectional training partnerships. Opportunities may exist to promote global health reciprocal innovation (GHRI) research by twinning K-awardees in the USA with those from LMIC or by intentionally creating partnerships between T32 and D43 training programmes.To sustain independent careers in GHRI research, trainees must be supported through the path to independence known as the K (mentored grantee)-to-R (independent grantee) transition. Opportunities to support this transition include comentorship, research training at both LMIC and US institutions and protected time and resources for research. Other opportunities for sustainability include postdoctoral training before and after the K-award period, absorption of trained researchers into home institutions, South-South training initiatives and innovations to mitigate brain drain.

What Is the Current Status of Global Health Training for US Postgraduate Trainees in Anesthesiology? What Are Possible Visions for the Future?

Purpose of Review

There is a great deal of interest in global health at all levels of educational attainment. Many residency programs wish to offer a global health opportunity (GHO) but lack the resources to create one de novo. This review will look at the prevalence of global health education in residency and consider the fellowships available. It will summarize the existing recommendations about a curriculum in global health and how best to prepare trainees for a GHO.

Recent Findings

While approximately 45% of residency programs make GHOs available to their residents, there is a lack of standardization of curriculum. Logistical and ethical challenges, funding, and the lack of international partners are all barriers to offering a GHO. Residents and fellows can benefit from a GHO as it helps achieve their ACGME core competencies, among other benefits.

Summary

We make the recommendation for more robust training and education with the investment of fewer resources by aligning with existing global health participation opportunities. We also recommend the use of the Consortium of Universities for Global Health (CUGH) which provided curriculum for creating a context in global health for trainees regardless of discipline.

Orthopaedic trauma observerships in North America for international surgeons: the visitors' perspective

International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented.

Methods

A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed.

Results

Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon.

Conclusions

Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed.

Level of Evidence

IV-Cross-Sectional Study.

A Scoping Review of Health Care Faculty Mentorship Programs in Academia: Implications for Program Design, Implementation, and Outcome Evaluation

INTRODUCTION

Formal mentoring programs have direct benefits for academic health care institutions, but it is unclear whether program designs use recommended components and whether outcomes are being captured and evaluated appropriately. The goal of this scoping review is to address these questions.

METHODS

We completed a literature review using a comprehensive search in SCOPUS and PubMed (1998-2019), a direct solicitation for unpublished programs, and hand-searched key references, while targeting mentor programs in the United States, Puerto Rico, and Canada. After three rounds of screening, team members independently reviewed and extracted assigned articles for 40 design data items into a comprehensive database.

RESULTS

Fifty-eight distinct mentoring programs were represented in the data set. The team members clarified specific mentor roles to assist the analysis. The analysis identified mentoring program characteristics that were properly implemented, including identifying program goals, specifying the target learners, and performing a needs assessment. The analysis also identified areas for improvement, including consistent use of models/frameworks for program design, implementation of mentor preparation, consistent reporting of objective outcomes and career satisfaction outcomes, engagement of program evaluation methods, increasing frequency of reports as programs as they mature, addressing the needs of specific faculty groups (eg, women and minority faculty), and providing analyses of program cost-effectiveness in relation to resource allocation (return on investment).

CONCLUSION

The review found that several mentor program design, implementation, outcome, and evaluation components are poorly aligned with recommendations, and content for URM and women faculty members is underrepresented. The review should provide academic leadership information to improve these discrepancies.

Scholarly Products for the Global Health Trainee: a Guide for Educators

There is consistent interest from medical trainees in high-income countries in academic global health education (GHE) programs. Academic scholarship in global health has traditionally been linked to longer-term programs. However, most programs for medical trainees offer short-term experiences in global health (STEGH). These experiences are typically brief and clinical, and present logistical and ethical challenges for producing scholarship. Given challenges inherent in global health medical education, educators should cultivate ethically sound scholarship prioritizing power, privilege, and decision-making within local communities. Utilizing the framework of community-engaged scholarship, GHE ethics guidelines and examples we present suggestions to guide scholarship in GHE.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange

Background

As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya.

Methods

Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed.

Results

Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program.

Conclusion

As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Perceived roles, benefits and barriers of virtual global health partnership initiatives: a cross-sectional exploratory study

Background

Virtual global health partnership initiatives (VGHPIs) evolved rapidly during the COVID-19 pandemic to ensure partnership continuity. However the current landscape for VGHPI use and preference is unknown. This study aimed to increase understanding of GH partners’ perspectives on VGHPIs.

Methods

From 15 October to 30 November 2020, An online, international survey was conducted using snowball sampling to document pandemic-related changes in partnership activities, preferences for VGHPIs, and perceived acceptability and barriers. The survey underwent iterative development within a diverse author group, representing academic and clinical institutions, and the non-profit sector. Participants from their professional global health networks were invited, including focal points for global health partnerships while excluding trainees and respondents from the European Economic Area. Analysis stratified responses by country income classification and partnership type. Authors used descriptive statistics to characterize responses, defining statistical significance as α = 0.05.

Results

A total of 128 respondents described 219 partnerships. 152/219 (69%) partnerships were transnational, 157/219 (72%) were of > 5 years duration, and 127/219 (60%) included bidirectional site visits. High-income country (HIC) partners sent significantly more learners to low- to middle-income country (LMIC) partner sites (p < 0.01). Participants commented on pandemic-related disruptions affecting 217/219 (99%) partnerships; 195/217 (90%) were disruption to activities; 122/217 (56%) to communication; 73/217 (34%) to access to professional support; and 72/217 (33%) to funding. Respondents indicated that VGHPIs would be important to 206/219 (94%) of their partnerships moving forward. There were overall differences in resource availability, technological capacity, and VGHPI preferences between LMIC and HIC respondents, with a statistically significant difference in VGHPI acceptability (p < 0.001). There was no significant difference between groups regarding VGHPIs’ perceived barriers.

Conclusions

The pandemic disrupted essential partnership elements, compounding differences between LMIC and HIC partners in their resources and preferences for partnership activities. VGHPIs have the potential to bridge new and existing gaps and maximize gains, bi-directionality, and equity in partnerships during and after COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41256-022-00244-4.

Development of the Association of Pediatric Program Directors Global Educator Scholarship-Expanding Bidirectional Efforts in Global Health Education

BACKGROUND

The Board of the Association of Pediatric Program Directors (APPD) partnered with the APPD Global Health Learning Community (GHLC) to establish the APPD Global Pediatric Educator Scholarship. This award seeks to recognize pediatric educators who demonstrate leadership in improving pediatric education in low- and middle-income countries, and provide them with career development opportunities by attending the APPD Spring meeting. Two educators per year have been awarded the scholarship since 2017.

AWARD EVALUATION

The authors sent survey questions via email and obtained responses from 6 (100%) of the scholarship awardees, 8 (75%) APPD GHLC leadership individuals, and 4 (67%) APPD Board members. Three authors analyzed the responses with consensus achieved on themes.

RESULTS

Awardees noted learning about educational strategies, academic opportunities through networking, and context for stronger bilateral exchange with partners. APPD leaders noted an expansion of the organization's mission to include global presence. Challenges included program visibility, sustainable funding, and logistics. Suggestions included better incorporation of awardees into APPD membership, longitudinal mentorship, targeted conference navigation, and visits to local academic institutions.

CONCLUSIONS

The APPD Global Educator Scholarship is a replicable model of organizational global outreach that expands the concept of bidirectional exchange to include career sponsorship for global partners.

Pediatric Orthopaedic Observerships in North America for International Surgeons: Perceived Barriers and Opportunities for Visitors and Hosts

BACKGROUND

Despite recommendations for high-income countries to partner with low-income and middle-income countries to expand surgical access, little is known about the barriers that are faced by international surgeons (ISs) who participate in short-term clinical observerships in North America and the barriers that are encountered by their North American (NA) hosts.

METHODS

Surveys were distributed to ISs who participated in a pediatric orthopaedic observership in North America in 2009 to 2019 and their NA hosts to assess the perceived barriers that are faced by both partners and identify possible opportunities for improvement.

RESULTS

Responses were received from 181 ISs and 46 NA hosts. The ISs reported facing a variety of barriers prior to, during, and after completion of their NA observerships, including financial burden, language and cultural barriers, and challenges with local accommodations and transportation. Only 49% of ISs reported that their NA hosts had sought feedback from them. Barriers noted by the NA hosts included financial burden, logistical challenges with hosting, language barriers, and lack of support from their co-faculty/staff. At least 43% of NA hosts reported that their observership program was unfunded. Based on the survey responses, potential areas that may enhance the observership experience include funding support, creating a centralized data bank of pediatric subspecialty opportunities that are available at each sponsoring institution, a pre-visit orientation for the visiting surgeon, improving inclusivity by addressing language and cultural barriers, improving access to observing surgical procedures, obtaining post-visit feedback, and creating a virtual community of international visitors and NA hosts for an ongoing exchange of ideas and resources.

CONCLUSIONS

The ISs who participated in a pediatric orthopaedic clinical observership and their NA hosts identified limited funding as a major barrier. There are several opportunities for enhancing this unique learning experience and exploring the role of contextual remote learning for all participants. Additional studies are needed to investigate the value of clinical observerships for ISs, including the downstream impact of such opportunities on capacity-building, bidirectional learning, and improving patient care.

Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting

Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.

Developing Ethical and Sustainable Global Health Educational Exchanges for Clinical Trainees: Implementation and Lessons Learned from the 30-Year Academic Model Providing Access to Healthcare (AMPATH) Partnership

Background:

There is strong interest among healthcare trainees and academic institutions in global health rotations. There are a number of guidelines detailing the ethical principles for equitable and ethical global health rotations and bilateral exchanges, but it is often challenging to know to implement those principles and develop longstanding partnerships.

Objectives:

The Academic Model Providing Access to Healthcare (AMPATH) is a 30-year continuous partnership between a consortium of 12 universities in North America and Moi University in Kenya. The AMPATH bilateral educational exchange has had 1,871 North American and over 400 Kenyan clinical trainees participate to date. The article describes the bilateral exchange of trainees including curriculum, housing, and costs and discusses how each is an application of the principles of ethical global engagement.

Findings:

The article takes the experiences of the AMPATH partnership and offers practical strategies for implementing similar partnerships based on previously published ethical principles.

Conclusions:

AMPATH provides a model for developing an institutional partnership for a bilateral educational exchange grounded in cultural humility, bidirectional relationships, and longitudinal, sustainable engagement.

An Ethics-based Approach to Global Health Research Part 2: Strategies for Overcoming Logistic and Implementation Challenges

With the growth of global pharmacy partnerships and collaborative research, particularly between high-income countries and low- or middle-income countries, it is necessary to establish best practices for fair and ethical collaboration and research. There is a gap in the pharmacy literature in this regard. Through this commentary, authors will present a pathway for future global health researchers including generating ideas based on mutual needs of the partnership and the community; exploring the importance of regulations including the need to conduct research and partnership projects within the confines of each participant's professional scope of practice, expertise, and licensure; describing the need to develop agreements and the components that should be included in such an agreement; discussing ethical guidelines for research planning, obtaining ethical approval, and planning for adverse events; and illustrating ethical considerations for research implementation with considerations around consent, data collection, linking patients to care after the completion of the study, and dissemination. Global examples, with a pharmacy-specific approach where applicable, within each section highlight the importance of discussion and action around ethics and equity when pursuing collaborative research, recognizing that many of these situations involve difficult decisions.

Improving Pediatric Academic Global Health Collaborative Research and Agenda Setting: A Mixed-Methods Study

Academic global health collaborations have the potential to improve joint understanding of health issues in low- and middle-income countries (LMICs). Our objective was to elucidate perceptions of benefits and challenges of academic global health collaborations as well as areas for improving collaborative research conducted in LMICs. This cross-sectional, mixed-methods study surveyed investigators' perceptions of benefits and challenges of pediatric academic global health collaborations. Authors of articles from four pediatric journals reporting pediatric research conducted in LMICs published between 2006 and 2015 were surveyed. Responses of LMIC investigators were compared with those of investigators in high-income countries (HICs). Responses to open-ended questions were analyzed using a combined thematic and content analysis approach. Of 1,420 potential respondents, 252 (17.7%) responded to the survey. Collaborative research with investigators from other countries was perceived as beneficial by 88.5% of respondents (n = 223), although this perception was more common among HIC respondents (n = 110, 94.0%) than LMIC respondents (n = 113, 83.7%) (p = 0.014). Sixty-seven percent (n = 170) of respondents perceived that HIC investigators had set the research agenda in work conducted in a LMIC. Respondents identified several critical factors to improve academic global health collaborations, including research capacity building, communication, and early involvement of LMIC investigators with shared decision-making during study conception and grant writing. Pediatric academic global health collaboration was widely perceived as positive. However, despite calls for capacity building and locally generated research ideas, many respondents felt that HIC investigators set the research agenda for work conducted in LMICs. This study provides suggestions for improving collaboration among pediatric academicians globally.