An ethics curriculum for short-term global health trainees

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.

Pediatrics in Disasters: Evolution of a Hybrid Global Health Training Program During the COVID-19 Pandemic

This report describes the Pediatrics in Disasters (PEDS) course during a novel hybrid in-person and virtual format due to the coronavirus disease 2019 pandemic. International and local faculty collaborated on 2021 precourse revisions and course facilitation for multinational in-person and virtual students. Student and facilitator 2021 surveys and 2019 to 2021 student feedback reported overall satisfaction with the course while suggesting needed improvements to maximize international and virtual student participation. The hybrid PEDS course structure successfully achieved course goals and incorporated international faculty. Lessons learned will guide future course revisions and fellow global health educators.

Perceptions of Global Health Engagements in Relation to the COVID-19 Pandemic Among Kenyan Health Care Workers and Administrators in Western Kenya: Protocol for Multi-stage Qualitative Study

BACKGROUND

There has been significant interest in global health in low- and middle-income countries (LMICs) among individuals living in high-income countries (HICs) over the past 30 years. Much of the literature on global health engagements (GHEs) has been presented from the perspective of individuals from HIC participants. Local stakeholders such as health care workers and health care administrators represent critical constituencies for global health activities, yet their perspectives are under-represented in the literature. The purpose of this study is to examine local health worker and administrator experiences with GHEs in Kenya. We will explore the perceived role GHEs play in preparing the health system to address a public health crisis, as well as their role in pandemic recovery and its aftermath.

OBJECTIVE

The aim of this study is to 1) examine how Kenyan health care workers and administrators interpret experiences with global health engagements as having advantaged or hindered them and the local health system to provide care during an acute public health crisis and 2) to explore recommendations to reimagine GHEs in a post-pandemic Kenya.

METHODS

This study will be conducted at a large teaching and referral hospital in western Kenya, with a long history of hosting GHEs in support of its tripartite mission of providing care, training, and research. This qualitative study will be conducted in three phases. In Phase 1, in-depth interviews (IDIs) will be conducted to capture participants' lived experience in relation to their unique understandings of the pandemic, GHEs, and the local health system. In Phase 2, group discussions, using nominal group technique (NGTs) will be conducted to determine potential priority areas to reimagine future GHEs. In Phase 3, IDIs will be conducted to explore these priority areas in greater detail to explore potential recommendations for potential strategies, policies, and other actions that might be employed to achieve the priorities determined to be of highest importance.

RESULTS

Study activities will commence late summer 2022, with findings to be published in 2023. It is anticipated that findings from this study will provide insight into the role GHEs play in a local health system in Kenya, and provide critical stakeholder and partner input, from persons hitherto ignored in the design, implementation, and management of GHEs.

CONCLUSIONS

This qualitative study will examine perspectives of global health engagements in relation to the COVID-19 pandemic among Kenyan health care workers and health care administrators in western Kenya using a multi-stage protocol. Using a combination of in-depth interviews and nominal group techniques this study aims to shed light on the roles global health activities are perceived to play in preparing health care professionals and the health system to address an acute public health crisis.

CLINICALTRIAL

INTERNATIONAL REGISTERED REPORT

PRR1-10.2196/41836.

Applicability of working abroad for physicians with a specialization in Global Health and Tropical Medicine

BACKGROUND

In The Netherlands, physicians specialized in global health and tropical medicine (Ps-GHTM) are trained to work in low-resource settings (LRS) after their training program of 27 months. After working for a period of time in LRS, many Ps-GHTM continue their careers in the Dutch healthcare system. While there is limited evidence regarding the value of international health experience for medical students and residents, it is unknown to what extent this applies to Ps-GHTM and to their clinical practice in the Netherlands.

METHODS

In this qualitative study we conducted semi-structured interviews and focus group discussions (FGDs) with Ps-GHTM to explore the perceived applicability of their experience abroad for their subsequent return to the Netherlands. Topic guides were developed using literature about the applicability of working abroad. Findings from the interviews served as a starting point for FGDs. The interviews and FGDs were analysed using directed content analysis.

RESULTS

15 themes are described relating experience abroad to healthcare delivery in The Netherlands: broad medical perspective, holistic perspective, adaptive communication skills, creativity, flexibility, cultural awareness, self-reliance, clinical competence, cost awareness, public health, leadership, open-mindedness, organization of care, self-development, and teamwork. Highlighting the variety in competencies and the complexity of the topic, not all themes were recognized by all respondents in the FGDs nor deemed equally relevant. Flexibility, cultural awareness and holistic perspective are examples of important benefits to work experience in LRS.

CONCLUSION

Ps-GHTM bring their competencies to LRS and return to the Netherlands with additionally developed skills and knowledge. These may contribute to healthcare delivery in the Netherlands. This reciprocal value is an important factor for the sustainable development of global health. Identifying the competencies derived from work experience in LRS could give stakeholders insight into the added value of Ps-GHTM and partly help in refining the specialization program.

Virtual global health in graduate medical education: a systematic review

OBJECTIVES

To synthesize recent virtual global health education activities for graduate medical trainees, document gaps in the literature, suggest future study, and inform best practice recommendations for global health educators.

METHODS

We systematically reviewed articles published on virtual global health education activities from 2012-2021 by searching MEDLINE, EMBASE, Cochrane Library, ERIC, Scopus, Web of Science, and ProQuest Dissertations & Theses A&I. We performed bibliography review and search of conference and organization websites. We included articles about primarily virtual activities targeting for health professional trainees. We collected and qualitatively analyzed descriptive data about activity type, evaluation, audience, and drivers or barriers. Heterogeneity of included articles did not lend to formal quality evaluation.

RESULTS

Forty articles describing 69 virtual activities met inclusion criteria. 55% of countries hosting activities were high-income countries. Most activities targeted students (57%), with the majority (53%) targeting trainees in both low- to middle- and high-income settings. Common activity drivers were course content, organization, peer interactions, and online flexibility. Common challenges included student engagement, technology, the internet, time zones, and scheduling. Articles reported unanticipated benefits of activities, including wide reach; real-world impact; improved partnerships; and identification of global health practice gaps.

CONCLUSIONS

This is the first review to synthesize virtual global health education activities for graduate medical trainees. Our review identified important drivers and challenges to these activities, the need for future study on activity preferences, and considerations for learners and educators in low- to middle-income countries. These findings may guide global health educators in their planning and implementation of virtual activities.

An Online Ethics Curriculum for Short-Term Global Health Experiences: Evaluating a Decade of Use

Background:

Medical students and early career healthcare professionals commonly participate in short-term experiences in global health (STEGH).

Objective:

The authors evaluate the use of a free-to-access, case-based online curriculum addressing ethical issues trainees should consider prior to engaging in STEGH.

Methods:

Demographic data and feedback on specific cases were collected from 5,226 respondents accessing the online curriculum between November 1, 2011 and October 31, 2021. Feedback on the curriculum included 5-point Likert scale and open-ended responses. Quantitative data were analyzed using standard descriptive statistics. Qualitative data were independently dual coded and analyzed thematically in NVivo.

Findings:

The curriculum reached respondents from 106 countries. Undergraduate (36%) and graduate (38%) respondents included those from several different professional specialties. Less than a quarter of all of respondents, less than half with previous global health experience, and one-third with planned future global health experiences had received prior global health ethics training. Overall, the curriculum was highly rated; respondents felt it provided necessary tools to improve their thought processes, confidence, and behavior when encountering ethical issues during STEGH. Areas for curriculum improvement include balancing case specificity with generalizability.

Conclusion:

This curriculum has met a need for accessible introductory global health ethics education and demonstrates successful use of an online platform in case-based ethics learning.

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.

Vilorio A, Stoff B, L. Comeau D, Gebremariam TH, Derbew M, M. Blumberg H, del Rio C, Kempker RR. American Medical Trainee Perspectives on Ethical Conflicts during a Short-Term Global Health Rotation in Ethiopia: A Qualitative Analysis of 30 Cases

There has been a significant increase in the number of students, residents, and fellows from high-income settings participating in short-term global health experiences (STGHEs) during their medical training. This analysis explores a series of ethical conflicts reported by medical residents and fellows from Emory University School of Medicine in the United States who participated in a 1-month global health rotation in Ethiopia. A constant comparative analysis was conducted using 30 consecutive reflective essays to identify emerging categories and themes of ethical conflicts experienced by the trainees. Ethical conflicts were internal; based in the presence of the visiting trainee and their personal interactions; or external, occurring due to witnessed events. Themes within internal conflicts include issues around professional identity and insufficient preparation for the rotation. External experiences were further stratified by the trainee's perception that Ethiopian colleagues agreed that the scenario represented an ethical conflict (congruent) or disagreed with the visiting trainee's perspective (incongruent). Examples of congruent themes included recognizing opportunities for collaboration and witnessing ethical conflicts that are similar to those experienced in the United States. Incongruent themes included utilization of existing resources, issues surrounding informed consent, and differing expectations of clinical outcomes. By acknowledging the frequency and roots of ethical conflicts experienced during STGHEs, sponsors may better prepare visiting trainees and reframe these conflicts as collaborative educational experiences that benefit both the visiting trainee and host providers.

Nursing students' experiences of moral uncertainty in the context of global health practicums

More students than ever are electing to take part in international practicums from health-related disciplines. With the goal of better understanding the moral experiences and ethical implications of global health practicums (GHPs), the purpose of this Interpretive Descriptive study was to examine the moral uncertainty of nursing students from one university in Canada. Seventeen nurses who had participated in a GHP in their undergraduate nursing program participated in semi-structured interviews. Data were analyzed inductively using constant comparative data analysis techniques, and a thematic account of participants' experiences was developed. Findings suggest that nursing students experienced considerable amounts of moral uncertainty during their GHP. Most often, participants' experiences of uncertainty stemmed from a misalignment between their expectations and reality, including encountering different approaches to healthcare, being situated in new cultural and clinical care environments, and grappling with how best to stay within one's scope of student professional practice. Participants inconsistently reflected on these experiences, which may present a missed opportunity for professional growth through the development of a heightened social consciousness. Educators can facilitate this process by implementing robust predeparture training for GHPs, clarifying program objectives, and providing clinical debriefing.

Global health classroom: mixed methods evaluation of an interinstitutional model for reciprocal global health learning among Samoan and New Zealand medical students

Background

Global health education partnerships should be collaborative and reciprocal to ensure mutual benefit. Utilisation of digital technologies can overcome geographic boundaries and facilitate collaborative global health learning.

Global Health Classroom (GHCR) is a collaborative global health learning model involving medical students from different countries learning about each other’s health systems, cultures, and determinants of health via videoconference. Principles of reciprocity and interinstitutional partnership informed the development of the GHCR. This study explores learning outcomes and experiences in the GHCR between students from New Zealand and Samoa.

Methods

This study used a mixed methods approach employing post-GHCR questionnaires and semi-structured face-to-face interviews to explore self-reported learning and experiences among medical students in the GHCR. The GHCR collaboration studied was between the medical schools at the University of Otago, New Zealand and the National University of Samoa, Samoa.

Results

Questionnaire response rate was 85% (74/87). Nineteen interviews were conducted among New Zealand and Samoan students. Students reported acquiring the intended learning outcomes relating to patient care, health systems, culture, and determinants of health with regards to their partner country. Interview data was indicative of attitudinal changes in relation to cultural humility and curiosity. Some reported a vision for progress regarding their own health system. Students in the GHCR reported that learning with their international peers in the virtual classroom made learning about global health more real and tangible. The benefits to students from both countries indicated reciprocity.

Conclusions

This study demonstrates GHCR to be a promising model for collaborative and reciprocal global health learning using a student-led format and employing digital technology to create a virtual classroom. The self-reported learning outcomes align favourably with those recommended in the literature. In view of our positive findings, we present GHCR as an adaptable model for equitable, collaborative global health learning between students in internationally partnered institutions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00755-8.

German-speaking medical students on international electives: an analysis of popular elective destinations and disciplines

Background

International medical electives are a well-established part of the curriculum of many western medical schools. It is widely accepted that these electives contribute to improved clinical examination and communication skills. Overseas electives also exert a strong influence over future career decisions and often pave the way for later international work. Whilst the positive outcomes are known, little information exists regarding elective preferences and destinations overall, information that could help optimise a safe learning experience and maximise the potential for one of the highlights of medical education. In order to obtain analytical data that could assist medical elective framework development, we systematically reviewed the two largest German online databases cataloguing abroad elective testimonies.

Results

We identified 856 overseas elective reports uploaded within the last five years. European destinations were the most sought-after choice among German-speaking medical students. Interest in abroad electives in the United States (U.S.), a traditionally popular destination, was much lower than expected. U.S. elective reports accounted for only 3 % of long-term electives. Electives in low- and middle-income countries were generally less popular than electives in high-income countries. General surgery was the most popular elective discipline, followed by Emergency Medicine and Gynaecology and Obstetrics.

Conclusions

We observed a large inhomogeneity in German-speaking medical students’ elective choices, potentially influenced by financial and organizational aspects as well as geopolitical developments. This highlights a crucial challenge for medical schools and other organizations involved in elective planning. In light of regional differences, our data suggest that a “one size fits all” preparation is not pertinent to optimize students’ elective experience. Country- or region-specific pre-departure trainings and more individualized elective frameworks might be necessary to address these differences and to ensure a safe learning experience for students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00742-z.

Grit as a Key Factor in the Ability of Students to Achieve Productive Global Field Research

Global fieldwork is an invaluable educational experience for students who aspire to pursue careers as global public health professionals and cancer experts. Student-led research projects can be mutually beneficial for students and host institutions by providing opportunities for bilateral learning, sharing resources, building databases, and ultimately creating uniquely informed multi-cultural health research relevant to global communities. The USA-host country partnerships can be delicate, requiring tactful approaches to the investment in the careers of students and the field projects. The US and host institutions must therefore be selective in determining which students have the privilege of participating in global field work. This paper examines the importance of grit as a character trait contributing to the success of student-led global health research projects. Grit has been explored at length as a predictor of student success in domestic educational experiences, yet is underrepresented in the context of global education, field training, and evaluation of research and learning outcomes. This manuscript utilizes testimonials of three public health graduate students recently returned from summer cancer epidemiology education training fellowships to explore the role that grit played in completion of their independent research projects. Ultimately, this paper discusses ways to identify grit in student applicants and to foster an improved capacity for grit before, during, and after their field experiences. We share the experiences with an aim of providing participant perspectives that may be used by educators, students, and administrators at US and international partner institutions to inform global research, experiential learning, and educational and training programs.

U.S. trainees' experiences of ethical challenges during research in low- and middle-income countries: A mixed methods study

High-income country (HIC) trainees are participating in research in low- and middle-income countries (LMIC) in increasing numbers, yet the ethical challenges they face have not been well described. We conducted a mixed methods study of U.S. graduate and undergraduate students who conducted research in LMIC, including an online survey and semi-structured interviews. Among 123 online survey respondents, 31% reported ethical challenges and nearly two-thirds of respondents did not feel well prepared to deal with ethical challenges. Qualitative analysis of the 17 semi-structure interviews and narrative survey responses revealed many themes of 'ethics in practice': challenges in setting research priorities, navigating relationships with host country partners, scope of research practice, and human subject protections. Respondents reported that pre-departure trainings were not reflective of ethical frameworks or research contexts in LMIC, and few described seeking host mentor help in addressing ethical challenges. These results suggest a need for improvements in training, oversight and mentorship of trainee researchers, and to further engage both HIC and LMIC institutions, educators and researchers in addressing ethical issues.

Pediatric nurses' perceptions of preparedness for global health fieldwork

OBJECTIVES

The purpose of this qualitative descriptive research study was to understand the current state, perceived content, and experiential needs of pediatric nurses preparing for global health (GH) fieldwork experience. This study aimed to inform stakeholders about the standard and unique preparation needs of pediatric GH nurses.

STUDY DESIGN AND METHODS

One group and five individual interviews were held with nurses from a large pediatric quaternary care facility in the Northeast United States. Data from the interviews were transcribed verbatim, eliminating personal data. Only deidentified transcripts were used for data analysis. Members of the study team used content analysis to systematically code and analyze the data.

RESULTS

Qualitative content analysis revealed five categories: (1) identifying clear objectives, (2) understanding the practice environment, (3) self-assessment of clinical skills, cultural competencies, and adaptability, (4) safety and logistics planning, and (5) psychological self-care and reentry anticipatory guidance.

CONCLUSIONS

Findings can provide a basis for program planning to prepare pediatric nurses for GH fieldwork. Program planning must account for the unique features of the site and situation. Organizational and personal preparation can influence the perceived success of the GH experience.

Global Health Education Programs in the Americas: A Scoping Review

Background:

The interest in Global Health (GH) as an academic discipline has increased in the last decade. This article reports the findings of a scoping review of studies about Global Health education in the Americas.

Objective:

To analyse educational programs on global health in the Americas.

Method:

Five electronic databases were used in a scoping review: PubMed, Scopus, Web of Knowledge, CINAHL, and Lilacs. Data collection happened in November 2017–March 2018. The following stages were rigorously observed: identification, selection, charting, and summarizing the studies that were included. To process the data, we used IRaMuTeQ software.

Findings:

Forty-six studies were identified and organized in categories: 1) diversity of the topics addressed in GH; 2) models of teaching; 3) emotional, cultural, and collaborative aspects in teaching GH; 4) student preparation for GH experiences; and 5) structures required for a GH course.

Conclusions:

The existing global health curriculum in the Americas is diffuse and limited, with a greater focus on clinical aspects. Thus, a minimum curriculum for students from different areas is needed. Results evidenced that the teaching of global health in the Americas is still incipient, although it is promising. The lack of a common curriculum for the courses in the region makes it difficult to train sensitive and capable professionals to achieve the 2030 Sustainable Development Goals.

Ethics in Global Surgery

As the population increases in the world's poorest countries, the need for surgical interventions will increase. Short-term surgical missions can play an important role in increasing access to solve this disparity by providing much-needed surgical services to vulnerable populations in low-income and middle-income countries. As short-term surgical missions increase, it is important that basic ethical principles are a foundation in service delivery. By following ethical principles outlined in this article, abiding by common moral language, and establishing long-term relationships, a significant contribution can be made to global surgery to increase access and deliver high-quality surgery.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

Background:

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

Objectives:

The primary aim was to identify characteristics of pre-departure training associated with participants’ reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students’ preferred subjects of study and teaching modalities for pre-departure training.

Methods:

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information.

Findings:

Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students’ preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

Conclusions:

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students’ preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible “buy-in” effect.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

BACKGROUND

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

OBJECTIVES

The primary aim was to identify characteristics of pre-departure training associated with participants' reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students' preferred subjects of study and teaching modalities for pre-departure training.

METHODS

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information. Findings: Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students' preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

CONCLUSIONS

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students' preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible "buy-in" effect.

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.

Characterizing a community health partnership in Dominican Republic: Network mapping and analysis of stakeholder perceptions

BACKGROUND

Medical trainees complete learning experiences abroad to fulfil global health curricular elements, but this participation has been steadily criticized as fulfilling learner objectives at the cost of host communities. This study uses network and qualitative analyses in characterizing a community coalition in order to better understand its various dimensions and to explore the perceived benefits it provided towards optimizing community outcomes.

METHODS

Data from a semi-structured survey was used for network and qualitative analyses. Partner linkages were assessed using network analysis tool UCINET 6 (version 6.6). Thematic analysis was conducted on qualitative responses around the perceived coalition strengths and weaknesses.

RESULTS

Network analysis confirmed that local member organizations were key network influencers based on reported formal agreements, general interactions, and information shared. While sharing of resources was rare, qualitative analysis suggested that information sharing contributed to engagement, enthusiasm, and communication that allowed visiting partners to expand their understanding of community needs and shift their focus beyond learner objectives.

CONCLUSION

Global health programs for medical students should consider the use of community health coalitions to optimally align the work undertaken by learners on global health experiences abroad. Network mapping can help educators and coalition partners visualize interactions and identify value.

Ethical learning on international medical electives: a case-based analysis of medical student learning experiences

BACKGROUND

Students on international medical electives face complex ethical issues when undertaking clinical work. The variety of elective destinations and the culturally specific nature of clinical ethical issues suggest that pre-elective preparation could be supplemented by in-elective support.

METHODS

An online, asynchronous, case-based discussion was piloted to support ethical learning on medical student electives. We developed six scenarios from elective diaries to stimulate peer-facilitated discussions during electives. We evaluated the transcripts to assess whether transformative, experiential learning took place, assessing specifically for indications that 1) critical reflection, 2) reflective action and 3) reflective learning were taking place. We also completed a qualitative thematic content analysis of the discussions.

RESULTS

Of forty-one extended comments, nine responses showed evidence of transformative learning (Mezirow stage three). The thematic analysis identified five themes: adopting a position on ethical issues without overt analysis; presenting issues in terms of their effects on students' ability to complete tasks; describing local contexts and colleagues as "other"; difficulty navigating between individual and structural issues, and overestimation of the impact of individual action on structures and processes.

CONCLUSION

Results suggest a need to: frame ethical learning on elective so that it builds on earlier ethical programmes in the curriculum, and encourages students to adopt structured approaches to complex ethical issues including cross-cultural negotiation and to enhance global health training within the curriculum.

A Meta-analytic Comparison of Face-to-Face and Online Delivery in Ethics Instruction: The Case for a Hybrid Approach

Despite the growing body of literature on training in the responsible conduct of research, few studies have examined the effectiveness of delivery formats used in ethics courses (i.e., face-to-face, online, hybrid). The present effort sought to address this gap in the literature through a meta-analytic review of 66 empirical studies, representing 106 ethics courses and 10,069 participants. The frequency and effectiveness of 67 instructional and process-based content areas were also assessed for each delivery format. Process-based contents were best delivered face-to-face, whereas contents delivered online were most effective when restricted to compliance-based instructional contents. Overall, hybrid courses were found to be most effective, suggesting that ethics courses are best delivered using a blend of formats and content areas. Implications and recommendations for future development of ethics education courses in the sciences are discussed.

Ethics Simulation in Global Health Training (ESIGHT)

INTRODUCTION

Many health care trainees and providers have reported feeling unprepared for the ethical dilemmas they faced while practicing in global health. Simulation is an effective teaching modality in the training of health care professionals. This resource describes the development, implementation, and assessment of an innovative simulation training program for global health ethics.

METHODS

We conducted simulation training with trainees and professionals from various health care disciplines. After a didactic component in which general ethical principles were introduced, participants acted as either lead or observer in four simulations representing different ethical challenges. Participants interacted with simulated patients within a set designed to resemble a resource-constrained environment. Data on the participants' experiences and evaluations of the program's effectiveness were collected through pre-/postsession surveys and focus groups.

RESULTS

All 53 participants (100%) agreed that the simulations "effectively highlighted ethical dilemmas I could face abroad," and 98% agreed that the content "was useful in my preparation for an international elective." Responses from surveys and focus groups stressed the importance of the realistic and emotional nature of the simulation in increasing confidence and preparedness, as well as a preference for simulation as the modality for teaching global health ethics.

DISCUSSION

Simulation for global health ethics training can help to raise awareness of the complex ethical challenges one may face abroad. Incorporating simulation training within broader global health curricula can improve trainee preparedness and confidence in appropriately and effectively identifying, strategizing, and navigating through ethical dilemmas in the field.

Review of Instructional Approaches in Ethics Education

Increased investment in ethics education has prompted a variety of instructional objectives and frameworks. Yet, no systematic procedure to classify these varying instructional approaches has been attempted. In the present study, a quantitative clustering procedure was conducted to derive a typology of instruction in ethics education. In total, 330 ethics training programs were included in the cluster analysis. The training programs were appraised with respect to four instructional categories including instructional content, processes, delivery methods, and activities. Eight instructional approaches were identified through this clustering procedure, and these instructional approaches showed different levels of effectiveness. Instructional effectiveness was assessed based on one of nine commonly used ethics criteria. With respect to specific training types, Professional Decision Processes Training (d = 0.50) and Field-Specific Compliance Training (d = 0.46) appear to be viable approaches to ethics training based on Cohen's d effect size estimates. By contrast, two commonly used approaches, General Discussion Training (d = 0.31) and Norm Adherence Training (d = 0.37), were found to be considerably less effective. The implications for instruction in ethics training are discussed.

More harm than good? The questionable ethics of medical volunteering and international student placements

It has been argued that much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteers’ grasp of the damage caused. The literature on ethical concerns in medical volunteering has grown tremendously over the last years highlighting the need for appropriate guidelines. These same concerns, however, and an appreciation of the reasons why current aid paradigms are flawed, can serve as indicators on how to change existing practices to ensure a better outcome for those who are in need of help. Such paradigm change envisages medical assistance in the spirit of solidarity, social justice, equality, and collegial collaboration.

Operational readiness for conducting global health research abroad

Research excellence is the goal of all researchers. Conducting quality research with the ultimate aim of improving health is a shared goal among researchers in the global health domain. The competencies required for conducting and producing quality research in global health go far beyond the academic or scientific spheres. They incorporate aspects of research partnership, which places humility, empathy, and mutual respect at its core. Conducting quality respectful global health research requires an appropriate balance of operational readiness (i.e., technical, physical, and mental readiness). This paper reports on the pertinence and potential shaping of conceptual work and exploratory research focusing on aspects of mental readiness. These aspects may be perceived to be significant enough to influence success and warrant further investigation in the context of conducting global health research abroad.

Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions

International health electives pose specific ethical challenges for students travelling from to low and middle income countries. We undertook a systematic review of the literature on interventions to prepare students to identify ethical issues addressed, educational approaches and to collate evidence on the effectiveness of different strategies. We searched nine electronic databases of peer-reviewed literature and identified grey literature through key word searches; supplemented through citation mapping and expert consultation. Articles that described ethical training conducted by universities or professional bodies were included for review. We reviewed forty-four full text articles. Ten sources of published literature and seven sources of grey literature met our inclusion criteria. We identified thirteen ethical situations that students should be prepared to manage and eight generic skills to support this process. Most interventions were delivered before the elective, used case studies or guidelines. Some suggested ethical principles or a framework for analysis of ethical issues. Only two papers evaluated the intervention described. Our paper collates a small but growing body of work on education to prepare students to manage ethical issues. Ethical training should have elements that are delivered before, during and after the elective. Interventions should include case studies covering thirteen ethical issues identified here, linked to ethical principles and a process for responding to ethical issues. We suggest that evaluations of interventions are an important area for future research.

What Are the Ethical Issues Facing Global-Health Trainees Working Overseas? A Multi-Professional Qualitative Study

The aim of this study was to identify global health ethical issues that health professional trainees may encounter during electives or placements in resource-limited countries. We conducted a qualitative study involving focus groups and an interview at the University of California San Francisco. Participants were multi-professional from the Schools of Medicine, Nursing and Pharmacy and had experience working, or teaching, as providers in resource-limited countries. Eighteen participants provided examples of ethical dilemmas associated with global-health outreach work. Ethical dilemmas fell into four major themes relating to (1) cultural differences (informed consent, truth-telling, autonomy); (2) professional issues (power dynamics, training of local staff, corruption); (3) limited resources (scope of practice, material shortages); (4) personal moral development (dealing with moral distress, establishing a moral compass, humility and self awareness). Three themes (cultural differences, professional issues, limited resources) were grouped under the core category of “external environmental and/or situational issues” that trainees are confronted when overseas. The fourth theme, moral development, refers to the development of a moral compass and the exercise of humility and self-awareness. The study has identified case vignettes that can be used for curriculum content for global-health ethics training.

Ethical Issues in Pediatric Global Health

Children are vulnerable to the priorities and decision-making of adults. Usually, parents/caregivers make the difficult healthcare decisions for their children based on the recommendations from the child's healthcare providers. In global health work, healthcare team members from different countries and cultures may guide healthcare decisions by parents and children, and as a result ethical assumptions may not be shared. As a result, ethical issues in pediatric global health are numerous and complex. Here we discuss critical ethical issues in global health at an individual and organizational level in hopes this supports optimized decision-making on behalf of children worldwide.

Training the next generation of global health advocates through experiential education: A mixed-methods case study evaluation

OBJECTIVES

This case study evaluates a global health education experience aimed at training the next generation of global health advocates. Demand and interest in global health among Canadian students is well documented, despite the difficulty in integrating meaningful experiences into curricula.

METHODS

Global health advocacy was taught to 19 undergraduate students at McMaster University through an experiential education course, during which they developed a national advocacy campaign on global access to medicines. A quantitative survey and an analysis of social network dynamics were conducted, along with a qualitative analysis of written work and course evaluations. Data were interpreted through a thematic synthesis approach.

RESULTS

Themes were identified related to students' learning outcomes, experience and class dynamics. The experiential education format helped students gain authentic, real-world experience in global health advocacy and leadership. The tangible implications for their course work was a key motivating factor. While experiential education is an effective tool for some learning outcomes, it is not suitable for all. As well, group dynamics and evaluation methods affect the learning environment.

CONCLUSION

Real-world global health issues, public health practice and advocacy approaches can be effectively taught through experiential education, alongside skills like communication and professionalism. Students developed a nuanced understanding of many strategies, challenges and barriers that exist in advocating for public health ideas. These experiences are potentially empowering and confidence-building despite the heavy time commitment they require. Attention should be given to how such experiences are designed, as course dynamics and grading structure significantly influence students' experience.

Global Health Opportunities in Obstetrics and Gynecology Training: Examining Engagement Through an Ethical Lens

This study aims to describe global health training (GHT) programs through the ethical lens suggested by the Working Group on Ethics Guidelines for Global Health Training (WEIGHT). A total of 35 GHT programs were identified, and general information was obtained online. Semi-structured telephone interviews of key members of 19 programs were then conducted and transcribed. The interview guide was constructed using WEIGHT recommendations. Transcript data were grouped according to domains: reciprocity, trainee selection and preparedness, needs assessments, and ethical questions. Many programs expressed difficulty in building reciprocal relationships due to imbalanced power structures. Eleven programs reported no formal application process for selecting trainees. Twelve (63%) programs reported only a single day of preparation. Nine (47%) programs did not conduct a formalized needs assessment of partner sites. Ethical considerations varied from concerns for safety to inadequate training for residents. This study reveals the limited preparedness curricula and lack of formalized needs assessments among several programs. Although many programs make an effort to build reciprocal exchanges with host partners, experiences for foreign trainees within the United States are limited, and U.S. residents are often tasked with duties above their training level abroad. This study demonstrates the need to restructure how GHT programs are formed and operated.

Teaching corner: the prospective case study : a pedagogical innovation for teaching global health ethics

Over the past decade, global health has emerged as one of the fastest growing academic programs in the United States. Ethics training is cited widely as an essential feature of U.S. global health programs, but generally it is not deeply integrated into the global health teaching and training curricula. A discussion about the pedagogy of teaching global health ethics is long overdue; to date, only a few papers specifically engage with pedagogy rather than competencies or content. This paper explores the value of case study pedagogy for a full-semester graduate course in global health ethics at an American university. I address some of the pedagogical challenges of teaching global health ethics through my innovative use of case study methodology-the "prospective case study" (PSC).

Teaching corner: "first do no harm": teaching global health ethics to medical trainees through experiential learning

Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountered during outreach clinical work. While global health training guidelines emphasize the importance of developing ethical and cultural competencies before embarking on fieldwork, their practical implementation is often lacking and consists mainly of recommendations regarding professional behavior and discussions of case studies. Evidence suggests that one of the most effective ways to teach certain skills in global health, including ethical and cultural competencies, is through service learning. This approach combines community service with experiential learning. Unfortunately, this approach to global health ethics training is often unattainable due to a lack of supervision and resources available at host locations. This often means that trainees enter global health initiatives unprepared to deal with ethical dilemmas, which has the potential for adverse consequences for patients and host institutions, thus contributing to growing concerns about exploitation and "medical tourism." From an educational perspective, exposure alone to such ethical dilemmas does not contribute to learning, due to lack of proper guidance. We propose that the tension between the benefits of service learning on the one hand and the respect for patients' rights and well-being on the other could be resolved by the application of a simulation-based approach to global health ethics education.

Development of global health education at Johns Hopkins University School of Medicine: a student-driven initiative

Global health is increasingly present in the formal educational curricula of medical schools across North America. In 2008, students at Johns Hopkins University School of Medicine (JHUSOM) perceived a lack of structured global health education in the existing curriculum and began working with the administration to enhance global health learning opportunities, particularly in resource-poor settings. Key events in the development of global health education have included the introduction of a global health intersession mandatory for all first-year students; required pre-departure ethics training for students before all international electives; and the development of a clinical global health elective (Global Health Leadership Program, GHLP). The main challenges to improving global health education for medical students have included securing funding, obtaining institutional support, and developing an interprofessional program that benefits from the resources of the Schools of Medicine, Public Health, and Nursing. Strategies used included objectively demonstrating the need for and barriers to more structured global health experiences; obtaining guidance and modifying existing resources from other institutions and relevant educational websites; and harnessing institution-specific strengths including the large Johns Hopkins global research footprint and existing interprofessional collaborations across the three schools. The Johns Hopkins experience demonstrates that with a supportive administration, students can play an important and effective role in improving global health educational opportunities. The strategies we used may be informative for other students and educators looking to implement global health programs at their own institutions.

Comparative analysis: potential barriers to career participation by north american physicians in global health

Physician interest in global health, particularly among family physicians, is reflected by an increasing proliferation of field training and service experiences. However, translating initial training involvement into a defined and sustainable global health career remains difficult and beset by numerous barriers. Existing global health literature has largely examined training experiences and related ethical considerations while neglecting the role of career development in global health. To explore this, this paper extrapolates potential barriers to global health career involvement from existing literature and compares these to salary and skills requirements for archetypal physician positions in global health, presenting a framework of possible barriers to sustained physician participation in global health work. Notable barriers identified include financial limitations, scheduling conflicts, security/family concerns, skills limitations, limited awareness of opportunities, and specialty choice, with family practice often closely aligned with global health experience. Proposed solutions include financial support, protected time, family relocation support, and additional training. This framework delineates barriers to career involvement in global health by physicians. Further research regarding these barriers as well as potential solutions may help direct policy and initiatives to better utilize physicians, particularly family physicians, as a valuable global health human resource.

Education for public health in Europe and its global outreach

INTRODUCTION

At the present time, higher education institutions dealing with education for public health in Europe and beyond are faced with a complex and comprehensive task of responding to global health challenges.

REVIEW

Literature reviews in public health and global health and exploration of internet presentations of regional and global organisations dealing with education for public health were the main methods employed in the work presented in this paper. Higher academic institutions are searching for appropriate strategies in competences-based education, which will increase the global attractiveness of their academic programmes and courses for continuous professional development. Academic professionals are taking advantage of blended learning and new web technologies. In Europe and beyond they are opening up debates about the scope of public health and global health. Nevertheless, global health is bringing revitalisation of public health education, which is recognised as one of the core components by many other academic institutions involved in global health work. More than ever, higher academic institutions for public health are recognising the importance of institutional partnerships with various organisations and efficient modes of cooperation in regional and global networks. Networking in a global setting is bringing new opportunities, but also opening debates about global harmonisation of competence-based education to achieve functional knowledge, increase mobility of public health professionals, better employability and affordable performance.

CONCLUSIONS

As public health opportunities and threats are increasingly global, higher education institutions in Europe and in other regions have to look beyond national boundaries and participate in networks for education, research and practice.