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Building a Framework for Global Health Learning: An Analysis of Global Health Concentrations in Canadian Medical Schools

Watterson, Rita MD; Matthews, David MD, MPhil; Bach, Paxton MD; Kherani, Irfan; Halpine, Mary MD; Meili, Ryan MD

doi: 10.1097/ACM.0000000000000648
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Purpose This study set out to explore the current state of global health concentrations in Canadian medical schools and to solicit feedback on the barriers and challenges to implementing rigorous global health concentration programs.

Method A set of consensus guidelines for global health concentrations was drafted through consultation with student and faculty leaders across Canada between May 2011 and May 2012. Drawing on these guidelines, a formal survey was sent to prominent faculty at each of the 14 English-speaking Canadian medical schools. A thematic analysis of the results was then conducted.

Results Overall, the guidelines were strongly endorsed. A majority of Canadian medical schools have programs in place to offer global health course work, extracurricular learning opportunities, local community service–learning, low-resource-setting clinical electives, predeparture training, and postreturn debriefing. Although student evaluation, global health mentorship, and knowledge translation projects were endorsed as important components, few schools had been successful in implementing them. Language training for global health remains contested. Other common critiques included a lack of time and resources, and difficulties in setting standards for student evaluation.

Conclusions The results suggest that these guidelines are appropriate and, at least for the major criteria, achievable. Although many Canadian schools offer individual components, the majority of schools have yet to develop formally structured concentration programs. By better articulating guidelines, a standardized framework can aid in the establishment and refinement of future programs.

Dr. Watterson is a resident in psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Dr. Matthews is a resident in psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Dr. Bach is a resident in internal medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Mr. Kherani is a senior medical student, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.

Dr. Halpine is a resident in physical medicine and rehabilitation, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

Dr. Meili is a family physician and assistant professor, Departments of Community Health and Epidemiology and Academic Family Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: The behavioral research ethics board at the University of Saskatchewan reviewed the study and informed researchers in writing that ethical approval was not required.

Previous presentations: Poster presentations at the Consortium of Universities for Global Health, Washington, DC, March 14–16, 2013; and the Canadian Conference on Global Health, Ottawa, Ontario, Canada, May 27–29, 2013. Oral presentation at the Canadian Conference on Medical Education, Ottawa, Ontario, Canada, April 27, 2014.

Correspondence should be addressed to Dr. Meili, Division of Social Accountability, Department of Community Health and Epidemiology, Health Science Building, 107 Wiggins Rd., University of Saskatchewan, Saskatoon, Saskatchewan, S7N 5E5; telephone: (306) 966-1797; e-mail: ryan.meili@usask.ca.

The profile of global health in medical school has grown rapidly over the past few years, driven in part by a steady rise in student interest in the field. This attention has provided significant incentive for universities to offer educational opportunities in global health, and a recent survey of medical schools from around the world demonstrated that 95% self-identify as incorporating elements of global health education into their curricula.1 The most recent data from the Association of American Medical Colleges show that nearly one-third of all medical graduates in the United States have participated in a global health elective at some point in their education.2 In Canada, a 2008 survey revealed that 10 of 17 medical school programs required lectures or modules that include global health topics, and 16 of 17 schools encouraged their students to participate in international electives.3 This growing demand has led to a call for the establishment of core competencies in global health to be integrated into medical curricula and has encouraged universities to explore innovative new ways to provide additional global health education to students with a particular interest in the field.4–7 One such approach has been the development of elective global health “tracks” or “concentrations,” designed to give students exposure to key themes through a combination of different educational approaches and experiences.

To our knowledge, the first comprehensive elective global health concentration program in Canada was established at the University of Saskatchewan College of Medicine in 2005.8 Named “Making the Links,” its stated goal is to equip students with the knowledge and the will to spend their careers working with marginalized populations both locally and globally. The program is structured over two years with students undertaking global health course work and practical experiences with Indigenous communities in Northern Saskatchewan, at the student-run SWITCH (Student Wellness Initiative Towards Community Health) clinic in inner-city Saskatoon, and in the global South (most notably Mozambique). In 2011, the University of Saskatchewan approved the transition of Making the Links from an extracurricular program to a recognized certificate in global health. This comprehensive approach to teaching global health has since caught the attention of other universities, and similar programs have begun appearing across the country.

Although students and faculty alike have rapidly embraced the idea of global health concentration programs, the concept remains relatively new. As a result, the nature of these concentrations varies widely across Canada depending on the resources and priorities of each individual medical school. Despite having largely arisen independently of one another, these global health concentrations have certain elements that consistently recur, including didactic teaching, service–learning, and clinical electives in low-resource settings. To provide a framework for schools wishing to develop their own programs and to enhance existing ones, a national student working group conducted this study to assess the status of these concentrations across the country and develop a set of recommendations on which future programs could be based. Through this consultation process, a set of consensus guidelines was drafted, outlining the theoretical pillars of global health concentrations. Formal surveying of faculty members at each of the 14 English-speaking Canadian medical schools was then carried out to examine the existing components at each school, to identify common themes, and to compare them against the drafted guidelines. The guidelines were adjusted to reflect any absent themes and are now being made available as a tool to encourage universities to provide enhanced global health education opportunities for future students.

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Method

Guideline development

The drafting of the National Guidelines for Global Health Concentrations was led by the Global Health Program of the Canadian Federation of Medical Students, in conjunction with the Global Health Interest Group of the Association of Faculties of Medicine of Canada. Drawing on the framework of the Making the Links program at the University of Saskatchewan, an initial set of guidelines was outlined by a working group (including R.W., D.M., P.B., and R.M.) in May 2011. Over the course of the following year, the draft guidelines were refined through a broad consultation process with student and faculty leaders in global health across the country, including working meetings at several high-profile national and international conferences between May 2011 and May 2012. Individual stakeholders at each school were approached for an assessment of these guidelines using a participatory approach. Feedback from stakeholders was then used to refine and enhance the guidelines. The guidelines are built around Bozorgmehr’s9 definition of global health as both supraterritorial and linked through the social determinants of health. They are also informed by the concept of service–learning, defined as “a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection.”10

The guidelines put forth a set of criteria designed to provide flexibility to schools in creating global health concentrations, while simultaneously promoting common standards across the country. The major criteria that are outlined in the guidelines are as follows:

  • Global health course work
  • Local community engagement
  • Student evaluation
  • Low-resource-setting elective
  • Predeparture training and postreturn debriefing

Minor criteria are:

  • Global health mentorship
  • Language training
  • Extracurricular global health learning opportunities
  • Knowledge translation project

It is expected that programs will include all of the major criteria and several of the minor criteria where feasible. Leadership development and advocacy training are intended to be overarching themes throughout the curricular components. Recognizing that Indigenous populations’ health and global health are closely linked in the Canadian context, it is hoped that schools will attempt to incorporate an Indigenous health component into their concentrations whenever possible.

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Survey methodology

After completing the national consultation process with faculty and student leaders, we developed a survey to formally evaluate the guidelines and their potential applicability. Institutional review board exception was formally given through the University of Saskatchewan. We identified a key faculty member or administrator who participated significantly in the organization of global health education at each of the 14 English-speaking Canadian medical schools and distributed the survey via e-mail. Several follow-up e-mails were sent to ensure high response rates. The survey asked respondents to comment on the following aspects of the criteria:

  1. Do you feel the criteria are valid?
  2. Do you have any suggestions for changes to the criteria?
  3. Does your faculty offer a program, either in existence or in development, that could meet the criteria?
  4. If so, could you submit a brief description of the program including time allotment (i.e., hours, weeks, credits), using the criteria to describe it where applicable?

Space was also left for any additional comments and suggestions on the guidelines and major and minor criteria. In this context, question 1 was meant to ask the survey respondents if the criteria are feasible, realistic, and contextually appropriate for their own unique setting.

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Analysis

We coded responses regarding criteria validity and availability of programs to meet each criterion as yes/no for each of the major and minor criteria. Qualitative responses on suggested changes to the criteria and program descriptions were analyzed using thematic analysis. Theme generation consisted of four steps.11 First, a general reading was undertaken with the purpose of gaining an understanding of the texts. Second, information was coded into preliminary themes by the two lead authors. Third, all authors independently generated themes. Fourth, peer debriefing was conducted. Using a consensus-based approach, we collectively identified the final themes.12

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Results

We received responses from personnel at 13 of the 14 schools contacted (93% response rate). Of these respondents, 9 were faculty leaders in global health and 4 were administrators of global health offices. The nonresponding school did not have a formal global health office or faculty lead in global health, and as such there was no suitable contact to comment on the guidelines. Table 1 summarizes the results of the thematic analysis of qualitative responses.

Table 1

Table 1

All respondents (13/13; 100%) endorsed the validity of all the major criteria. All responding schools (13/13; 100%) reported that they had existing programs in place that could meet the major criteria of global health course work, local community engagement, low-resource-setting electives, predeparture training, and postreturn debriefing. However, only 9/13 (69%) had existing programs of student evaluation in place.

In evaluating the minor criteria, all survey respondents agreed that extracurricular global health learning opportunities, global health mentorship, and knowledge translation projects were valid criteria. Language training was only supported by 10/13 (77%) schools. Although the minor criteria were strongly supported in principle, in practice only select programs provide language training (3/13; 23%), global health mentorship (3/13; 23%), and knowledge translation projects (7/13; 54%). The exception to this was the universal presence (13/13; 100%) of extracurricular global health learning opportunities.

Our thematic analysis revealed many similarities in the manner in which these criteria have been incorporated into existing programs (Table 1). Recommendations have often been adapted to fit local circumstances, but certain themes recurring across the country include combinations of curricular and extracurricular opportunities, the prevalence of student-led activities, and the emergence of global health offices to help oversee programs. Respondents identified several challenges to implementing the guidelines, focusing on several main themes. A lack of financial means and dedicated global health faculty was an overarching critique that hinders many medical schools from achieving several of the criteria. Other identified challenges included difficulties with providing appropriate student evaluation and a need for clear objectives and high-quality standards. A focus on rural, remote, and Indigenous communities remains an important goal for global-health-minded faculty and was strongly supported by our thematic analysis.

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Discussion

To create tomorrow’s leaders, a shift toward comprehensive learning within global health has been proposed.13 This entails not a single experience but, instead, a recurring theme and framework embedded within the undergraduate experience.13 Global health concentrations are an example of one effort to create these experiences for medical students, building capacity to advance the health of marginalized communities both locally14 and internationally.

Individually, the criteria of the National Guidelines for Global Health Concentrations are strongly supported by global health literature. For example, low-resource electives are speculated to give students a greater sense of the importance of social responsibility and community engagement in health.15 Global health course work may allow for a better understanding of the field so that students will be more prepared to meet the needs of the underserved in their home countries.7 Local community engagement, through service–learning, allows students to see how inequities and social determinants affect health outcomes of those less fortunate, potentially allowing for a greater understanding of health advocacy.15 Global health concentrations combine these elements, with the belief that an experiential, multidimensional learning environment will equip medical students with the knowledge, experiences, and skills to become socially accountable practitioners and future leaders in global health.

Our survey results strongly support the guideline criteria, but our thematic analysis reveals some of the challenges in bringing a global health concentration into practice in Canada. The major criteria are strongly supported across the country, both in theory and in current programming. Respondents universally validated all of the minor criteria except language competency, yet few schools offered these experiences in practice. Survey respondents identified financial resources and a lack of global health capacity at individual schools as two main reasons why schools are unable to offer these programs. With few global-health-minded faculty, departments find it difficult to develop the community-driven and longitudinal programming required for transformative learning experiences. Our analysis identifies that Canadian medical schools support global health concentrations, but the capacity to create transformative change within global health learning is met with many challenges.

Several limitations were identified in our study. Firstly, our survey was only distributed in English, and so French-speaking medical schools are not represented in our results. Key faculty members or administrators responded to our survey, which may have introduced bias through their self-reported data. In addition, as our survey was directed primarily at these stakeholders, the student population was not engaged. The students’ opinions of their personal experiences could be valuable in understanding what it is actually like to participate in one of these programs, but this was beyond the scope of our study. The survey questions on criteria validity and availability were coded as binary data, which may have been interpreted differently by survey respondents. Lastly, many of the authors were involved in the initial generation of the guidelines, introducing a potential bias in our research analysis.

There are several strengths of our research study that helped to mitigate our identified weaknesses. Firstly, our survey response rate was excellent, and comments and critiques reflected the respondents’ high level of expertise within the field of global health. This created a data set that reflected global health programming and challenges experienced at individual schools. In the development of the guidelines, stakeholders’ opinions were sought from diverse and varied backgrounds. The authors involved in the analysis of the guidelines were also drawn from all parts of Canada. Ultimately, we believe that the diversity of knowledge and experiences of stakeholders and authors allowed for a balanced representation in the guideline criteria and an unbiased interpretation of the survey results.

Great strides have been made to identify the experiences, learning, and competencies needed to create globally minded practitioners. This new literature has driven the development and formation of the National Guidelines for Global Health Concentrations. Overall, these guidelines are supported across the country as ambitious but obtainable goals for medical schools. In practice, criteria are variably met as medical schools are challenged by a lack of global-health-minded faculty and limited resources. Although the difficulties in creating global health concentrations are significant, the gains in student learning, knowledge, and future practice are potentially great. Existing programs show the feasibility of such concentrations, as well as the impact on the career choices and practice learning of the participants.8 There is a call for improvement of global health within medical education from partners, students, and faculty alike, and it is through comprehensive programs, such as global health concentrations, that the needs of underserved communities both at home and abroad can be met.

Acknowledgments: The authors wish to thank the Canadian Federation of Medical Students Global Health Program and Association of Faculties of Medicine of Canada Global Health Interest Group for their valuable input and logistical support.

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References

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