The Executive Board of the American College of Obstetricians and Gynecologists (the College) issued a policy statement (July 2012) that endorsed women's health and rights globally,1 emphasizing the need for health care in settings where health disparities result in a higher burden of disease2 and increased maternal morbidity and mortality.3 Improving women's health care in low-resource settings was highlighted by the United Nations Millennium Development Goals, which promote gender equality and maternal and child health,4 and is a focus of both the recent United Nations Sustainable Development Goals and the Secretary General's Global Strategy for Women's, Children's, and Adolescent's Health.5,6
Resident and medical student interest in global health has paralleled the increased attention in worldwide health care disparities. Data from the Association of American Medical Colleges indicate that 65% of incoming students want a global health opportunity during medical school,7 with participation increasing from 6% to 31% over the past 20 years.8 Resident surveys demonstrate that global health electives are highly rated, increase recruitment to residency programs, and foster long-term global health involvement,9–12 yet only an estimated 17% of obstetrics and gynecology residency programs offer structured global health electives.13
In response to the increased commitment to and focus on global health, the Council on Resident Education in Obstetrics and Gynecology (CREOG) developed and administered a resident survey with the following goals: 1) understand the extent of interest and participation in global health experiences among residents, 2) analyze factors that influence participation in global health experiences, and 3) assess intent to incorporate global health into future practice.
MATERIALS AND METHODS
A 23-item survey, developed and tested by members of CREOG and the CREOG Education Committee, queried demographics, motivation, experience, and future intent to participate in global health (Fig. 1). The survey was created in response to concerns brought to CREOG by residency program directors regarding an increased interest, from both residents and applicants, in global health experiences. The survey was distributed to all U.S. obstetrics and gynecology residency programs participating in the 2015 CREOG in-training examination. The survey was voluntary and did not require completion of any one question to advance to the subsequent question. Respondents completed and returned the survey to the site proctor before starting the CREOG in-training examination. The surveys were returned by each residency program to CREOG in a separate packet from the examinations.
Survey forms were created using Concord Form Design Software 6.0, published by Data Blocks (www.datablocks.com). Returned surveys were scanned on a Fujitsu fi-4340C scanner using Remark Office OMR 8.0 (www.gravic.com). This software marks recognition errors in scanned fields for manual review; handwritten fields were individually reviewed and coded. Scanned and reviewed data were saved to a tab-delimited data file, which was imported and analyzed in SPSS 20.0.0.
Results of each question were reported by number and percent of responses to each answer choice. Blank responses and multiple responses for a question were excluded. Additionally, participants were excluded entirely if they either did not respond to the postgraduate year (PGY) question or responded as “other” as nonresident participants (residency program directors sometimes take the CREOG examination). Some demographic responses were grouped for analysis such as partner status (three “nonpartnered” answer choices combined into one) and future primary clinical practice focus (different types of nonsubspecialty practices grouped into one). The relationship between resident characteristics and expected participation in a global health elective during residency was analyzed by the Pearson χ2 test. A P value of <.01 was considered significant. Residents who responded “don't know” to the question of “expected participation in a global health experience” were not included in this analysis. Pearson χ2 analysis was also used to compare the cohort of residents who answered the question of “the importance of global health” (Fig. 1, question 8) with those who left it blank.
This study was reviewed and deemed exempt by the College’s institutional review board.
Of, 5,056 U.S. participants who took the 2015 CREOG in-training examination, 19 were excluded for no response and 32 for a response of “other” for their PGY status, leaving 5,005 eligible participants (Table 1). Of the 5,005 eligible participants, 4,929 completed at least a portion of the survey for a response rate of 98.5%. Blank responses increased with progression through the survey with a question response rate of 97.4% (4,803/4,929) for the first question after the demographic section and 72.7% (3,581/4,929) for the last question.
Of the residents who rated the importance of a global health experience, 33.6% (1,313/3,904) rated it as “very important,” 62.7% (2,448/3,904) as “somewhat important,” and 3.7% (143/3,904) as “not important.” When asked about the most important aspect of a global health experience, 69.2% (2,993/4,326) indicated educational opportunities (Fig. 1, question 1, response options 1–4: 20.7%, 18.0%, 15.3%, and 15.3%, respectively) and 17.7% (764/4,326) indicated humanitarian opportunity as most important; 12.2% (524/4,326) indicated it was a “chance to see the world” or “not important.” The response rate for this question was 79.2% (3,904/4,929). Pearson χ2 analysis of characteristics of the 1,025 residents with a blank response as compared with the 3,904 who completed the question demonstrated that there was a significant association between answering this question and having a global health experience before or during residency (P<.001 for both). Of the 1,025 residents who left this question blank, 33.1% had a global health experience before residency and 1.0% had a global health experience during residency as compared with 60.7% and 10.8%, respectively, who completed the question.
Before residency, 54.9% (2,660) of respondents had a global health experience. Of these, 38.9% (1,034) expected to have one during residency. Conversely, 17.5% (378/2,158) of those without a previous global health experience expected to have one during residency. When residents who had a global health experience before residency rated the importance of global health (2,322), 43.5% (1,010) rated a global health experience as “very important,” 54.7% (1,271) as “somewhat important,” and 1.8% (48) as “not important.” Of the residents who did not have a global health experience before residency (1,481), 19.9% (294) rated a global experience as “very important,” 77.3% (1,145) as “somewhat important,” and 2.8% (42) as “not important.”
Global health experience during residency considerably increased the rating of the importance of global health and intent to incorporate it into future practice (Table 2). Additionally, global health experiences were more common as respondents progressed through their residency as follows: 1.7% (22/1,286) of PGY-1s, 3.5% (44/1,241) of PGY-2s, 10.5% (129/1,223) of PGY-3s, and 19.4% (229/1,179) of PGY-4s.
Of the 4,816 residents who responded to the question of whether they intended to have a global health experience during residency, 29.6% (1,427) expected to have one, 50.7% (2,444) did not, and 19.6% (945) were not sure. When residents who expected to have a global health experience during residency rated the importance of global health, 60.3% (841/1,394) rated global health as “very important,” 38.9% (542/1,394) as “somewhat important,” and 0.8% (11/1,394) as “not important.” Of those who did not expect to have a global health experience during residency, 19.7% (308/1,564) rated global health as “very important,” 77.1% (1,206/1,564) as “somewhat important,” and 3.2% (50/1,564) as “not important.”
Residency programs administer a global health elective differently. Of 4,155 respondents, 18.0% (747) reported their residency program would arrange the elective, 44.0% (1,828) would arrange the elective themselves, 36.4% (1,514) would arrange it themselves as a noncredit experience during vacation time, and 1.6% (66) reported it was a required rotation. Of the 409 residents who had a global health experience during residency and indicated how it was administered, 26.4% (108) had it arranged by the residency, 42.1% (172) arranged their own elective, 25.4% (104) used vacation time, and 6.1% (25) had a required rotation.
Female gender, residents with no partner, residents with no children, having a global health experience before residency, and a plan to incorporate global health into future practice were all significantly associated with expectation for a global health experience during residency (Table 3). Training in community-based compared with university-based residency programs did not significantly affect resident expectation for a global health experience. The same held true for residents anticipating nonsubspecialist compared with subspecialist practice with the exception of those who intended to become reproductive endocrinology and infertility subspecialists, who were less likely to expect to participate.
This national survey of obstetrics and gynecology residents reveals a strong interest in a global health experience during residency training. Participation in global health electives during medical school and residency was associated with a greater perceived importance of global health and increased the desire for future global health involvement. This study also highlights the fact that that many residency programs do not provide organized global health experiences; residents often need to arrange their own global health elective or use their vacation time to participate.
To understand how to bridge the gap between trainee interest in global health and developing structured global health electives, coming to a shared definition of the term “global health” is important. “Global health” grew out of “international health,” which focused on activities that prevented the spread of epidemics between national borders beginning in the late 19th century. Global health was initially used interchangeably with international health but has come to mean much more, because it now encompasses the goal of improving worldwide health through the reduction of health care disparities.14 Many U.S. medical schools and residencies have developed curricula for global health rotations, yet there is currently no standardization of what these educational experiences entail. U.S. low-resource settings may also be underutilized for these experiences. Additionally, the burden of overseeing these rotations often falls to program directors who may have no background or training in global health.15
Predeparture training and experienced faculty mentorship are thought to be essential elements of a dedicated global health education curriculum for medical students and residents.16,17 Ethical considerations are also a crucial component of a global health curriculum to ensure sustainable practices, appropriate supervision, and proper care in low-resource settings.18–20 However, a recent survey of U.S. obstetrics and gynecology program directors demonstrates that few dedicated global health training programs exist.21 A model for such a program was described in a single surgical residency.22 This residency track focuses on mentoring from experienced global health faculty; building skills to deliver care in resource-limited settings; promoting ethical conduct in vulnerable populations; and developing relationships, through both clinical and research efforts, tailored to the needs of the underresourced country. Such a program, however, requires significant financial resources and global health faculty investment—which are unlikely to be feasible for many residency programs.
We identified a number of characteristics of obstetrics and gynecology residents that were associated with interest in a global health experience. Our results showed that having a partner or children, which might be considered to be a “personal commitment,” was associated with less interest in participating in global health. This was also seen in a survey of female pelvic medicine and reconstructive surgery fellows.23 Female residents were also more likely to expect a global health experience as compared with their male counterparts. Our finding that both previous experience and planned future participation were positively associated with expectation for global health participation is consistent with smaller resident surveys, which demonstrate that having an established global health program in residency is correlated with both increased residency recruitment and continued future integration of global health in practice.9–12
Strengths of our study include the large number of obstetrics and gynecology resident respondents across varying types of residency programs throughout all regions of the United States. An important limitation is that the survey focused on just one medical specialty. The cross-sectional aspect of the study also has inherent limitations and results may differ if the study is completed over a different timeframe with this cohort or with future resident cohorts. Another limitation is the loss of respondents as they progressed through the survey, as an increased proportion of residents with a global health experience completing the entire survey.
In summary, this study demonstrates that the majority of U.S. obstetrics and gynecology residents rate a global health experience as important, and many expect to have a global health experience during training. Additionally, the study identifies that the majority of residents plan their own global health elective or use their own vacation time for this experience, suggesting that residency programs may need access to more organized global health opportunities led by global health faculty who can sustain ethically responsible educational experiences. Given the cost of building such programs within each medical school or center, centralization of this endeavor—either regionally through academic centers or nationally through organizations such as the College—may expedite these efforts.
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