Jessica Evert

Identifying Interprofessional Global Health Competencies for 21st-Century Health Professionals

BACKGROUND At the 2008 inaugural meeting of the Consortium of Universities for Global Health (CUGH), participants discussed the rapid expansion of global health programs and the lack of standardized competencies and curricula to guide these programs. In 2013, CUGH appointed a Global Health Competency Subcommittee and charged this subcommittee with identifying broad global health core competencies applicable across disciplines. OBJECTIVES The purpose of this paper is to describe the Subcommittees work and proposed list of interprofessional global health competencies. METHODS After agreeing on a definition of global health to guide the Subcommittees work, members conducted an extensive literature review to identify existing competencies in all fields relevant to global health. Subcommittee members initially identified 82 competencies in 12 separate domains, and proposed four different competency levels. The proposed competencies and domains were discussed during multiple conference calls, and subcommittee members voted to determine the final competencies to be included in two of the four proposed competency levels (global citizen and basic operational level - program oriented). FINDINGS The final proposed list included a total of 13 competencies across 8 domains for the Global Citizen Level and 39 competencies across 11 domains for the Basic Operational Program-Oriented Level. CONCLUSIONS There is a need for continued debate and dialog to validate the proposed set of competencies, and a need for further research to identify best strategies for incorporating these competencies into global health educational programs. Future research should focus on implementation and evaluation of these competencies across a range of educational programs, and further delineating the competencies needed across all four proposed competency levels.

Beyond Medical “missions” to Impact-driven Short-term Experiences in Global Health (steghs): Ethical Principles to Optimize Community Benefit and Learner Experience

Increasing demand for global health education in medical training has driven the growth of educational programs predicated on a model of short-term medical service abroad. Almost two-thirds of matriculating medical students expect to participate in a global health experience during medical school, continuing into residency and early careers. Despite positive intent, such short-term experiences in global health (STEGHs) may exacerbate global health inequities and even cause harm. Growing out of the “medical missions” tradition, contemporary participation continues to evolve. Ethical concerns and other disciplinary approaches, such as public health and anthropology, can be incorpo rated to increase effectiveness and sustainability, and to shift the culture of STEGHs from focusing on trainees and their home institutions to also considering benefits in host communities and nurtur ing partnerships. The authors propose four core principles to guide ethical development of educational STEGHs: (1) skills building in cross-cultural effective ness and cultural humility, (2) bidirectional participatory relationships, (3) local capacity building, and (4) long-term sustainability. Application of these principles highlights the need for assessment of STEGHs: data collection that allows transparent compar isons, standards of quality, bidirectionality of agreements, defined curricula, and ethics that meet both host and sending countries’ standards and needs. To capture the enormous potential of STEGHs, a paradigm shift in the culture of STEGHs is needed to ensure that these experiences balance training level, personal competencies, medical and cross-cultural ethics, and educational objectives to minimize harm and maximize benefits for all involved.

Short term global health experiences and local partnership models: a framework.

AbstractContemporary interest in in short-term experiences in global health (STEGH) has led to important questions of ethics, responsibility, and potential harms to receiving communities. In addressing these issues, the role of local engagement through partnerships between external STEGH facilitating organization(s) and internal community organization(s) has been identified as crucial to mitigating potential pitfalls. This perspective piece offers a framework to categorize different models of local engagement in STEGH based on professional experiences and a review of the existing literature. This framework will encourage STEGH stakeholders to consider partnership models in the development and evaluation of new or existing programs.The proposed framework examines the community context in which STEGH may occur, and considers three broad categories: number of visiting external groups conducting STEGH (single/multiple), number of host entities that interact with the STEGH (none/single/multiple), and frequency of STEGH (continuous/intermittent). These factors culminate in a specific model that provides a description of opportunities and challenges presented by each model.Considering different models, single visiting partners, working without a local partner on an intermittent (or even one-time) basis provided the greatest flexibility to the STEGH participants, but represented the least integration locally and subsequently the greatest potential harm for the receiving community. Other models, such as multiple visiting teams continuously working with a single local partner, provided an opportunity for centralization of efforts and local input, but required investment in consensus-building and streamlining of processes across different groups.We conclude that involving host partners in the design, implementation, and evaluation of STEGH requires more effort on the part of visiting STEGH groups and facilitators, but has the greatest potential benefit for meaningful, locally-relevant improvements from STEGH for the receiving community. There are four key themes that underpin the application of the framework: 1.Meaningful impact to host communities requires some form of local engagement and measurement2.Single STEGH without local partner engagement is rarely ethically justified3.Models should be tailored to the health and resource context in which the STEGH occurs4.Sending institutions should employ a model that ultimately benefits local receiving communities first and STEGH participants second. Accounting for these themes in program planning for STEGH will lead to more equitable outcomes for both receiving communities and their sending partners.

Global Health Educational Engagement—A Tale of Two Models

Global health learning experiences for medical students sit at the intersection of capacity building, ethics, and education. As interest in global health programs during medical school continues to rise, Northwestern University Alliance for International Development, a student-led and -run organization at Northwestern University Feinberg School of Medicine, has provided students with the opportunity to engage in two contrasting models of global health educational engagement. Eleven students, accompanied by two Northwestern physicians, participated in a one-week trip to Matagalpa, Nicaragua, in December 2010. This model allowed learning within a familiar Western framework, facilitated high-volume care, and focused on hands-on experiences. This approach aimed to provide basic medical services to the local population. In July 2011, 10 other Feinberg students participated in a four-week program in Puerto Escondido, Mexico, which was coordinated by Child Family Health International, a nonprofit organization that partners with native health care providers. A longer duration, homestays, and daily language classes hallmarked this experience. An intermediary, third-party organization served to bridge the cultural and ethical gap between visiting medical students and the local population. This program focused on providing a holistic cultural experience for rotating students. Establishing comprehensive global health curricula requires finding a balance between providing medical students with a fulfilling educational experience and honoring the integrity of populations that are medically underserved. This article provides a rich comparison between two global health educational models and aims to inform future efforts to standardize global health education curricula.

Host community perspectives on trainees participating in short‐term experiences in global health

High‐income country (HIC) trainees are undertaking global health experiences in low‐ and middle‐income country (LMIC) host communities in increasing numbers. Although the benefits for HIC trainees are well described, the benefits and drawbacks for LMIC host communities are not well captured.

Developing ethical awareness in global health: four cases for medical educators.

In recent years, the growth of interest in global health among medical students and residents has led to an abundance of short-term training opportunities in low-resource environments. Given the disparities in resources, needs and expectations between visitors and their hosts, these experiences can raise complex ethical concerns. Recent calls for best practices and ethical guidelines indicate a need for the development of ethical awareness among medical trainees, their sponsoring and host institutions, and supervising faculty. As a teaching tool to promote this awareness, we developed a scenario that captures many common ethical issues from four different perspectives. Each perspective is presented in case format followed by questions. Taken together, the four cases may be used to identify many of the elements of a well-designed global health training experience.

Career opportunities in global health: A snapshot of the current employment landscape.

Recent decades have witnessed a burgeoning interest in improving health and health systems in low and middle–income countries (LMIC). With the increase in program funding came parallel increases in the number of university programs in the US and Europe offering concentrations or degrees in a global health field [1–6]. The changes have been brisk and substantial [5–8], and beg the question: What do we know about the global health job market? While a few studies have provided limited insights into the employment landscape, the last comprehensive attempt to answer this question was by Baker 30 years ago [9]. Key questions (as yet largely unanswered) about the current global health job market include: How satisfactory is the numerical balance between job aspirants and job openings? Are the trend lines of aspirants and openings similar or divergent? Are we at risk of having too many job seekers or too few? How good is the qualitative match between employer needs and training program outputs? Which competencies are in short supply [10–12]? What are the contributions, and liabilities, of short–term trainee and volunteer participation in the workforce? How do their contributions fit into the larger picture of the global health workforce [5,10–12]? Answering these questions will take substantial effort through carefully structured investigations to provide reliable answers. In this article, we present a limited pilot study through a targeted web–based job posting review that does not attempt to answer all these questions but sheds some light on the current landscape of employment opportunities in program management, clinical, and public health–related aspects of global health in international settings. The investigative team consisted of five physicians, one with a doctorate in psychology, and another with a doctoral degree in Public Health. The team convened in March 2013. Review of online job postings occurred between November 2013 and January 2014. Websites with employment opportunities in global health were identified using the Google search engine. The terms, “Global Health Work,” “Global Health Jobs,” “Global Health Job Opportunities,” “Global Health Workforce,” “Global Health Hiring” were searched in August 2013. These searches returned a large number of results with potential sources of job information. From this sizeable response, for feasibility and efficiency’s sake, an initial cohort of 14 websites were selected, limited to English language websites primarily affiliated with organizations in North America, and (if the site permitted access) to a regularly available and rotating list of job postings. A similar consideration in prioritizing this initial pilot list was the Google “PageRank” of each site. Page Rank is an objective measure of a citation’s importance that corresponds with users subjective idea of importance [13]. Over the course of the entire survey, 12 further sites were selected to accrue additional postings by applying the same inclusion criteria. The need for additional sites addressed cyclical pauses in available job postings on several sites. Global health workforce employment opportunities were described as positions that focus on health–related efforts in low– and middle–income countries (LMIC). The investigative team developed a standardized selection and coding tool using a shared online document matrix. The tool allowed for easy categorization of a number of factors related to the job in question. 26 websites in total were selected for inclusion. Each investigator was assigned one high traffic website with frequent job postings and another with lower traffic and fewer postings. The six investigators then each reviewed a subset of the websites during two 6–week sampling periods. Each investigator retrieved a minimum of 10 job postings during each sampling period. The results were then tabulated and underwent basic statistical analysis. In this limited, but wide–reaching review of online job postings that included 178 employment opportunities from 26 websites, key findings included: 67% (119/178) of the positions were in non–governmental organizations (NGOs) in both developed countries and LMICs. When combined with multinational organizations such as the World Health Organization (WHO) and the World Bank, the two employer types accounted for 89% (158/178) of the total (Figure 1, plate A). Figure 1 Depiction of survey results of career opportunities in global health. A) Breakdown of types of global health employers. B) The primary disciplines sought by employers. C) Highest academic achievement required or desired by employers. D) A sub–categorization ... 14% (25/178) of the positions involved clinical disciplines primarily medicine. (Figure 1, plate B). 50% (89/178) of job posts included the request for applicants to have the kind of knowledge and skills normally acquired in schools of public health offering courses relevant to global health.(Figure 1, plate B) 51% (91/178) of the listed opportunities required at least a Master’s degree level of qualification or doctoral degree (23%, 41/178) (Figure 1, plate C). Photo: Courtesy of Trisha Pasricha, personal collection (from the documentary “A Doctor of My Own”, directed by T. Pasricha) 84% (149/178) of the positions were program–related. Program–related jobs included planning, program direction, finance, management and other supportive functions (not depicted but subcategorized in Figure 1, plate D). The majority of program–related jobs were identified to be at the senior program management and direction level (58% (87/149) (Figure 1, plate D). Second most common were supportive program functions (28% 41/149) followed by other support activities (9% 13/149) and program financing (5% 8/149) (Figure 1, plate D). Salary information, which could provide a basis for assessing the strength of demand and for calculating a rate of return on a global health job, was provided in only 18% (32/178) of the job offerings. Of those listed, most (56%, 18/32) were in the US

Service Learning as a Framework for Competency-Based Local/Global Health Education

61 000 – 90 000 range (Figure 2). Figure 2 Distribution of global health jobs based on salary range. The size, characteristics and trends of the global health workforce and jobs available are largely unknown. Our pilot study of internet–based job postings provides a initial snapshot of one view of global health employment opportunities in international settings. Aside from highlighting the many as yet unanswered questions regarding the global health workforce, the study itself has limitations with respect to its specific focus on the job market. These include: small sample size, use of only English language job postings accessible on the internet, the scant salary and benefit information available, and the generally limited scope of positions in LMICs. The salary ranges available may be on the lower end as higher salary jobs may conceivably not be publicized. We did not attempt detailed analysis of the many discrete skills sought by employers, nor did we make follow up phone calls to employers to learn whether they readily filled the advertised positions and with the requisite qualifications. Despite these limitations our findings have implications for the curricula of global health educational programs and to graduates seeking employment and career opportunities. For instance, our investigation draws attention to the importance of public health training and to program management skills. Global health programs should seek to include training in public health with an emphasis on leadership, planning, management, financial, communication, evaluation and related programmatic skills. Given that 74% of the jobs we surveyed required a Master’s degree or higher, the importance of advanced academic credentials is evident. This high level academic qualification has clear implications for students and trainees seeking a career in global health as they will be required to spend more time and tuition in academia before entering the job market. Given the ongoing increases in tuition costs for many undergraduate and advanced degrees, the average salaries offered may appear inadequate for those needing to repay student loans. Our study suggests the importance of probing more deeply into the dynamics of the global health workforce, including how this workforce is trained and educated as well as the employment opportunities available following the completion of training. Pending an updated investigation along the lines of the Baker 1982 study, several interim studies might be considered: (1) studies to gain a better understanding of the content and the characteristics of global health (and related) training programs; (2) studies to understand the match between employer needs and applicant qualifications; (3) analyses of the likely trends and stability of the global health job market; (4) surveys of the Global South host countries to determine if training among visitors from the Global North adequately meets their needs; (5) analyses of the intersections between domestic and international employment opportunities, training and career paths. We welcome exchanging views with others interested in learning more about the global health workforce.

Guidelines for responsible short-term global health activities: developing common principles

Service learning is a field that can provide the foundation for emphasizing the relevancy and realities of local/global health. Service learning is now widely accepted as a form of experiential education in which students “engage in activities that address human and community needs together with structured opportunities intentionally designed to promote student learning and development.” Service-learning courses are not just regular courses with community service for homework; rather, they are courses that unite service and classroom and include a rigorous pedagogy to maximize student development, as well as community priorities. As a result of these carefully drawn distinctions, service learning has survived throughout the years as a formal construct that allows for academic foundations, community engagement, and assessment. With the recent expansion in global health competency sets, including those with interprofessional applications, service learning becomes an increasingly relevant construct for competency-based global health education. Service learning is a construct that optimizes the relevance and effect of local global health education and community engagement. Global service learning (GSL) is a specialty within this field. GSL focuses on service learning in international settings, as well as cross-cultural engagement wherever it occurs. Like global health, GSL is not geographically specific or only applicable internationally. It builds on lessons and practices from domestic service learning, but borrows from both international education and international development literature to develop a distinctive set of values and principles. According to Hartman and Kiely, GSL stands apart in 5 key ways:

Improving the Safety and Security of Those Engaged in Global Health Traveling Abroad

BackgroundGrowing concerns about the value and effectiveness of short-term volunteer trips intending to improve health in underserved Global South communities has driven the development of guidelines by multiple organizations and individuals. These are intended to mitigate potential harms and maximize benefits associated with such efforts.MethodThis paper analyzes 27 guidelines derived from a scoping review of the literature available in early 2017, describing their authorship, intended audiences, the aspects of short term medical missions (STMMs) they address, and their attention to guideline implementation. It further considers how these guidelines relate to the desires of host communities, as seen in studies of host country staff who work with volunteers.ResultsExisting guidelines are almost entirely written by and addressed to educators and practitioners in the Global North. There is broad consensus on key principles for responsible, effective, and ethical programs--need for host partners, proper preparation and supervision of visitors, needs assessment and evaluation, sustainability, and adherence to pertinent legal and ethical standards. Host country staff studies suggest agreement with the main elements of this guideline consensus, but they add the importance of mutual learning and respect for hosts.ConclusionsGuidelines must be informed by research and policy directives from host countries that is now mostly absent. Also, a comprehensive strategy to support adherence to best practice guidelines is needed, given limited regulation and enforcement capacity in host country contexts and strong incentives for involved stakeholders to undertake or host STMMs that do not respect key principles.