Global Health Promotion

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A snapshot of global health education at North American universities Raphael Lencucha and Katia Mohindra Global Health Promotion published online 23 January 2014 DOI: 10.1177/1757975913514464

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PED0010.1177/1757975913514464CommentaryR. Lencucha and K. Mohindra

Commentary A snapshot of global health education at North American universities Raphael Lencucha1 and Katia Mohindra2

Abstract: Global health education is becoming increasingly prominent in North America. It is widely agreed upon that global health is an important aspect of an education in the health sciences and increasingly in other disciplines such as law, economics and political science. There is currently a paucity of studies examining the content of global health courses at the post-secondary level. The purpose of our research is to identify the content areas being covered in global health curricula in North American universities, as a first step in mapping global health curricula across North America. We collected 67 course syllabi from 31 universities and analyzed the topics covered in the course. This snapshot of global health education will aid students searching for global health content, as well as educators and university administrators who are developing or expanding global health programs in Canada and the United States. Keywords: curriculum, education, global health

Introduction Global health education is becoming increasingly prominent in North America, in part due to students who desire more global health content in their training (1). There is a growing need to establish core competencies for those engaged in global health research and practice, and to examine whether there should be common components in global health courses across academic institutions (2,3). What is widely agreed upon is that global health is an important aspect of an education in the health sciences given that our current context is undeniably ‘globalized’ and that health is interconnected with international and transnational developments (4–7). There is debate about what should be included in global health education; however, there is a paucity of studies that help us to understand what is currently being covered in global health courses. If we are to enhance our discussions about what could or should be covered in global health education it is important to know what is being covered. For example, do we

know what the content-gaps are in global health education? Are we confident that the ‘core’ features of global health are currently being covered? Do students of global health have an understanding of the different actors involved in global health activities and their relationship to one another? Do these students understand the relationship between the political, economic and social determinants of health and health indicators across countries? Global health is an inherently interdisciplinary field requiring coverage of a wide range of topics, such as climate change, economic development, legal and normative contexts, and industry regulation. The purpose of this research is to identify the content areas being covered in global health curricula in North American Universities, as a first step in mapping global health curricula across North America as a tool to aid students searching for global health content as well as educators and university administrators who are developing or expanding global health programs in Canada and the United States.

1. School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada. 2. Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Correspondence to: Raphael Lencucha, McGill University – Medicine, Hosmer House, 3630 Promenade Sir William Osler, Montreal, Quebec H3G1Y5, Canada. Email: [email protected] Global Health Promotion 1757-9759; Vol 0(0): 1–5; 514464 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913514464 http://ghp.sagepub.com Downloaded from ped.sagepub.com at MCGILL UNIVERSITY LIBRARY on January 29, 2014

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Methods

Results

In order to analyze the content being covered in global health courses we collected course syllabi from universities across North America for the 2008–2009 academic year. We first identified global health courses by using key words in the Google internet search engine. We then searched specific university websites for global health courses. Key words included ‘global health’, ‘course’, ‘undergraduate’, and ‘graduate’. We did not choose to narrow our search to courses in a particular faculty or department. We made this decision based on the understanding that students can access elective courses outside of their home faculty. To limit our search we chose to collect syllabi from universities in the Medical-Doctoral category. We made this decision, in part, to ensure that we were including universities that offer health professional education, such as the rehabilitation sciences (i.e., Physiotherapy, Occupational Therapy, and Speech Therapy), nursing and medicine. We recognize that this decision excludes universities that do not offer health professional education but do offer global health courses. We downloaded syllabi that were posted online and if the syllabus was not posted online, we contacted the instructor requesting the syllabus. A framework was developed by the authors to analyze the syllabi. The framework included seven categories: 1) Geography; 2) Cooperation; 3) Individual/ Population Level; 4) Health, Equity and Trade; 5) Discipline Department; 6) Perspectives and 7) Health Determinants. Each category contained sub-categories, which was the level at which we analyzed the data. For example, the Geography category included five sub-categories (i.e., Transborder, North/South, National, and Regional and Local reference). Each syllabus was coded using binary systems (yes/no) for each sub-category. The conclusions of whether each particular subcategory was addressed in the class was based on a review of all aspects of the syllabus, including the overview, course objectives, learning outcomes and required and suggested readings. This process of analysis formed the basis of our findings. In order to expedite the analysis each author analyzed half of the syllabi. However, 10 syllabi were chosen for both authors to review in order to ensure interrater reliability.

We collected 67 syllabi for analysis from 31 universities. Seven of the universities were Canadian (11 courses) and 24 were in the US (56 courses) (see Table 1 for details). Out of the 67 syllabi analyzed, over half the courses addressed transborder issues (n = 48), while less than half made reference to North–South issues (n = 21). Of the courses analyzed 50 made reference to specific countries, 25 made reference to issues in a particular region such as North America, and 22 made reference to local issues. Under the category of cooperation, only 26 courses made reference to intergovernmental organizations, 17 made reference to non-governmental organizations, and 33 made reference to the role of governments in global health. This particular finding is surprising given the recent emphasis placed on global health governance and the role of different actors in either facilitating improvements in or hindering global health objectives. Most of the courses that we analyzed addressed topics under the subcategory of illness prevention (n = 59). Forty courses covered the topic of health promotion, whereas less than half of the courses addressed primary health care (n = 32) and clinical care (n = 27). The majority of courses were found in public health programs (n = 32) followed by Medicine (n = 21), Sociology/Anthropology (n = 19) and Epidemiology (n = 18). Many of the courses were cross listed with a secondary program. We chose six prominent determinants of global health in our analysis. Of the chosen determinants, 44 courses included content on socioeconomic status, 33 covered the topic of governance, 24 addressed food issues and war or disaster, 21 courses addressed environmental degradation, and only nine touched on the topic of international trade in goods and services. Under the final category of Health, Equity and Trade, 26 courses covered material on global health ethics, 12 covered the topic of foreign aid, and 11 addressed the issue of gender, while 10 covered the issue of foreign direct investment and global health.

Discussion While the historical emphasis on infectious disease remains prominent in the training of medical

IUHPE – Global Health Promotion Vol. 0, No. 0 2014


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Commentary

Table 1. Course content results. Topics Geography Transborder North/South National reference Regional reference Local Cooperation Intergovernmental organization reference Non-governmental organization reference Government reference Interdependence/otherness Individual/population Illness prevention Health promotion Primary health care Clinical care Health equity trade Foreign direct investment Aid Gender Global health ethics Discipline department Medicine Sociology/anthropology Epidemiology Public health Political science History Geography Philosophy Law Engineering Perspectives Postcolonialism Gender Neoliberalism Equity Health determinants Environmental degradation Socioeconomic status issues Food Trade Governance War/Disaster

Courses Addressing Issue (x/67)

Percentage of total

48 21 50 25 22

71.64 31.34 74.62 37.31 32.84

26 17 33 29

38.80 25.37 49.25 43.28

59 40 32 27

88.05 59.7 47.76 40.29

10 12 11 26

14.92 17.91 16.41 38.80

21 19 18 32 10 5 4 5 4 2

31.34 28.35 26.86 47.76 14.92 7.46 5.97 7.46 5.97 2.98

36 14 10 26

53.73 20.89 14.92 38.80

21 44 24 9 33 24

31.34 65.67 35.82 13.43 49.25 35.82



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professionals (8), there have been increasing calls for the inclusion of a broadened slate of issues including health equity and justice (9–11), governance and law (2) and other topics drawn from non-medical disciplines (3). In fact, a recent definition of global health has incorporated the expansive elements of the field: Global health is an area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individuallevel care.(6) Our review of 67 course syllabi from medicaldoctoral academic institutions across North America found that multiple disciplines are involved in teaching global health; however, the majority of global health courses are being offered by public health and medicine. Despite the importance of law, less than 6% of the global health courses included for analysis came from the legal perspective. Our framework exposes this bias towards a disciplinary emphasis on public health and medicine. This bias is particularly relevant as these health disciplines turn to the law to intervene in areas such as disease prevention and treatment. Global health law, particularly treaty law, is increasingly cited as a desirable approach to controlling alcohol, unhealthy food and tobacco consumption (12,13). It is thus important for both those in health disciplines and legal scholars and practitioners to be familiar with the intersection of health and legal interventions. It is particularly important for academic institutions to respond to this growing field and address these complex issues in curricula. Increased interdisciplinary training outside of traditional health science disciplines will advance global health as a more comprehensive field. The challenge of managing global health issues clearly falls to both the health professions such as medicine and nursing as well as fields such as political science, economics and law (14,15). Many of the courses did not include reference to the different actors involved in addressing or influencing global health. This may point to the need to familiarize students of global health to the roles played by governments, non-state

actors, industry and intergovernmental organizations. For example, it is crucially important for students to understand the international political context whereby state sovereignty is a dominant norm, while at the same time intergovernmental cooperation is a prominent feature of this landscape (16). The independence of states sets a particular dynamic in the establishment of global norms to address health, specifically in the establishment of global standards of diet and physical activity, health research and product regulation. Our findings may also point to the difficulty of including the breadth of issues pertaining to global health in a single course. We also acknowledge that the program that is offering the global health course will likely gear this course to its specific objectives. For example, departments may not see the need to include issues of trade or foreign direct investment when training physicians to diagnose and treat tropical disease. However, as evidence of the relationship between health and disease and the various transnational determinants of health continue to emerge, it is hoped that this content can be included regardless of the discipline. For example, the treatment of disease in resource-poor regions is highly dependent on the donor environment and the ability of governments that do not possess the internal capacity to develop affordable medication to access generic medications from other countries without fear of trademark infringement (17,18). Based on this particular example, we can assume that a rudimentary understanding of international law, financial and other aid, and basic economics would complement any global health curriculum. Our framework has attempted to disentangle what would be considered ‘determinants’ of health from the broader system of global health governance. Despite the fact that this effort is somewhat artificial given that aspects of global health, such as who is involved in managing a particular health issue, have bearing on the nature of the health issue, we suggest that it is useful to embed or link the determinants with other information about the history and systems of international relations. For example, how has the history of, say, colonial rule influenced the current design of a public health or health care system in a country? This linkage can also encourage students to grapple with how international arrangements such as the World Trade Organization



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Commentary

agreements or regional and bilateral trade and investment agreements might influence dietary practices at the domestic level. It is interesting to observe that almost three-quarters of the courses included content that was considered transborder. In other words, the content was not directly tied to a particular country or geography, but dealt with health from a global perspective. This finding suggests that global health courses are aligning with contemporary definitions of global health that are not limited to ‘other’ countries or regions, typical of classical definitions of international health.

Limitations There are two main limitations to our study. First, course information was collected from universities in North America, which had listed their courses online; therefore, we cannot be sure that we have identified all courses for the period of 2008–2009, notably those in smaller universities. Second, we relied on course syllabi to conduct our analysis. Instructors include various levels of detail on their syllabi and do not necessarily represent the full scope of and approach to teaching that course.

Conclusion Global health education continues to find its place in the curricula of different disciplinary programs. There is wide recognition that global health education spans a breadth of topic areas, ranging from disease prevention and treatment to social and economic development. This study has provided a snapshot of the various topics being addressed in global health courses in North American Universities. This snapshot can provide a starting point from which to continue to collect and examine the content of global health education, and can contribute to ongoing dialogue around this crucially important area of education. Conflict of interest None declared.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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