|ORIGINAL RESEARCH PAPER
|Year : 2013 | Volume
| Issue : 2 | Page : 73-77
Global child health education in Canadian paediatric residency programs
Tobey Ann Audcent1, Heather MacDonnell1, Lindy Samson1, Jennifer L Brenner2
1 Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
2 Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
|Date of Web Publication||29-Oct-2013|
Tobey Ann Audcent
Division of Infectious Diseases. Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario K1H 8L1
Source of Support: None, Conflict of Interest: None
Context: Globalisation has led to significant changes in health care, yet medical education remains domestically focused. The majority of the world's children live in developing countries, and education related to global child health is important for paediatric residents. Methods: Chief residents and program directors from the 16 Canadian paediatric training programs were surveyed using a questionnaire regarding global child health training program content, electives, attitudes and perceptions towards global child health. Results: No programs had a formalised global health curriculum. All program directors and chief residents reported that programs offer global child health sessions, but 50% of the programs did not address six out of twelve of the content areas including topics such as refugee health and international adoption. All program directors agreed global child health understanding is important for paediatric trainees; 83% agreed more emphasis should be placed on this during post-graduate training. Discussion: A formalised global child health curriculum is lacking for Canadian paediatric residents: Program directors are willing to integrate global child health training modules into their post-graduate training programs.
Keywords: Curriculum, global health, international health, paediatrics, residency education
|How to cite this article:|
Audcent TA, MacDonnell H, Samson L, Brenner JL. Global child health education in Canadian paediatric residency programs. Educ Health 2013;26:73-7
| Context|| |
Globalisation is impacting child health and health systems worldwide.  The majority of the world's children live in developing countries. Most of the 7.6 million annual deaths occurring in children under 5 years of age worldwide could be easily prevented. , Twenty-five percent of Canada's increasing immigrant and refugee populations are children.  A global perspective has become increasingly relevant to the practice of today's paediatricians.
Global health has been defined as the health of populations that "transcends the perspectives and concerns of individual nations".  Despite the lack of consensus around a clear definition  , the importance of global health education for North American medical trainees is increasingly recognised. ,,,,, Canadian medical educators have also argued that Canada's increasing ethnic diversity necessitates that Canadian trainees be well trained in global health issues in order to address the broader health concerns accompanying migrants. 
A recent survey of American paediatric residency training programs demonstrated a growing interest in global health as well as increased resident participation in global health electives (GHEs) when compared with a prior survey in 1996.  Tangible benefits of global health physician training include altruism, volunteerism and improved provision of care to marginalised populations including indigenous peoples, refugees and immigrants. , Subjective improvements in physician competency in communication, clinical decision making, resource allocation and diagnostics following global health experiences during medical school and residency training have been described in addition to a career influence towards public health, primary care and employment in low-income clinics. ,,,, A recent American study  of paediatric residents participating in an international health track showed statistically significant knowledge gain when a formal global health curriculum was employed, although there was no sub analysis included for elective participation. More medical schools are introducing mandatory global health sessions and pre-departure elective courses into their curriculum, in addition to encouraging overseas electives. 
A national survey of global health education of paediatric residents in the United States was recently published,  but there is currently a lack of published data about global health training during paediatric residency specific to Canada. In terms of medical education, a 2006 report by the Association of Faculties of Medicine of Canada documented the need for Canadian medical students to be educated in global health.  The Royal College of Physicians and Surgeons of Canada competency framework (CanMEDS),  on which all current residency training and evaluation programs in Canada are based, emphasises resource equity promotion, care for marginalised populations, advocacy and altruism  all of which may be fostered through global health training and experiences.
Globally, there is also a growing recognition among medical educators of the imperative for change. The 2010 Lancet independent commission, Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World describes how today's physicians must learn how to synthesise vast amounts of information necessary for clinical and population-based decision making and how educational institutions will need to broaden their traditional roles to meet the needs of this rapidly evolving context. The developed and developing world need to act as partners in confronting new environmental, societal and infectious health challenges, with the first step in preparing physicians to meet these needs being education. 
Our study aimed to quantify existing formal exposure to global health training in Canadian paediatric residency programs, assess programmer and trainee attitudes towards global child health and better understand global child health training needs and barriers to expanding global child health training.
| Methods|| |
An online, self-administered survey tool was developed and validated de novo and considered the CanMEDS framework of essential physician competencies. , Close-ended (4 point Likert scale) and open-ended questions were used to elicit attitudes and perceptions towards global child health, residency program global child health content, international electives, and potential global child health training opportunities and barriers. The survey was developed in English, externally reviewed for content validity and underwent purposeful piloting and was then translated. In 2006-2007 chief residents and program directors from all 16 accredited Canadian paediatric programs were invited to complete the survey in English or French with reminders sent at 3 and 5 months. Descriptive statistics were used to tabulate close-ended responses in aggregate format. All open-ended responses were analysed using content analysis. One author read through each comment and grouped those with similar content together. On the basis of these groupings key themes were extracted, summarised and reported. Approval was granted by the Children's Hospital of Eastern Ontario Research Institute Ethics Review Board.
| Results|| |
Thirty chief residents and 16 program directors were invited to participate in the survey. Fifty-two percent of potential respondents completed the survey including 75% (12/16) of program directors and 40% (12/30) of chief residents with at least one respondent from 81% of training programs.
Attitudes and Perceptions
All respondents agreed that understanding global child health issues is important for Canadian Paediatric Trainees. Eighty-six percent agreed formal curricula should increase emphasis on global child health topics. All program directors reported that program applicants inquired about global health opportunities during selection interviews.
No programs had a formalised global child health curriculum; most global child health training occurred during educational presentations (92%), academic half day (66%) and guest lectures (66%) [Figure 1]. Global child health content areas reportedly covered are shown in [Figure 2]. Critical knowledge topics including tuberculosis, refugee health and malaria were not universally covered at all sites. All respondents agreed increased global child health knowledge and skills by paediatric residents could contribute to the achievement of CanMEDS roles, specifically those of medical expert, communicator and health advocate.
|Figure 1: Program director responses: Does your program provide any formal teaching sessions on global child health issues?|
Click here to view
|Figure 2: Program director's responses: Are the following topics part of your formal academic curriculum? WHO = World Health Organisation; MDG-=Millennium development goals; PTSD = Post-traumatic stress|
disorder; TB = Tuberculosis; HIV/AIDS: Human Immune deficiency virus/Acquired immune defi ciency syndrome
Click here to view
Most chief residents and program directors (81% and 100%, respectively) agreed that their trainees had benefited from GHEs to low and middle-income countries. Program directors' estimates of the number of residents undertaking GHEs from their program ranged from 1 to 4 trainees/year (mean = 2.3). Seven programs (53%) reported having a long-term elective collaboration with a less-resourced country. Most respondents identified their programs as supportive of GHEs (91% of chief residents and 100% of program directors). Respondents overwhelmingly felt that the most significant barrier to GHEs was cost (81% of chief residents and 67% of program directors). Logistical difficulties of identifying and arranging the electives were another barrier identified primarily by chief residents (50%), and by only 18% of program directors [Figure 3] and [Figure 4]. Open-ended responses from program directors indicated that their information regarding who had done international electives was incomplete. They also reported heterogeneity in pre-elective preparation, and supervision.
In the open-ended responses one respondent stated: "A significant proportion of Canada's population include immigrant and refugee children. Therefore we need to be prepared to understand conditions specific to this population and learn how to approach them in a culturally sensitive manner." Ninety-one percent of program directors indicated that their program would be interested in new global child health training initiatives. The majority (91%) agreed that global child health educational modules of approximately 6 hours could be incorporated into their formal resident curriculum during protected academic time.
| Discussion|| |
There was a great deal of enthusiasm for global child health education among Canadian paediatric chief residents and program directors, which is consistent with an interest in global health during the period of residency training as reported by several other studies. ,, Global child health content is felt to be relevant and important for paediatricians-to-be and can contribute to the achievement of CanMEDS competencies. However, no Canadian paediatric residency program formally integrated global child health into their academic curriculum and significant gaps in formal teaching of key global child health topics were identified. This finding is in keeping with a recently published survey of global health education in US Paediatric residency programs, which identified global child health training opportunities as important to residents, but an overall low exposure to global child health topics in formal training. 
Though GHEs for trainees were perceived as beneficial, cost and logistics were identified as major barriers to their organisation and execution. These barriers are consistent with challenges documented in previously published studies. ,, In a 2003 literature review by Thompson et al., which looked at the educational effects of GHEs on medical students and residents from 1996 to 2000, electives were also perceived as having a positive effect on clinical diagnostic skills, knowledge, communication and attitude. The authors postulate that the enthusiasm of the trainees has not been matched by more rigorous evaluation by medical educators.  A more recent systematic review by Jeffrey et al. looking at the same question in regards to medical students showed similar findings but also highlighted the lack of reliable outcome measures of provider behaviour and quality of patient care. 
The response rate of program directors for this survey of 75% is excellent and the resident response rate of 40% is comparable with similar surveys, , Though a high percentage of programs were represented, those responding may have had an increased interest in global health. The presence of two or more chief residents at several sites precluded site-specific analysis of the resident responses. Additionally, surveys assumed chief residents and program directors were fully informed of global child health training and elective opportunities at their sites throughout residency.
Our needs assessment results are important and timely as the demand for global health exposure and training for medical trainees, including Canadian paediatric residents increases. Canadian paediatric chief residents and program directors are on board to integrate more global child health opportunities into post-graduate training programs. However, barriers such as lack of time in an already dense curriculum , and potentially a lack of local experts organised to deliver seminars and training sessions may provide real and important obstacles. The development of standardised global child health modules, which could be incorporated into formal training academic half days, presents an opportunity.
Further practical questions are raised by this study: How can clinical exposure to global health issues be maximised to enable new paediatricians to better meet the needs of new immigrants and refugees? How can paediatric resident exposure to global health through electives be better supported and funded and balanced with proper pre-departure training needs and ethical practices while overseas? How can the outcomes of GHEs be better quantified?
There is also a larger question: What is the relevance of our findings for other resource-rich and resource-poor countries? While our study focused on Canadian trainees, the findings contribute to a conversation around what it means to be a global citizen.  What would be the potential contribution of standardised education in global child health issues in the training of paediatricians?
The first step towards improving the health of children worldwide is to ensure that paediatricians receive a minimum basic level of education in the health issues affecting children globally. Could laying the foundations for a global perspective in child health in Canada result in a greater level of expertise, engagement and advocacy around these issues? Could the ripple effect from that culture change ultimately improve health education, outcomes and equity worldwide? Although this seems like a huge leap to make from such a small study, medical educators worldwide are calling for educational reform that promotes a common set of values around social accountability, and our findings show our readiness to embrace these changes and to take steps towards transformative action.
The landscape of global health training in North America has continued to evolve, even since the time this survey was conducted. There have been publications regarding the importance of global health training for paediatricians, including curriculum guidelines from the American Academy of Paediatrics.  The results of a 2006-2007 survey of paediatric residency programs in the United States, Puerto Rico and the Caribbean showed that 47% had formally incorporated global health into their training curricula. 
On the basis of the results of our survey, a global health curriculum committee, which is comprised of global health practitioners from eight Canadian centres, initiated the development, evaluation and dissemination of formalised modules to help residents develop a foundational knowledge and awareness of global child health issues. The modules were launched nationally in 2011 and are incorporated into academic half days at most Canadian paediatric training programs, and at other centres internationally. The modules and accompanying trainer manual are available for free to all Canadian Paediatric Society (CPS) members at: http://www.cps.ca/en/curriculum. Non-members can purchase a copy for the cost of printing and mailing.
| Acknowledgements|| |
The authors would like to recognize the support of the Children's Hospital of Eastern Ontario Research Institute in the form of a resident research grant.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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