|Year : 2014 | Volume
| Issue : 1 | Page : 55-58
Think global, act local: Medical students contextualize global health education
George M. Ibrahim1, Shawn Hoffart2, Russell A. Lam3, Evan P. Minty4, Michelle Theam Ying5, Jeffrey P. Schaefer6
1 Division of Neurosurgery, University of Toronto, Ontario, Canada
2 Chronic Disease Management, Alberta Health Services, Calgary, Canada
3 Department of Pediatric Emergency Medicine, University of Calgary, Calgary, Canada
4 Department of Internal Medicine, University of Calgary, Calgary, Canada
5 Department of Anesthesia, University of Alberta, Alberta, Canada
6 Department of Internal Medicine, University of Calgary; Medical Education Office, Rockyview General Hospital, Calgary, Alberta, Canada
|Date of Web Publication||11-Jun-2014|
Dr. George M. Ibrahim
Division of Neurosurgery, Hospital for Sick Children, 1503-555 University Ave., Toronto, ON, M5G 2R2
Source of Support: None, Conflict of Interest: None
Background: There is considerable heterogeneity in the extent to which global health education is emphasized in undergraduate medical curricula. Here, we performed an exploratory analysis to test the hypothesis that exposure to global health education may influence the attitudes of medical students toward the treatment of local vulnerable patient populations. Methods: All pre-clerkship students at an urban Canadian university were invited to attend a voluntary global health education session on challenges in treating human immunodeficiency virus (HIV) in the developing world. Those who attended as well as those who did not completed pre- and post-session surveys measuring willingness to treat patients with HIV and related attitudes. A repeated measure analysis of variance (ANOVA) was performed to assess the effect of the intervention on attitudes toward locally affected populations. Results: A total of 201 (81.4%) and 143 (58.3%) students completed the pre- and post-session surveys, respectively. Students who scored their willingness to treat patients with HIV within highest 10% of the scale on the pre-session survey were excluded from the analysis to account for a ceiling effect. On repeated measure ANOVA, willingness to treat local patients with HIV increased significantly following the session (P < 0.01). Students intending to attend the session also reported a greater propensity to treat patients with HIV than those who did not (P = 0.03). Discussion: In this exploratory study, we find that following exposure to a global health lecture on the challenges of HIV in the developing world, students possessed more favorable attitudes toward the treatment of marginalized local patient populations, a finding that may be exploited in undergraduate and continuing medical education.
Keywords: Attitudes, global health education, HIV/AIDS, medical students
|How to cite this article:|
Ibrahim GM, Hoffart S, Lam RA, Minty EP, Ying MT, Schaefer JP. Think global, act local: Medical students contextualize global health education. Educ Health 2014;27:55-8
| Background|| |
Global health education is increasingly recognized as an important focus in undergraduate medical education as well as in continuing medical education. Exposing medical professionals and students to global health topics may better prepare them for culturally sensitive patient encounters,  global pandemics  and raise awareness of inequities in access to healthcare in the developing world. Importantly, medical students themselves consistently seek out global health opportunities and express an interest in greater exposure to these topics in undergraduate medical education.  There are, however, numerous challenges to the implementation of an undergraduate global health education strategy, including the limited amount of didactic teaching time available relative to the vast amount of knowledge that must be covered. Furthermore, limited studies have examined the benefits or role of global health education in continuing medical education. Exposing medical students and health professionals to global health topics remains a low priority for many training programs.
The dichotomy between 'local' and 'global' education, however, is based on the premise that the two contexts are mutually exclusive. Contrarily, it has been suggested that greater exposure to global health education in medical school is associated with an increase in learners' interest in working with underserviced local communities.  Here, we tested the hypothesis that the attitudes of medical students toward treating local populations are influenced by learning about those affected by the same disease in a global context. Attitudes toward treating patients with human immunodeficiency virus (HIV) were evaluated before and after a voluntary session on the burden of HIV in Africa, delivered by a recognized leader in the field. To our knowledge, this is the first study to directly evaluate the extent to which medical students contextualize global health teaching and to which it translates into greater propensity to treat local vulnerable populations.
| Methods|| |
Study Design and Populations
All pre-clerkship (first and second year) students at an urban Canadian university were invited to attend a voluntary seminar by a world-renowned speaker on the subject of the burden of HIV in the developing world. The content of the 2 h lecture was exclusively centered on challenges in access to treatment and the provision of care to individuals affected by HIV in Africa. All students, whether they attended or not, were asked to anonymously complete a pre- and post-session questionnaire regarding attitudes toward treating North American patients with HIV. The former took place one week prior to the scheduled lecture, while the latter was completed approximately 2 weeks following the lecture date. The survey instrument was composed of multiple statements with 7-point Likert-scale responses designed by Carter and colleagues for the same objective as our study.  The instrument gauged willingness to treat patients with HIV, as well as related attitudes. A composite score for each category was derived by averaging the ratings of all questions for each topic. The University Conjoint Research Ethics Board approved this project and use of the survey instrument.
The primary outcome of our study was pre- and post-differences in the willingness to treat patients with HIV between attendees and non-attendees, as measured by the survey instrument. We accounted for a ceiling effect by excluding students who rated themselves within the top 10% of the scale for willingness to treat patients with HIV on the pre-session survey (i.e., a score greater than 6.3 out of 7). This was performed because increases in attitudes for students who already rate themselves at the higher end of the scale cannot be measured by the survey instrument. We performed a repeated measure analysis of variance (ANOVA) in order to determine significance of desired outcomes, while adjusting for covariates. In the statistical model, the pre-post sessions and attendance were considered independent variables. The students' age, sex and year of study were also included as covariates in the model. Within-subject (pre-post session and attendance) and between-subject (age, sex, class, attendance) main effects and interactions were identified. All analysis was performed using R statistical software.
| Results|| |
A total of 201 (81.4%) and 143 (58.3%) completed the pre- and post-session surveys, respectively [Table 1]. On the pre-session survey, the mean score for willingness to treat patients with HIV (± standard deviation) was 6.19 ± 0.73 out of a possible 7. Those who indicated an intent to attend the global health session possessed a greater propensity to treat patients with HIV than those who indicated that they did not intend to attend the lecture (6.37 ± 0.63 vs. 6.01 ± 0.79; P < 0.01). To adjust for a ceiling effect, we excluded subjects who rated their willingness to treat patients with HIV greater than 6.3 out of 7 on the pre-session survey (upper 10% of survey instrument; 71 subjects); therefore, 72 students with completed pre- and post-session surveys were included in the analysis.
|Table 1: Demographic information of 141 medical students completing both the pre- and post-session survey|
Click here to view
Students who attended and did not attend the lecture rated their willingness to treat local patients with HIV as 5.70 ± 0.41 and 5.51 ± 0.61 out of a possible 7 on the pre-session survey, respectively. On the post-sessions survey, students who attended and did not attend rated themselves 6.0 ± 0.51 and 5.60 ± 0.70, respectively. On repeated measures ANOVA [Table 2] and [Figure 1], the main effect of the intervention was significant (F (1,70)=8.37; P < 0.01), indicating that following the lecture, students' expressed a stronger propensity to treat local populations with HIV. There was a near significant interaction between attendance and pre-post session scores (P < 0.1). Independent of the pre-post session effect, students who attended the session also rated themselves as significantly more likely to treat patients with HIV (F (1,67)=4.75; P = 0.03).
|Figure 1: Interaction plot for analysis of variance. Interaction plot showing increase in willingness to treat patients with HIV post-session compared with pre-session and greater propensity to treat patient with HIV among individuals who attended the session|
Click here to view
|Table 2: Repeated measures ANOVA for 72 subjects included in the analysis|
Click here to view
| Discussion|| |
This exploratory analysis found that while students who indicated they would attend the voluntary global health session on HIV in the developing world were already more willing to treat patients with HIV locally, the pre-post within-subject effect of the lecture was significant, suggesting that their willingness to treat local patients with HIV increased following the intervention (P < 0.01). These data provide an important first demonstration that medical students may contextualize their global health education experience and that such teaching may translate into greater propensity to treat local vulnerable communities.
This study adds to the increasingly prominent body of literature demonstrating that the inclusion of global health education in undergraduate medical curricula is both beneficial and practical. We tested this hypothesis following a lecture on HIV in the developing world for several reasons. First, it has been previously shown that medical students were unwilling to treat patients with HIV and have stated their education had not adequately prepared them to treat this patient cohort.  Second, local populations affected by HIV continue to face social stigma and significant barriers in access to healthcare.  In fact, certain HIV-associated attitudes may not have changed among matriculating medical students over a 12-year follow-up period.  Third, HIV is present both in the developing world (i.e., in the global context), as well as in the developed world (i.e., the local context), however, the nature of and stigma surrounding the disease are highly discrepant between these two contexts. Based on our findings, we speculate that the phenomenon of the contextualization of global health teaching may also generalize to other contextually relevant topics. We also suspect that benefits may be seen when global health education is integrated into continuing medical education strategies.
Insights may be gleaned from the behavioral sciences as to why students who are engaged in a lecture about communities elsewhere experience an increased willingness to help local communities. A recent meta-analysis of studies that have examined how empathy can be taught to medical students identified various effective types of interventions such as patient narrative or interviews, writing interventions, drama, communication skills training, problem-based learning, interpersonal skills training and experiential learning.  It is possible that global health education may encompass several of these domains and result in increased empathy among medical students. Importantly, global health need not necessarily refer exclusively to the developing world. We speculate that the observed effect may be related to exposure about health-related issues in a healthcare system other than that of the home country.
The contextualization of illness is an important and interesting finding with implications for medical education. It has been previously reported in a large review of 522 medical students and 166 residents that international health electives broaden the trainees' skills and knowledge, and are associated with career choices to enter primary care or work with underserviced communities.  Chiller and colleagues found that American students those who embarked on international electives were more likely to work in a resource-poor area of the United States at 2-year follow-up  and Haq and colleagues found that similar cohorts report positive influences on awareness of cultural and socioeconomic determinants of health and careers working with underserviced communities.  Our study adds meaningfully to previous findings. Using longitudinal cross-sectional survey methodology, we show that attitudes toward the treatment of patients change following exposure to global health education. We therefore propose that future studies should explore the effect of global health education on medical students' willingness to treat underserviced patients and their attitudes toward illness within undergraduate medical education curricula.
The primary limitations of the current study is that our intervention consisted of a very brief educational intervention and that our outcome was the students' self-reports of their willingness to treat patients with HIV. It is unclear whether the long-term effects of this intervention will remain for the students. Furthermore, information on other potential covariates was not collected, such as previous international training, experience and cultural background. Influence from response bias may have affected our results. Future work is needed to identify how and to what extent global health education should be emphasized and to measure the long-term effects of its implementation.
| Conclusion|| |
Global health education may modify medical students' attitudes toward local vulnerable patient populations. These findings suggest that medical students may contextualize the global health teaching. Further studies exploring how the integration of global health education in undergraduate medical curricula affects the interaction of medical students with local vulnerable populations are indicated. Global health education addressing global health themes can be effective to raise students' awareness and engagement with local communities.
| References|| |
|1.||Goldner BW, Bollinger RC. Global health education for medical students: New learning opportunities and strategies. Med Teach 2012;34:e58-63. |
|2.||Bateman C, Baker T, Hoornenborg E, Ericsson U. Bringing global issues to medical teaching. Lancet 2001;358:1539-42. |
|3.||Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: A call for more training and opportunities. Acad Med 2007;82:226-30. |
|4.||Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on U.S. and Canadian medical students and residents: A literature review. Acad Med 2003;78:342-7. |
|5.||Carter D, Lantos J, Hughes J. Reassessing medical students' willingness to treat HIV-infected patients. Acad Med 1996;71:1250-2. |
|6.||Kopacz DR, Grossman LS, Klamen DL. Medical students and AIDS: Knowledge, attitudes and implications for education. Health Educ Res 1999;14:1-6. |
|7.||Vargas RB, Cunningham WE. Evolving trends in medical care-coordination for patients with HIV and AIDS. Current HIV/AIDS Rep 2006;3:149-53. |
|8.||Hoffart S, Ibrahim GM, Lam RA, Minty EP, Theam M, Schaefer JP. Medical students' attitudes towards treating patients with HIV: A 12-year follow-up study. Med Teach 2012;34:254. |
|9.||Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. Teaching empathy to medical students: An updated, systematic review. Acad Med 2013;88:1171-7. |
|10.||Chiller TM, De Mieri P, Cohen I. International health training. The Tulane experience. Infect Dis Clin North Am 1995;9:439-43. |
|11.||Haq C, Rothenberg D, Gjerde C, Bobula J, Wilson C, Bickley L, et al. New world views: Preparing physicians in training for global health work. Fam Med 2000;32:566-72. |
[Table 1], [Table 2]