Preparing Today’s Students for Tomorrow’s Global Health Workforce: What they Need to Know

Jean Boucher PhD, RN, ANP-BC Michele P. Pugnaire, MD

With the rise of the globally interconnected millennial generation, it’s no surprise that today’s health profession students are increasingly engaged in global health as part of their studies, and for some, their future career plans. Nation wide, about one-third of students entering pre-medical programs have participated in an international volunteer experience, with two-thirds of enrolled medical students expecting to participate in global health experiences during medical school.(1) At UMass Chan Medical School, student participation in global health programs rose two-fold from 33.8 percent in 2004 to 67percent in 2011.(2) Not unexpectedly, Tan Chingfen Graduate School of Nursing students are increasingly seeking out opportunities to participate in global health initiatives . This rising demand for international programs has fueled the expansion of UMass Chan’s global health offerings for School of Medicine and Graduate School of Nursing students and has accelerated the development of high-quality experiences consistent with educational standards in global health.(2,3,4,5,6,7)

Our contribution to this issue of Worcester Medicine offers an evolutionary perspective on global health education and how UMass Chan is best preparing today’s students for our future global health workforce. Our featured program is the Dominican Republic Batey Health Initia-

tive (DR-BHI), an interprofessional global health program for UMass Chan students and faculty in the School of Medicine and Graduate School of Nursing. Our DR-BHI overview describes four examples of challenges and lessons learned in global health education that illustrate how our students are actively learning four core precepts of best-practice global health:

• community engagement and empowerment

• cross cultural awareness and humility

• interprofessional teamwork and collaborative practice

• advocacy for sustainable development of communities being served

Challenge: limitations of the shortterm medical mission model

Like many global health experiences, the DR-BHI, based in La Romana, Dominican Republic, is a short-term (one week) experience in global health (STEGH). Like other STEGH’s, our twice-yearly visits to the Dominican Republic initially focused on “mobile” ambulatory clinics based in remote communities know as bateyes (home to underserved Haitian migrant cane workers and families) with a key goal of hypertension control. With twice-yearly visits, our team experienced the shortfalls of STEGH models with limited continuity, follow-up and longitudinal engagement, and the risk of doing more harm than good for the communities we served. Addressing these limitations, we partnered with our host partner to designate two bateyes that we would serve long-term to promote continuity and community engagement. We also partnered with a local La Romana-based NGO (non-governmental organization) to support two additional hypertension clinics per year, so clinics were offered on both bateyes every three months rather than twice yearly. To assess the effectiveness of our continuity-based model, DR-BHI medical and nursing students collaborated with the bateyes, host sponsor, and partner NGO to study hypertension control. Study outcomes demonstrated improved systolic blood-pressure control following implementation of the continuity model. Lesson learned: Establishing continuity of care and longitudinal engagement with communities requires community-based partnerships and collaborative practice with local healthcare organizations.

Challenge: building local community workforce capacity to best serve the needs of local populations

With our continuity-based hypertension program in place, our batey-based health workers (or “promotoras”) were empowered to participate more actively in blood-pressure monitoring and batey-based care of their hypertensive patients. To advance the promotoras’ skills, the DR-BHI and our local sponsor overseeing the promotora program jointly established a promotora blood-pressure training program to build capacity in the promotora workforce and empower them as active partners in our hypertension management program. Both the promotoras and host sponsor endorsed the program, with the sponsor now supplying the promotoras with blood-pressure cuffs and ongoing training. Building on the success of this training model, additional promotora training has been offered in malnutrition screening, HIV prevention, and wound care. This training model was a collaborative effort with promotoras, the host sponsor, and DR-BHI medical and nursing students, with all sessions featuring interprofessional teambased care. Lesson learned: Building local community capacity is best achieved when responding to the host community’s needs through relationship building, empowerment, and interprofessional teamwork.

Challenge: unanticipated roadblocks limiting on-the-ground service commitments abroad

Pandemic-related travel shutdowns threatened the sustainability of the DR-BHI’s hypertension program and promotora training. To sustain the clinics, during the pandemnic funds for DR-BHI travel were reallocated to our NGO partner to support hypertension clinics every three months . For on-the-ground promotora training sessions, we partnered with our host to support real-time DR-BHI training sessions via Zoom. Our sponsor provided technology infrastructure and safe transport for promotoras to attend hospital-based Zoom sessions. We also recognized the reliance of promotora training on DR-BHI support. To promote long-term sustainability, we forged a new partnership with our host and two other affiliated organizations serving the bateyes to establish a train-the-trainers program, empowering local physicians to provide promotora training, thereby establishing a sustainable model for long-term promotora training without reliance on ongoing DR-BHI support. Lesson learned: Sustainability of on-the-ground service commitments requires partnerships, capacity-building, and empowering local individuals, programs, and organizations.

Challenge: cultural effectiveness and humility as core values and skills for global health teams

It is widely recognized that ethical principles of cultural awareness and humility are foundational in preparing for global health experiences. Consistent with this understanding, DR-BHI requires cross-cultural awareness and humility training as part of pre-departure preparation. Our training in this area continues to evolve and is informed by the experiences of our students and feedback from DR-BHI participants including, our local partners. Through this iterative process, peer-topeer engagement has emerged as the backbone of our cross-cultural awareness training. With an increasingly diverse student body, DR-BHI students represent an expanding range of cultural, racial, ethnic, economic, and linguistic backgrounds. Given this rich diversity, students directly experience cross-cultural awareness through group interactions, allowing them to both inform and teach each other. Structuring time for peer-to-peer interaction as part of pre-travel preparation and through daily debrief sessions while in the Dominican Republic, have proven effective in promoting both cross-cultural awareness and humility among our learners. Another important contributor to cross-cultural development has been our local DR-BHI program advisor, a Haitian Dominican from La Romana who is now a United States citizen residing in Worcester. He serves many roles: guest lecturer, consultant on Dominican Republic-based initiatives, and reviewer of project materials to ensure cultural and linguistic alignment with our local based partners. Our advisor also serves as “culture broker,” assisting us in better understanding and collaborating with our Dominican Republic-based colleagues. Lesson learned: Cultural awareness and humility training can be promoted through the diversity of representation among student learners, along with the engagement of individuals representing the communities and cultures being served.

Building on these lessons learned, we continue to expand and enrich global health education to best prepare today’s students for tomorrow’s global health challenges. Now is also the time to nurture and support today’s students as the teachers and role models for future global health education who will teach the rising generation of new student learners. The need for high-quality, best-practice global health education has never been greater as we prepare to pass the baton to today’s students as our global health educators, workforce, and leaders of the future. +

Jean Boucher PhD, RN, ANP-BC is professor of nursing and medicine and director of the nursing practice PhD program in the Tan Chingfen Graduate School of Nursing at UMass Chan Medical School.

Michele P. Pugnaire, MD isprofessor emeritus, Office of Educational Affairs in the T.H. Chan School of Medicine atUMass Chan Medical School

References

1. Melby, Melissa K., et al. “Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): ethical principles to optimize community benefit and learner experience.” Academic Medicine 91.5 (2016): 633-638.

2. 2011 GQ Medical School Graduation Questionnaire Individual School Report University of Massachusetts Medical © 2011, Association of American Medical Colleges.

3. Guidelines for Premedical and Medical Students Providing Patient Care During Clinical Experiences Abroad. Approved by the AAMC GSA Steering Committee on February 25, 2011 available at https://www.aamc.org/news-insights/packing-ethicsmedical-students-global-health-trips. Accessed as of November 11, 2022.

4. Jogerst, Kristen, et al. “Identifying interprofessional global health competencies for 21st-century health professionals.” Annals of global health 81.2 (2015): 239-247.

5. DeCamp, Matthew, et al. “Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper.” Annals of Internal Medicine 168.9 (2018): 651-657.

6. Douglas MK, Reencounter M, Pacquiao DF, et al. Guidelines for Implementing Culturally Competent Nursing Care. J of Transcultural Nurs. 2014; 25(2): 109–121.

7. National Academy of Medicine. A framework for educating health professionals to address the social determinants of health; 2016. Available at: https://www. nationalacademies.org/ hmd/~/media/Files/ Report%20Files/2016/ SDH-Resources/ SDHeducation-RiB.pdf. Accessed December 26, 2018.