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Assessment, Evaluation and Implementation of International Health

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Assessment, Evaluation and Implementation of International Health ...

    International Health Undergraduate Medical/Dental Curriculum

    Development Project, University of Alberta

Collaborators: Anne Fanning MD, Michael Bullard MD, Lory Laing PhD, Ehor Gauk

    MD, Peter Crockford MD, Lola Baydala MD, Chris Cheeseman PhD, Dee Hoyano,

    Bernard Sowa, James Felix

Report Submitted by:

James Felix

    Medical Class of 2003

    University of Alberta

    June 26, 2010

    Table of Contents

    Introduction……………………………………………………………………………...3 Mission Statement…………………………………………………………………….…4 Objectives………………………………………………………………………………..4 Methods……………………………………………………………………………….…5 Results…………………………………………………………………………………...7 Conclusions and Future Goals……………………………………………………….….11 Acknowledgements……………………………………………………………………..12

Appendices

    Appendix A Year 1 and 2 Curriculum Survey……………………………….….…..…13

     Introductory Block…………………………………………………………….…14

     Infection/Immunity/Inflammation (III) Block……………………………...……17

     Endocrinology and Metabolism……………………………………………….…21

     Cardiovascular/Pulmonary/Renal……………………………………………..…25

     Gastroenterology and Nutrition………………………………………….………28

     Reproduction/Urology………………………………………………………...…34

     Muscoloskeletal/Rehabilitation Medicine/Rheumatology/Dermatology……...…36

     Neurosciences and Special Senses……………………………………………….41

     Oncology…………………………………………………………………………46

    Appendix B Opportunities for IH Enrichment…………………………………………49

     Introductory Block…………………………………………………………….…50

     Infection/Immunity/Inflammation (III) Block………………………………...…51

     Endocrinology and Metabolism……………………………………………….…52

     Cardiovascular/Pulmonary/Renal……………………………………………..…53

     Gastroenterology and Nutrition……………………………………………….…55

     Reproduction/Urology……………………………………………………...……56

     Muscoloskeletal/Rehabilitation Medicine/Rheumatology/Dermatology…...……57

     Neurosciences and Special Senses………………………………………….……58

     Oncology…………………………………………………………………………59

     Dentistry………………………………………………………………………….60

    Appendix C Block Coordinator Email…………………………………………………61

Appendix D Sample International Health Enriched Cases/Presentations in Development

     Contraception……………………………………………………………….……63

     HIV and Pregnancy………………………………………………………………65

     The Politics of Cancer……………………………………………………………66

    Appendix E International Health Curriculum Core Content…………………………..68

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Introduction

    Regardless of the type or location of their clinical practice, physicians and dentists alike are often challenged to meet the needs of the disadvantaged. Death, disability, personal

    health risk factors and environmental health hazards are not distributed evenly or

    randomly in society. There is a systematic pattern; it may be said that death is a social

    disease, and that there is a heavier burden of illness and exposure to health hazards in the more socially disadvantaged groups. Added to this is the fact that health services are

    often least accessible and of poorest quality where they are most needed. This is true in

    Canada and around the world. We can enhance our ability to solve local health problems

    and meet the needs of our own patients by taking a global perspective.

We are encouraging the development of responsible global citizens who understand the

    burden of disease, and maldistribution of resources. Since only a few physicians or

    dentists will choose a career in international health, introducing a global health

    perspective into the undergraduate curriculum needs to be both interesting and relevant.

Key issues include: developing responsible global citizens (burden of disease, third world

    poverty, and appropriate resource utilization), the impact of travel and translocation on

    disease transmission, the impact of culture and custom on medical expectation, and

    recognizing different approaches to similar problems.

While undergraduate medical and dental training leads to a wide variety of post-graduate

    training opportunities, the majority of students are anxious to participate in clinical

    patient care. To that end, it is important to introduce international health into the

    curriculum in a clinical context.

Why do we need International Health (IH) in the undergraduate medical/dental

    curriculum?

    1. Health issues in other regions of the world are no longer isolated to those locations.

    Modern patterns of travel, transport and migration can quickly spread a regional

    disease globally.

    2. Intercultural sensitivity and awareness is important for all physicians, especially

    given the increasingly multicultural character of Canadian society. Specific skills and

    knowledge need to be developed, rather than simply acknowledging the existence of

    cross-cultural issues.

    3. Students with interest in working in developing areas need to have basic knowledge

    about the kinds of problems and conditions they will encounter in practice. They may

    go to developing areas at any point in their training as medical students or residents,

    or as new graduates or experienced clinicians.

    4. An awareness of global issues is becoming a fundamental part of a comprehensive

    education in our society. As a school and university we are interested in developing

    well-rounded, knowledgeable citizens as well as physicians.

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    5. The principles of dealing with disadvantaged populations can be very similar in both

    a local and an international context. Studying examples of health delivery systems in

    different countries helps to critically looks at our own local methods

What are the Benefits and Advantages of IH education?

    1. An IH curriculum will raise interest in the student population and encourage students

    to pursue electives, research or clinical work in developing areas. 2. IH will stimulate students to develop research interests in areas of international

    disease burden.

    3. IH issues are an opportunity to review diseases already presented in the curriculum,

    and offer a different perspective on the problem, investigation or management

    strategies.

    4. IH material offers variety and human interest in the presentation of course content.

    The International Health Initiative identified education as its first priority for increasing awareness of the global burden of disease, health problems and priorities. To that end a

    summer 2001 project funded by the faculty education advisory committee examined the

    existing curriculum, identified essential elements and proposed enrichment examples.

Mission Statement

The International Health Curriculum Development Project identifies the following as its

    mission statement:

To encourage and enrich the international health content within undergraduate medical

    and dental education at the University of Alberta with the goal of producing globally

    informed and sensitive health professionals able and willing to provide enlightened care

    to disadvantaged populations and patients.

Objectives

The International Curriculum Development Project has be designed:

    1. To determine the essential elements of international health curriculum content (i.e. IH

    core content)

    2. To identify international health knowledge being taught presently to first and second

    year medical/dental students.

    3. To identify places in the curriculum where international health issues could be

    addressed appropriately, enhance the existing content, and add interest for the

    students.

    4. To develop a comprehensive plan to introduce the international health core content

    throughout the curriculum and develop a number of sample teaching modules, or

    instruments, to assist the teachers.

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Methods

To achieve the aforementioned objectives the following methods were used.

Objective 1: IH Core Content

    To develop the essential elements of international health curriculum several resources

    were researched and discussed with the collaborators. Resources consisted of:

1. Collaboration with authors

    2. World Health Organization (WHO) health topic list at www.who.int

    3. The American Medical Students Association (AMSA) at www.amsa.org

    4. Academic Medicine Vol 68 No.6 1998 pp. 596-598 (Heck, et al.)

    5. International Health Medical Education Consortium at www.ihmec.org

Objective 2: Identification of IH knowledge being presently taught in the

    undergraduate medical/dental curriculum

    A manual search of the Year 1 and 2 undergraduate medical/dental curriculum lecture

    handouts was completed. The curriculum was searched for mentions of IH content that

    correlated with the developed IH Core Content. The following parameters were

    quantified:

    1. Number of lecture hours/lab hours/small group hours per block

    2. Number of “International Health Mentions” throughout the block.

    An IH Mention is a mention (in written form on a lecture handout) of a topic

    reflective of the IH Core Content.

eg. Endocrinology Block: Pathophysiology of Obesity Lecture

    - IH Mention: “Obesity is far more common on Western Samoa and several other

    Pacific islands” Source: Obesity Pathophysiology Lecture Notes 2000, T.

    Kieffer

eg. Gastroenterology and Nutrition Block: Pediatric Diarrhea and Infectious Colitis

    - IH Mention: “3-5 billion cases of acute diarrhea per year worldwide” Source:

    Lecture Notes, 2001, Pediatric Diarrhea and Infectious Colitis, L. Smith

This method of searching the curriculum had several limitations. To be quantified, IH

    topics needed to be typed directly onto the lecture handout. Hence, spoken mentions of

    IH content during a lecture could not be quantified. The search was by hand and

    therefore subject to human error. The weighting of an IH topic could not be accurately

    assessed using this method. Because this method only quantifies “mentions” of IH, it

    does not differentiate between IH specific topics (such as an entire TB lecture) or merely

    IH mentions of interest (such as the prevalence of a particular genetic disease in a certain

    ethnic background).

Objective 3: Identification of areas within the curriculum where international

    health could be addressed appropriately

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    Upon surveying the existing curriculum for IH Core Content, lectures which were felt could be enriched by IH content were flagged and topical examples were researched using mainly using the World Health Organization (WHO) website at www.who.int

    Objective 4: Development of a plan to introduce IH content throughout the curriculum and development of sample teaching modules

    Based on the identification of IH areas of enrichment a plan was outlined as to how to present IH material through specific lectures to discuss overarching issues and enrichment items to include in already scheduled lectures/small group sessions.

    For each block, and IH enrichment package was created, illustrating the IH content presently contained within the block as well as examples of possible IH enrichment areas. These packages were presented to the block coordinators either in a face to face meeting or through a telephone introduction and follow up email for those whom we (Michael Bullard MD, and James Felix) were unable to meet with. The block coordinators level of enthusiasm towards IH was noted, was well as their level of preparedness for development of IH educational materials.

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Results

1. IH Core content

    From our research, a set of ten IH core content topics were identified as the essential

    components of international health education at the undergraduate level (Table 1).

Table 1: International Health Core Content

    _________________________________________________________

    _

    International Health Undergraduate Medical

    and Dental Training Core Content

1. Global burden of disease

    a. Define disease burden and terms and definitions to help stratify needs resources

    and level of development.

    b. Disease burden (diseases with significant penetration, especially if preventable

    and/or treatable, and high in societal cost).

    c. Cost to the society (monetary, loss productivity, individual suffering, comparative

    disparity between 1st and 3rd world (rich and poor countries) in ability to pay

    'market" costs)

2. Determinants of health (inequities, disadvantaged populations, over population, basic

    needs for survival, community health, [political /societal stability], sanitation, etc.).

    a. Basic epidemiology

    b. Demographics: the relationship of age, income, resources, health spending,

    literacy, etc., to health and disease

    c. Overview of health indicators such as infant mortality, incidence, prevalence,

    quality of life, and comparison of these indices among sites in Canada and

    developing countries

3. Basic Health Interventions/Services (immunizations and communicable disease

    control, education [public/health care providers/politicians, varying role of physicians

    and other health care workers, essential drugs, laboratory diagnosis in developing

    countries)

4. Maternal/child health and family planning and population programs (maternal

    mortality, access to safe abortion, contraception, women’s rights, breastfeeding and

    marketing of breast milk substitutes, etc)

5. Diseases of Specific International Importance

    a. HIV / AIDS, TB

    b. Malaria, diarrheal diseases, childhood pneumonia

    c. Malnutrition

    d. Trauma

    6. Cross cultural issues (medical beliefs, traditional healers/healing, religious beliefs,

    language and communication, family structures and decision makers, gender, age)

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    and how they impact on medical encounters and doctor-patient relationships in

    Canadian practice.

    7. Health Care Organization(s) (comparison of systems, policy making resource

    allocation, Aid agencies [Red Cross, WHO, other NGOs]).

    8. Travel Medicine (preparation/risk for travelers, investigation/management of the

    returning traveler)

    9. IH Ethics (government - government assistance [history, politics, economics],

    responsible global citizenry [multinationals, profit at all costs pharmaceutical

    companies, tobacco companies, etc], individual learner I provider responsibility,

    international research [should provide benefit to population being tested] and

    individual and organizational responsibility for degradation of the environment

    (associated health risks) and consumption of non-renewable resources.

    10. Response to International Disaster (anatomy and comparisons of disasters

    [earthquakes, weather calamities, war, famine, etc.], stages of need and potential

    responses [initial survival strategies by the collective victims and local medical/rescue

    systems, search and rescue units, immediate resource needs, national and

    international ongoing support, rebuilding], different national responses, resource

    requirements, Medicins Sans Frontieres

    __________________________________________________________

2. Identification of IH knowledge being presently taught in the undergraduate

    medical/dental curriculum

After surveying the blocks for IH content it was found that the blocks contained between

    2 to 69 mentions of IH content with the average being 25.5 IH mentions (see Table 2).

    Table 2: Undergraduate Medical/Dental Curriculum and IH content

Introductory 6 58.5 11 14 83.5 7.0% 15 Infection/Immunity/ 7 103.5 14.5 11 129 10.9% 69 Inflammation Endocrinology and 6 82 5 17 104 8.8% 22 Metabolism Pulmonary 5 42 37 22 101 8.5% 23 Cardiovascular 5 49 21 22 92 7.8% 2 Renal 4 39 4 18 61 5.2% 7 Gastroenterology and 6 69 17 24 110 9.3% 51 Nutrition Reproduction/Urology 7 81 7 22 110 9.3% 29 Musculoskeletal/ 7 101 18 17 136 11.5% 11 Rehabilitation/ Rheumatology/Dermatology Neurosciences and Special 11 161 34 10 205 17.3% 26 Senses/Psychiatry Oncology 4 36 0 17 53 4.5% 19 TOTALS 68 821.5 168.5 194 1,184.5 100.0% 274

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Each mention of IH within a block lecture was documented and quantified. The

    complete curriculum survey may be seen in Appendix A.

3. Opportunities for IH Enrichment

    Upon completion of the curriculum survey, topics deemed to be relevant for IH

    enrichment were summarized for each block. These topics are presented in Appendix B.

    The topics were obtained from a survey of the Health topics from A to Z from the World

    Health Organization website (www.who.int) and from collaboration with authors.

4. Meeting with Block Coordinators

IH “packages” for each block were prepared. These packages consisted of 1) a one-page

    overview of the project 2) the IH Core Content 3) a complete Block curriculum survey of

    IH content 4) Opportunities for IH Enrichment and 5) Examples of types of topics for IH

    enrichment. The examples were drawn largely from various sections of the WHO

    website).

After identifying areas for IH enrichment, meetings were organized with block

    coordinators to 1) present our block package and ideas for enrichment 2) determine level

    of coordinator’s interest in IH enrichment 3) assess coordinator’s preparedness to develop

    IH teaching materials.

Five block coordinators were met with directly by Dr. Michael Bullard and James Felix.

    Phone calls were made to the other coordinators to give them a general overview of the

    IH Project. These phone calls were followed by an email (Appendix C) to the

    coordinators with out IH Block Package attached.

As of August 24, 2001, Table 3 summarizes our contact with each of the block

    coordinators.

Legend:

    Bold/underline = met with directly

    Underline = spoke with directly on the telephone

    Italics = voice message left but haven't called back

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     Table 3: Block Coordinator Contact List

    Block Name Coordinator(s) Introductory Block David Begg

    Bruce Stevenson

    Norma Leonard (Genetics)

    Infection/Immunity/Inflammation Geoff Taylor

    Laurie Mereu Endocrinology

    Pulmonary/CardiologyNephrology

    David Rayner

     Alan McMahon (Nephrology Only)

    Karen Madsen Gastroenterology

     Mang Ma Reproduction/Urology

    Reproduction Valerie Capstick

    Urology Gerry Todd MSK/Rehab/Rheum/Derm

    Orthopedics David Reid

    Physical Medicine an Rehabilitation Mario DiPersio

    Joanne Homik Rheumatology

    Andrew Lin Dermatology

    Neurosciences and Special Senses

    Neurology Dorcas Fulton

    Neuroanatomy Anil Walji

    Psychiatry Douglas Spaner

    Nicholas Coupland

    Garry Drummond Ophthalmology

    Oncology Martin Palmer Dentistry Wayne Raborn POMD (overall POMD coordinator) Lory Laing

     Neuro David Cook

     Oncology Martin Palmer

4. Plan for IH Enrichment

Based on the feedback from block coordinators, a plan was made for IH enrichment in

    the undergraduate medical/dental curriculum.

The plan calls for a new one hour Introductory Block lecture, an existing four hour

    session in Infection/Immunity/Inflammation (III) Block (two hours classroom and two

    hours small group discussion), and a final two hour session in Practice of Medicine and

    Dentistry (POMD) during year 2 as bridging and overview sessions to ensure important

    IH concepts are understood and appreciated.

It was proposed that other relevant topics be addressed through enrichment items (eg.

    questionable business ethics with Nestle promoting baby formula in countries where

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