The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions

The American Journal of Tropical Medicine and Hygiene, Jan 2017

Global health education has been expanding rapidly and several universities have created an undergraduate major degree (bachelor's degree) in global heath or global health studies. Because there are currently no national guidelines for undergraduate degrees in global health, each of these programs was developed along individual lines. To guide the development of future global health majors, we conducted a systematic review of undergraduate majors in global health. We identified eight programs and invited program directors or representatives to a symposium at the Consortium of Universities for Global Health 2016 conference to review their existing undergraduate major in global health and to discuss lessons learned and recommendations for other colleges and universities seeking to develop undergraduate degrees in global health. We noted significant diversity among the existing programs in terms of required courses, international field experiences, and thesis research projects. In this review, we describe these global health programs, their student characteristics, as well as the key educational competencies, program requirements, and core global health courses. Based on program reviews and discussions, we identify seven recommendations for the development and expansion of an undergraduate major in global health and discuss issues that have arisen in the curricular development of these programs that warrant further exploration. As the field of global health education continues to expand, following these students after graduation will be essential to ensure that the degree programs in global health both meet student needs and launch students on viable career pathways.

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The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions

Am. J. Trop. Med. Hyg. Perspective Piece The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions Paul K. Drain 0 1 3 11 Charles Mock 3 7 11 David Toole 6 11 Anne Rosenwald 5 11 Megan Jehn 4 11 Thomas Csordas 9 11 Laura Ferguson 8 11 Caryl Waggett 2 11 Chinekwu Obidoa 10 11 Judith N. Wasserheit 3 11 0 Department of Epidemiology, University of Washington , Seattle, Washington 1 Department of Medicine, University of Washington , Seattle, Washington 2 Global Health Studies, Allegheny College , Meadville, Pennsylvania 3 Department of Global Health, University of Washington , Seattle, Washington 4 School of Human Evolution and Social Change, Arizona State University , Tempe, Arizona 5 Department of Biology, Georgetown University , Washington, District of Columbia 6 Duke Global Health Institute , Durham, North Carolina 7 Department of Surgery, University of Washington , Seattle, Washington 8 Institute for Global Health, Keck School of Medicine, University of Southern California , Los Angeles, California 9 Department of Anthropology, University of California-San Diego , San Diego, California 10 Department of International and Global Studies, Mercer University , Macon , Georgia 11 Authors' addresses: Paul K. Drain and Judith N. Wasserheit, Depart- ment of Global Health, University of Washington , Seattle, WA , Department of Medicine, University of Washington , Seattle, WA , and Department of Epidemiology, University of Washington , Seattle, WA Global health education has been expanding rapidly and several universities have created an undergraduate major degree (bachelor's degree) in global heath or global health studies. Because there are currently no national guidelines for undergraduate degrees in global health, each of these programs was developed along individual lines. To guide the development of future global health majors, we conducted a systematic review of undergraduate majors in global health. We identified eight programs and invited program directors or representatives to a symposium at the Consortium of Universities for Global Health 2016 conference to review their existing undergraduate major in global health and to discuss lessons learned and recommendations for other colleges and universities seeking to develop undergraduate degrees in global health. We noted significant diversity among the existing programs in terms of required courses, international field experiences, and thesis research projects. In this review, we describe these global health programs, their student characteristics, as well as the key educational competencies, program requirements, and core global health courses. Based on program reviews and discussions, we identify seven recommendations for the development and expansion of an undergraduate major in global health and discuss issues that have arisen in the curricular development of these programs that warrant further exploration. As the field of global health education continues to expand, following these students after graduation will be essential to ensure that the degree programs in global health both meet student needs and launch students on viable career pathways. - INTRODUCTION Global health is a highly interdisciplinary, rapidly evolving field that spans health sciences, including medicine and public health, and also bridges a broad range of academic disciplines, including agriculture, anthropology, business, engineering, environmental sciences, economics, history, law, psychology, public policy, and sociology. Global health aims to improve the lives of all people worldwide by reducing health disparities through addressing modifiable health determinants, providing sustainable health services, and promoting human development.1 The objectives are achieved through sustainable provision of health services and human development, taking into account the complex transactions between societies, a defining feature of globalization.1 Applying global health principles, skills, and knowledge may be critical to achieving healthy populations, but their incorporation into the curriculum of undergraduate health science and liberal arts programs has been slow.2,3 Student interest in global health education has grown exponentially over the last decade.2,3 In 2010, the Commission on Education of Health Professions recommended changes to facilitate development of a generation of health professionals who will be better equipped to address present and future health challenges.4,5 The report called for harnessing global resources, experience, and knowledge through international exchange programs to generate capacity for addressing local challenges.5 Until recently, most global health degree programs have focused on graduate students pursuing master’s degrees in public health (MPH), PhD, or DrPH degrees. While some universities have created undergraduate global health programs, the majority grant either a certificate or minor in global health studies or have global health tracks within other majors. Recently, several colleges and universities have introduced undergraduate majors (bachelor’s degrees) in global heath or global health studies. Given the trajectory of global health education, it is likely that additional colleges and universities will seek to develop undergraduate majors in global health in the coming years. Since there is little guidance on the competencies and requirements for a bachelor’s degree in global health, we reviewed the existing programs to compare and contrast these components and other key characteristics. The goal was not to encourage uniformity, but to identify and learn from common elements and practices that might be used to guide the development of new academic global health degree programs. We conducted a systematic review of existing academic programs that offer a bachelor’s degree in global health. We searched PubMed for “bachelor degree” or “undergraduate major” and “global health,” reviewed the Consortium of Universities for Global Health (CUGH) database and university websites known to offer global health education, and had discussions with key leaders in global health education. We included programs that already have conferred a bachelor’s degree in “global health,” “global health studies,” or “global public health.” We excluded programs that offered only an undergraduate track, concentration, certificate program, or minor in global health. Through this process, we identified seven colleges or universities that have matriculated students into an undergraduate major program and conferred a bachelor’s degree in global health. We then contacted each program to obtained detailed program data from the program director or an academic representative. Each of the seven colleges or universities agreed to participate and provide information. In April 2016, we convened a satellite symposium at the CUGH conference in San Francisco to present and discuss each program. A representative from six of the seven identified programs attended the conference and provided a summary of their undergraduate major program, students, and requirements. After the presentations, we discussed the themes of existing programs and major recommendations for other colleges and universities seeking to develop a similar degree. During the conference, we learned that an eighth school, New York University, confers a co-major in global health, and we invited their participation in this review. Development and focus of degree programs. A summary of the eight undergraduate global health degrees, students, key competencies, and program requirements reveals both marked similarities and striking differences (Table 1). Four programs (Arizona State University, Duke University, Mercer University, and University of California–San Diego) offer only a bachelor of arts (BA degree, two universities (Georgetown University and University of Southern California) offer only a bachelor of science (BS, and two programs (Allegheny College and New York University) offer BA and BS degrees. The title for most degrees is either “global health” or “global health studies” while one program degree (New York University) is “global public health,” and another (Georgetown University) is “biology of global health.” The eight global health programs are housed within a wide variety of departments across the institutions, ranging from the Department of Biology (Georgetown University) to the Department of Anthropology (University of California– San Diego). In addition, global health programs are managed by a variety of schools and colleges, from the multidisciplinary School of Human Evolution and Social Change (Arizona State University) to the School of Medicine (University of Southern California). All programs have been created within the last 10 years. In general, most programs started with a small number of students in the first graduating class before rapidly expanding. The largest program, Arizona State University, has conferred 264 undergraduate degrees. Only Arizona State University offers an online learning degree program. Student career trajectories, and program competencies and requirements. The career trajectories of students enrolled in global health programs were similar across programs. Many students planned to pursue either a professional health science degree (i.e., medical or nursing degree) or an advanced degree in another field while some students wanted to engage in global health practices and/or international work experiences through nonprofit organizations and international governmental organizations, including the Peace Corps, Teach for America, Global Health Corps, Fulbright, and AmeriCorps. However, we were unable to assess the long-term career trajectory of global health graduates after graduation, due to the relatively short time frame since establishment of these programs and limited follow-up information. All degree programs had developed key objectives or educational competencies before the inception of their major degree program. Several programs are still revising their key educational competencies, and at least one university (Arizona State University) has mapped their objectives to the 39 competencies across 11 educational domains defined by the CUGH for professional global health education.6 Most undergraduate program objectives emphasize appreciation of multidisciplinary approaches to understanding both local and global health issues. Several programs also describe the need to maintain a cultural understanding of health and to recognize the ethical challenges that might arise in resource-limited settings. Other important learning objectives include understanding the social, economic, political and environmental factors that shape individual, community, and population health; and working collaboratively to develop sustainable solutions to global health issues. The majority of programs emphasize the need for students to be able to critically analyze global health issues and articulate key concepts across several disciplines.7 The major credit hours and other requirements varied considerably by program, which reflects differences in academic structures. A thesis is required by two programs (Allegheny College and University of California–San Diego), and recommended by two others (Duke University and Georgetown University). In two programs, students complete a required (Duke University) or recommended (Mercer University) research capstone project while the University of Southern California requires students to undertake directed research with a global health focus. Four programs require a practicum experience, and only two programs require an international experience. Two programs (Duke University and New York University) require the global health major to be paired with a co-major. Students at Duke University pair their global health major with a variety of different majors, including biology (20%), public policy (16%), anthropology (16%), psychology (11%), or another major (37%). New York University offers an undergraduate co-major degree in global public health that must be paired with one of 10 disciplines. The core global health courses and requirements were similar among the programs (Table 2). Most require both introductory courses in global health that emphasize critical thinking and problem solving, and experience with communitybased research design and methods. The programs diverge in more advanced courses. The majority of programs, including Allegheny College, Arizona State University, Duke University, and Mercer University, focus more on public health issues (e.g., epidemiology, biostatistics, health systems), social sciences (e.g., anthropology, psychology, sociology), and public policy. At Duke University, 15% of the students pair the global health major with a major in the humanities. The program at Georgetown University focuses on advanced courses in the biological sciences, including cellular biology, immunology, and ecology while still providing education on a broad array of current global health issues. Similarly, the program at University of Southern California has core f ia o y f rno l l its rn ityo ilfa ab oo e r eh ia rs C o s h in ve tu rn o S H S ce M o o C 0 s S 0 e B K 2 Y A G S le s te e e e h ? ic ? litcaanoopm ykee ifttseceeno rraegopm ifee?ndd treeeh itsceeenopm freeeobd iitrecannopm tyeecenopm ftreaed iitrecannopm itrrseeenuqm itrced irrrseeudq roA reeeg iirrseeudq reeegd ?m cu th pm reg en ,w c in g k is g m r B d ed vae co ed eb sye yke fed rop ree rve rop Description of core global health courses and requirements in undergraduate global health major programs Core global health courses and requirements Core global health courses and requirements Medical Geography International Public Health Interventions Health in Africa Medical Anthropology Health and Gender Special Topics Study abroad experience Senior Capstone Project New York University Biostatistics Epidemiology Health Policy Environmental Health Sociobehavioral Health Complete a Global Public Health Internship Complete additional requirements in co-major degree University of California– History of Public Health San Diego Global Health and Cultural Diversity Essentials of Global Health Project Management in the Health Services 1 Policy Analysis course 1 of the following Sociology courses Science, Technology, and Society Sociology of Health-Care Issues General Sociology for Premed Students Statistics Capstone: senior thesis preparation Require 8 electives among biological science courses and medical social science courses University of Southern Introduction to Global Health California Case Studies in Global Health Globalization: Issues and Controversies General Biology: Cell Biology and Physiology or Advanced General Biology: Cell Biology and Physiology General Chemistry or Advanced General Chemistry Biological and Behavioral Basis of Disease Principles of Microeconomics Calculus I Health Behavior Statistical Methods Health Behavior Research Methods Directed Research (with an international focus) At least eight elective units from Health Promotion or International Relations courses in the biological sciences, and also requires electives on international relations and health behavior. At Arizona State University, “global” is incorporated in the anthropological sense—to understand disease, health, and well-being in ways that incorporate a variety of cultures, places, and time along with their social, biological, historical, and ecological significance. Although there was no clear consensus on course requirements, most programs choose either a public health-oriented, medical anthropology-oriented, or a biomedical-oriented approach in the core curriculum. RECOMMENDATIONS FOR EMERGING UNDERGRADUATE GLOBAL HEALTH PROGRAMS Based on the review and experience of existing programs during the CUGH symposium, we offer the following seven Undergraduate major degree development Create clear educational objectives at program inception Build program capacity by starting with a certificate or minor degree program Consider logistic and programmatic challenges of interdepartmental collaborations Strengthen local, domestic, and international global health partnerships Student education and requirements Facilitate and encourage experiential practicum and internship experiences Consider the risks/benefits of offering international experiences Ensure strong ethical practices recommendations for consideration by emerging programs developing an undergraduate major in global health (Table 3). Create clear educational objectives at program inception. All of the programs had clearly defined objectives and/or competencies at the outset, which were helpful in guiding curriculum development, faculty recruitment, and student engagement. Universal educational competencies for global health have been proposed,6,8 but these competencies have been developed for graduate education and are not specific for undergraduate objectives. Since undergraduate education has a different goal, we suggest that program directors develop clear educational objectives before program inception, and that the global health community define key competencies designed to address the goals of undergraduate global health education. These objectives might include the following: To educate students to articulate fundamental global health concepts, tools, and frameworks. To prepare students for work with different types of organizations or to enroll in a graduate degree program related to global health issues. To enable students to understand the implications of international events and conditions related to global health inequalities and the social determinants of health. To develop students’ capacity to analyze the growing complexities and interrelatedness of globalization, environmental change, economic development, and political forces that influence global health. To encourage students to participate in appropriate and sustainable initiatives intended to raise the standard of living, improve health and well-being, and reduce health inequalities both at home and abroad. Build program capacity by starting with a certificate or minor degree program. Most of the existing global health programs, except Arizona State University and Georgetown University, introduced a global health certificate, concentration area, or minor program before offering a major degree. This allowed programs to build curriculum, student interest, and faculty engagement, while forging connections across disciplines that later proved essential. However, students pursuing a certificate or minor degree in global health often intend to pursue another primary career field. Conversely, those students who want to pursue a global health major are often committed to making global health the primary focus of their careers. The establishment of a global health co-major at Duke University and New York University leaves open the question of what students identify as “primary” in a truly interdisciplinary curriculum. Existing programs have experienced rapid surges of student interest and enrollment immediately following the creation of the undergraduate major. By first having experience with a smaller program, existing program directors felt that this expansion process was easier. An ongoing challenge, however, has been maintaining faculty and administrative support to meet the student interest and rapid growth of matriculated students. Consider logistic and programmatic challenges of interdepartmental collaborations. At most universities, global health degree programs have involved a wide variety of faculty, departments, schools, and colleges to cover the breadth and depth of global health education. Crossdepartmental collaborations can create unique logistical, administrative, and financial challenges. At some universities, departmental funds are disbursed based on student enrollment, which may create conflict. An additional issue may be the conflict for faculty who have responsibilities of publishing research for promotion, but might be asked to spend more time advising and mentoring students. Any logistical, programmatic, and financial issues that might arise through a collaborative interdepartmental degree program should be discussed and addressed early in the process and repeatedly as the need arises. Strengthen local, domestic, and international global health partnerships. Because global health involves reducing health disparities and improving the lives of people worldwide, exposing students to both local and international issues is important.9 Many of the programs have found that well-developed and sustained partnerships with both local and global organizations have strengthened their education programs, and for those programs that require practicum experiences, these partnerships are an essential part of the educational platform. A recent report on global health partnerships, commissioned by the Center for Strategic and International Studies and conducted by the Department of Global Health at the University of Washington, concluded that “Partnerships are a key component of successful global health programs but could be strengthened by addressing inequities in relationships between high- and low-income institutions, developing additional collaborations and better preparing North American students for training in low-resource settings.”10 The results of this report are consistent with the descriptions of global health partnerships described by the existing degree programs. Academic program directors should also recognize that “local is global” by ensuring that the program and curriculum reflect this important global health principle. Facilitate and encourage experiential practicum or internship experiences. Program directors have consistently expressed that practicum or internship experiences are transformational learning components for undergraduates in many fields, including global health. They also often open doors to graduate programs and jobs. The experiences during a practicum can be critical for both students and their community partners for the success of a program. Protecting a partnership by ensuring oversight, training students on appropriate expectations, and preparing host supervisors to be effective mentors can maintain the quality of an experience and partnership. Consider the risks/benefits of offering international experiences. Among universities that require or encourage an international global health experience, program faculty have indicated that this is an important component of their educational program. One successful model at Arizona State University includes a cross-cultural research training project— known as the Global Ethnohydrology Study—that is integrated into the global health study abroad programs through an intensive year-round teaching and research process.11 However, including international experiences as a training requirement can create significant burdens on faculty, staff, and students. For this reason, most programs recommend, but do not require, an international global health experience. The risks of having unsupervised undergraduate students studying global health-related activities in resource-limited settings could cause logistical problems, safety issues, or ethical concerns.12 Suggested strategies to mitigate these risks are having close supervision of students by university educators or officials, utilizing well-established partnerships in local communities that have resources to provide adequate supervision and support, developing specific guidelines for undergraduate involvement, and requiring predeparture curricula and training to prepare students for their assignment. Ensure strong ethical practices. Awareness of ethical issues and professional behavior are critical, and global health educators and learners must be sensitive when learning across different cultures, ethnicities, and health beliefs.13 Students who complete a practicum or international experience should operate within the context of local needs and be aware of their own limitations, competencies, and skills.14 Health-care needs and priorities will change over time within countries and regions; therefore educators and students need to be able to access reliable information, critique and interpret complex data, and be socially aware of various cultural situations. Students should be encouraged to maintain a sense of humility when learning from a diverse community that may take an alternative approach.15 Integrating global health ethics into the core curriculum may help prepare future generations of global health leaders for some of the most difficult challenges. CONCLUSION Given the growing interest in global health by undergraduate students, additional colleges and universities are likely to prepare to offer an undergraduate major in global health, and we provide recommendations to help guide the development of new degree programs. Global health should become an integral aspect of clinical practice and public health intervention, and educators from various fields should make global health awareness a primary learning objective. However, complex real-world global health challenges require new interdisciplinary educational models. These global health curricula should integrate knowledge of health’s social, historical, political, biological, and ecological dimensions while preparing students to think critically and identify problems to create effective solutions. Undergraduate students have recognized the interconnectedness of society, the impact of health inequalities, and the need to provide adequate health care for all people—which has led to the rapid rise of global health education. As educators, our responsibility is to ensure that students are learning content-appropriate material and to support students eager to learn from a practicum or international experience. In addition to fostering critical analysis and reasoning, a global health major should provide students with a set of core skills and an understanding of the broad range of issues that influence health around the world. Although an undergraduate global health degree can open doors to many career pathways, most students will either explore international work or pursue a professional degree. As global health majors become more common, educators should consider how an undergraduate major can best dovetail with an advanced degree.16 For example, related master’s degrees should build upon an undergraduate global health major with minimal duplication, but without excluding students from other undergraduate disciplines. A primary benefit of establishing an undergraduate program in global health includes developing the framework for an international, interdisciplinary understanding to address socioeconomic determinants of health and health inequalities. Global health undergraduate major degree programs offer the higher education community an opportunity to prepare the next generation for global citizenship using a new, highly interdisciplinary approach that recognizes the interconnectedness of our world in the twenty-first century and links health with critical issues such as economic development, environmental sustainability, and social justice. As is sometimes the case, the vision and appetite of students on many campuses for undergraduate global health programs have outpaced that of faculty. The lessons from the eight undergraduate majors discussed here provide a strong foundation for the development of future undergraduate global health programs. It is time to rise to the challenge. 1. Koplan JP , Bond TC , Merson MH , Reddy KS , Rodriguez MH , Sewankambo NK , Wasserheit JN ; Consortium of Universities for Global Health Executive Board , 2009 . Towards a common definition of global health . Lancet 373 : 1993 - 1995 . 2. Drain PK , Primack A , Hunt DD , Fawzi WW , Holmes KK , Gardner P , 2007 . Global health in medical education: a call for more training and opportunities . Acad Med 82 : 226 - 230 . 3. Drain PK , Holmes KK , Skeff KM , Hall TL , Gardner P , 2009 . Global health training and international clinical rotations during residency: current status, needs, and opportunities . Acad Med 84 : 320 - 325 . 4. Bhutta ZA , Chen L , Cohen J , Crisp N , Evans T , Fineberg H , Frenk J , Garcia P , Horton R , Ke Y , Kelley P , Kistnasamy B , Meleis A , Naylor D , Pablos-Mendez A , Reddy S , Scrimshaw S , Sepulveda J , Serwadda D , Zurayk H , 2010 . Education of health professionals for the 21st century: a global independent Commission . Lancet 375 : 1137 - 1138 . 5. Frenk J , Chen L , Bhutta ZA , Cohen J , Crisp N , Evans T , Fineberg H , Garcia P , Ke Y , Kelley P , Kistnasamy B , Meleis A , Naylor D , Pablos-Mendez A , Reddy S , Scrimshaw S , Sepulveda J , Serwadda D , Zurayk H , 2010 . Health professionals for a new century: transforming education to strengthen health systems in an interdependent world . Lancet 376 : 1923 - 1958 . 6. Jogerst K , Callender B , Adams V , Evert J , Fields E , Hall T , Olsen J , Rowthorn V , Rudy S , Shen J , Simon L , Torres H , Velji A , Wilson LL , 2015 . Identifying interprofessional global health competencies for 21st-century health professionals . Ann Glob Health 81 : 239 - 247 . 7. Rowson M , Willott C , Hughes R , Maini A , Martin S , Miranda J , Pollit V , Smith A , Wake R , Yudkin JS , 2012 . Conceptualizing global health: theoretical issues and their relevance for teaching . Global Health 8 : 36 . 8. Arthur MAM , Battat R , Brewer TF , 2011 . Teaching the basics: core competencies in global health . Infect Dis Clin North Am 25 : 347 - 358 . 9. Behforouz HL , Drain PK , Rhatigan JJ , 2014 . Rethinking the social history . N Engl J Med 371 : 1277 - 1279 . 10. Farley J , Osterman A , Hawes SE , Martin K , Morison SJ , Holmes KK , 2016 . Global Health Programs and Partnerships: Evidence of Mutual Benefit and Equity. Washington, DC: Center for Strategic and International Studies (CSIS). 11. Larson KL , Stotts R , Wutich A , Brewis A , White DD , 2016 . Cross-cultural perceptions of water risks and solutions across select sites . Soc Nat Resour 29 : 1049 - 1064 . 12. McCall D , Iltis AS , 2014 . Health care voluntourism: addressing ethical concerns of undergraduate student participation in global health volunteer work . HEC Forum 26 : 285 - 297 . 13. Crump JA , Sugarman J , 2008 . Ethical considerations for shortterm experiences by trainees in global health . JAMA 300 : 1456 - 1458 . 14. Hill DR , Ainsworth RM , Partan U , 2012 . Teaching global public health in the undergraduate liberal arts: a survey of 50 colleges . Am J Trop Med Hyg 87 : 11 - 15 . 15. Elit L , Hunt M , Redwood-Campbell L , Ranford J , Adelson N , Schwartz L , 2011 . Ethical issues encountered by medical students during international health electives . Med Educ 45 : 704 - 711 . 16. Johnson O , Bailey SL , Willott C , Crocker-Buque T , Jessop V , Birch M , Ward H , Yudkin JS ; Global Health Learning Outcomes Working Group , 2012 . Global health learning outcomes for medical students in the UK . Lancet 379 : 2033 - 2035 .


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Paul K. Drain, Charles Mock, David Toole, Anne Rosenwald, Megan Jehn, Thomas Csordas, Laura Ferguson, Caryl Waggett, Chinekwu Obidoa, Judith N. Wasserheit. The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions, The American Journal of Tropical Medicine and Hygiene, 2017, 16-23, DOI: 10.4269/ajtmh.16-0687