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Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents

      Abstract

      Objective

      To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global women's health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum.

      Methods

      We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents.

      Results

      Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001).

      Conclusion

      Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

      Résumé

      Objective

      Pour devenir des praticiens compétents sur le plan culturel étant en mesure de prodiguer des soins aux populations vulnérables et de défendre leur cause, les résidents doivent recevoir une formation abordant les priorités de la santé à l'échelle mondiale. Dans le domaine de l'obstétrique-gynécologie, nous ne disposons que de peu de renseignements au sujet de la formation en santé des femmes à l'échelle mondiale (SFEM) qu'offrent les programmes de résidence et de l'intérêt envers ce type de formation que l'on y constate. Nous souhaitions déterminer ce qui suit en ce qui concerne les programmes canadiens de résidence en obstétrique-gynécologie : (1) la situation actuelle pour ce qui est de l'enseignement de la SFEM et du soutien disponible à cet égard; (2) l'importance de la SFEM pour les résidents et les directeurs de programme; et (3) le degré d'intérêt envers un curriculum national de cycle supérieur dans le domaine de la SFEM.

      Méthodes

      Nous avons mené, à l'échelle du Canada, un sondage en ligne auprès des directeurs des programmes de résidence en obstétrique-gynécologie et des résidents de dernière année du domaine.

      Résultats

      Parmi les 297 résidents sollicités, 101 (34,0 %) ont répondu au sondage et 76 (26 %) ont rempli le sondage en entier. Onze des 16 directeurs de programme sollicités (68,8 %) ont répondu et 10/16 (62,5 %) nous ont fourni des réponses complètes. Quatre des 11 programmes (36,4 %) comptaient un curriculum de SFEM, 2/11 (18,2 %) comptaient un budget de SFEM et 4/11 (36,4 %) comptaient un président de la SFEM. Neuf directeurs de programme sur 10 (90 %) et 68 résidents sur 79 (86,1 %) étaient d'avis qu'une compréhension des questions de SFEM est importante pour tous les stagiaires canadiens en obstétrique-gynécologie. Seulement un directeur de programme sur 10 (10 %) et 11 résidents sur 79 (13,9 %) étaient d'avis que leur programme offrait une formation suffisante sur ces questions. Parmi les résidents des programmes comptant un curriculum de SFEM, 12/19 (63,2 %) étaient d'avis que les résidents de leur programme qui n'entreprenaient pas un stage au choix international auraient tout de même l'occasion de se sensibiliser à la SFEM, par comparaison avec seulement neuf des 50 résidents (18,0 %) des programmes ne comptant pas un tel curriculum (P < 0,001).

      Conclusion

      Les résidents et les directeurs de programme du domaine de l'obstétrique-gynécologie estiment que la formation au sujet de la SFEM est importante pour tous les stagiaires et qu'elle est actuellement insuffisante. La mise sur pied d'un module pédagogique national de cycle supérieur en SFEM suscite un vif intérêt.

      Key Words

      ABBREVIATIONS

      APOG
      Association of Academic Professionals in Obstetrics and Gynaecology
      GWH
      global women's health
      PD
      program director

      INTRODUCTION

      In 1978, under the auspices of the World Health Organization, global leaders produced the Alma-Ata Declaration, which stated that health is “a fundamental human right” and that “the attainment of the highest possible level of health is a most important social goal.”
      • Declaration of Alma-Ata
      International Conference on Primary Health Care; 1978 Sept 6–12.
      The Declaration also stated “The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.”
      • Declaration of Alma-Ata
      International Conference on Primary Health Care; 1978 Sept 6–12.
      Physicians have long played an important role in advocating for equity in health care and have a long history of providing health care to marginalized communities.

      Medecins Sans Frontieres. Founding. MSF: 40 years of independence. Toronto (ON): MSF Canada; 2014. Available at: http://www.msf.ca/en/founding. Accessed on June 2, 2015.

      The physician's professional contract has always included the values of altruism and compassion. More recently, the advocacy role has been explicitly developed, and many professional associations, residency training programs, and medical schools now state that physicians have a duty to address the needs of vulnerable populations and to advocate for justice in health.

      Canadian Medical Association (CMA). Code of ethics. Ottawa (ON): CMA; 2004 [updated 2015 Mar]. Available at: https://www.cma.ca/En/Pages/code-of-ethics.aspx. Accessed on June 4, 2015.

      Association of Faculties of Medicine of Canada. Towards a medical education relevant to all: the case for global health in medical education: a report of the Global Health Resource Group of the Association of Faculties of Medicine of Canada. Ottawa (ON): Canadian Federation of Medical Students; 2006. Available at: http://www.cfms.org/downloads/The%20Case%20for%20Global%20Health%20in%20Medical%20Education-%20AFMC.pdf. Accessed on June 4, 2015.

      Royal College of Physicians and Surgeons of Canada. Draft CanMEDS 2015 Physician Competencies Framework—Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2015. Available from: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/canmeds2015_framework_series_IV_e.pdf. Accessed on May 26, 2015.

      The Royal College of Physicians and Surgeons of Canada's 2005 CanMEDS Physician Competency Framework, which describes the knowledge, skills, and abilities that specialist physicians need to improve patient outcomes, articulates the role of physicians as health advocates.

      Frank JR, ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa (ON): The Royal College of Physicians and Surgeons of Canada; 2005. Available at: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf. Accessed on Jun 2, 2015.

      The importance of physician engagement and activity in promoting better health care for patients, communities, and larger populations, both locally and globally, is captured in the 2015 draft of the CanMEDS Physician Competencies Framework–Series IV. The final version of this document is to be officially released in October 2015.

      Royal College of Physicians and Surgeons of Canada. Draft CanMEDS 2015 Physician Competencies Framework—Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2015. Available from: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/canmeds2015_framework_series_IV_e.pdf. Accessed on May 26, 2015.

      Medical education must therefore include training and experiences focused on providing physicians with a fundamental education in the socio-economic, political, and cultural determinants of health that will allow them to be effective health advocates within a wide range of communities. Many medical students and residents have participated in this training through international electives, with the number of trainees participating in electives in low-and middle-income countries increasing substantially over the past 25 years.

      Association of Faculties of Medicine of Canada. Towards a medical education relevant to all: the case for global health in medical education: a report of the Global Health Resource Group of the Association of Faculties of Medicine of Canada. Ottawa (ON): Canadian Federation of Medical Students; 2006. Available at: http://www.cfms.org/downloads/The%20Case%20for%20Global%20Health%20in%20Medical%20Education-%20AFMC.pdf. Accessed on June 4, 2015.

      ,
      • Drain P.K.
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      • Gardner P.
      Global health training and international clinical rotations during residency: current status, needs, and opportunities.
      In a recent survey of pediatric residency programs in the United States, 52% of programs had residents participating in international health electives in the previous 12 months.
      • Nelson B.D.
      • Lee A.C.
      • Newby P.K.
      • Chamberlin M.R.
      • Huang C.C.
      Global health training in pediatric residency programs.
      These trainees are exposed to a greater variety of disease states and are believed to develop stronger clinical examination skills, decreased reliance on laboratory or imaging tests, and greater awareness of cost issues and resource allocation than peers who do not undertake such electives. Trainees who undertake these electives develop skills in cross-cultural communication and are more likely to pursue careers that involve serving marginalized, underserved, and multicultural communities, both in their own region or internationally.

      Association of Faculties of Medicine of Canada. Towards a medical education relevant to all: the case for global health in medical education: a report of the Global Health Resource Group of the Association of Faculties of Medicine of Canada. Ottawa (ON): Canadian Federation of Medical Students; 2006. Available at: http://www.cfms.org/downloads/The%20Case%20for%20Global%20Health%20in%20Medical%20Education-%20AFMC.pdf. Accessed on June 4, 2015.

      However, even trainees who do not choose (or are unable) to pursue international electives are increasingly exposed to “international” health concerns among patient populations at home. In 2006, 19.8% of the Canadian population was foreign-born. In Toronto and Vancouver, foreign-born citizens make up 46% and 40% of the population, respectively.
      • Chui T.
      • Tran K.
      • Maheux H.
      Immigration in Canada: a portrait of the foreign-born population, 2006 Census.
      Other local marginalized populations, including Aboriginal Canadians, the homeless, and those living in remote communities, may experience barriers to health and may be affected by health conditions that are similar to those experienced by immigrants and refugees or residents of low- and middle-income countries.
      • Gupta A.
      • Talavlikar R.
      • Ng V.
      • Chorny Y.
      • Chawla A.
      • Farrugia M.
      • et al.
      Global health curriculum in family medicine: resident perspective.
      The interconnectivity of international health concerns across countries is reflected in more recent, inclusive definitions of the term “Global Health” as “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”
      • Koplan J.P.
      • Bond T.C.
      • Merson M.H.
      • Reddy K.S.
      • Rodriguez M.H.
      • Sewankambo N.K.
      • et al.
      Towards a common definition of global health.
      This definition is further elaborated by Gupta et al.: “Global health does not only involve going overseas and volunteering for disaster-stricken areas or low-income countries, but also includes advocating and providing care for underserved populations within Canada, such as the homeless, refugees and immigrants, and remote communities.”
      • Gupta A.
      • Talavlikar R.
      • Ng V.
      • Chorny Y.
      • Chawla A.
      • Farrugia M.
      • et al.
      Global health curriculum in family medicine: resident perspective.
      An education in global health concerns and strategies is therefore relevant for medical trainees in all training locations, regardless of whether or not they are specifically interested in international clinical practice.
      Despite having an understanding of the importance of training global health advocates, and strong interest on the part of medical trainees, medical schools and residency programs often lack formal global health curricula. This means that residents who do not participate in international electives may never be exposed to vital global health topics, and that those who do travel overseas may not have appropriate grounding in the clinical, social, ethical, and political contexts of their experiences.
      • Nelson B.D.
      • Lee A.C.
      • Newby P.K.
      • Chamberlin M.R.
      • Huang C.C.
      Global health training in pediatric residency programs.
      ,
      • Gupta A.
      • Talavlikar R.
      • Ng V.
      • Chorny Y.
      • Chawla A.
      • Farrugia M.
      • et al.
      Global health curriculum in family medicine: resident perspective.
      ,
      • Peluso M.J.
      • Encandela J.
      • Hafer J.P.
      • Margolis C.Z.
      Guiding principles for the development of global health education curricula in undergraduate medical education.
      ,
      • Anspacher M.
      • Frintner M.P.
      • Denno D.
      • Pak-Gorstein S.
      • Olness K.
      • Spector J.
      • et al.
      Global health education for pediatric residents: a national survey.
      A formal education in global health is necessary to ensure that graduates are culturally competent and socially responsible independent practitioners.
      In the field of obstetrics and gynaecology in Canada, there is little information about the number of residents participating in international experiences and the quantity and quality of global health education within residency programs. Global health concerns in obstetrics and gynaecology are wide-ranging. For graduates of obstetrics and gynaecology residency programs to become culturally competent practitioners with the ability to care for and advocate on behalf of vulnerable populations, they must be educated in global health priorities, including access to contraception, maternal mortality, unsafe abortion, gender-based violence, sexual and reproductive rights, gynaecologic malignancies, and female genital cutting.
      To this end, Canada's Association of Academic Professionals in Obstetrics and Gynaecology, the professional organization that provides leadership in education and research to academic programs across the country, is supporting a process of developing a formal Global Health Curriculum for postgraduate trainees in obstetrics and gynaecology. The vision of this curriculum is “to prepare Canadian obstetrics and gynaecology residents for practice in a global environment; placing a priority on equity in health for all women, both at home and abroad, and on applying the principles of human rights to the daily practice of women's health care.”
      • Spitzer R.F.
      • Kent N.E.
      • Nakajima A.K.
      • Shaw D.
      This initiative follows upon a Global Child Health Curriculum launched by the Canadian Paediatric Society in 2011 to educate all Canadian postgraduate pediatric trainees to at least a minimum standard.

      Canadian Paediatric Society. Global child health curriculum. Ottawa (ON): CPS; 2014. Available at: http://www.cps.ca/en/curriculum. Accessed on May 26, 2015.

      A key initial step in the development of a global health curriculum is an assessment of current activities and interest in global health education in obstetrics and gynaecology residency programs across Canada. Using an online survey, we aimed to determine:
      • 1.
        the current status of global health teaching and support provided by residency programs,
      • 2.
        the importance of global health concerns to residents and program directors, and
      • 3.
        whether residents and program directors are interested in a national GWH curriculum.
      We hypothesized that there would be a high level of interest in global health issues from participants, minimal formal teaching currently in place, and strong support for the development of a national curriculum.

      METHODS

      Program directors and senior residents (in the third, fourth, and fifth postgraduate years) of the 16 accredited Canadian obstetrics and gynaecology residency programs were invited to participate. Participants were contacted via email through their program secretaries and through resident contacts via the Society of Obstetricians and Gynaecologists of Canada Resident Committee. Reminder invitations were sent to all participants on three separate occasions over the course of a single academic year (October 2013 to June 2014). The number of potential participants contacted was approximately 313 (based on reported residents per year, per program, and program directors), including 297 potential residents and 16 PDs.
      The online survey was created using the Fluid Surveys program and used closed-ended (5-point Likert scale) and open-ended questions to evaluate current curriculum content, attitudes and perceptions regarding global health topics, barriers to participating in or implementing global health curricula, and future directions of global health curricula within programs. The survey tool was modelled after a similar survey created and validated by the Canadian Paediatric Society,
      • Audcent T.A.
      • MacDonnell H.
      • Samson L.
      • Brenner J.L.
      Global child health education in Canadian paediatric residency programs.
      and the obstetrics and gynaecology-specific survey was then validated for content by external experts at the University of Toronto. In the survey introduction, participants were advised to consider “global health” in its broadest sense and were provided with the definitions of global health developed by Koplan et al.
      • Koplan J.P.
      • Bond T.C.
      • Merson M.H.
      • Reddy K.S.
      • Rodriguez M.H.
      • Sewankambo N.K.
      • et al.
      Towards a common definition of global health.
      and Gupta et al.
      • Gupta A.
      • Talavlikar R.
      • Ng V.
      • Chorny Y.
      • Chawla A.
      • Farrugia M.
      • et al.
      Global health curriculum in family medicine: resident perspective.
      Survey responses were analyzed using descriptive statistics and Fisher's exact test. Likert categories were combined in order to evaluate responses as categorical data.
      Ethics approval for the study was obtained from the University of Toronto Research Ethics Board prior to participant contact.

      RESULTS

      Of the 313 participants invited to complete the survey, 112 responses were obtained, for an overall response rate of 36%. The response rate of residents was 34% (101/297), with 75% of the responses (76/101) complete. The response rate of PDs was 69% (11/16), with 91% (10/11) complete.

      Curriculum Support and Content

      According to PD responses, only 36% of programs (4/11) have a global health curriculum. Eighteen percent of programs (2/11) have a global health budget, 36% (4/11) have a global health chairperson, and 36% (4/11) have faculty members with funded positions that allow protected time dedicated towards global health activities. In evaluating resident access to formal global health oriented clinical activities, 5/11 programs reported having residents rotating through clinics involving Aboriginal health, 7/11 programs reported having residents rotating through refugee/immigrant health clinics, and 4/11 programs reported having residents rotating through travel clinics. The formal teaching sessions involving global health topics held, and the coverage of key global health topics in this formal academic curriculum, are shown in Table 1.
      Table 1Program/curriculum content, according to program directors
      n/N (%)
      Does your program currently have a curriculum in global health? (yes)4/11 (36.4)
      Does your department retain faculty members who have funded positions that allow protected time to dedicate towards global health activities? (yes)4/11 (36.4)
      Does your department have a global health chairperson or coordinator? (yes)4/11 (36.4)
      Does your department have a dedicated global health budget? (yes)2/11 (18.2)
      Do residents in your program rotate through any of the following clinics? (yes)
        Aboriginal health5/11 (45.5)
      2/11 (18.2) mandatory
      3/11 (27.3) elective
        Refugee/immigrant health7/11 (63.6)
      3/11 (27.3) mandatory
      4/11 (36.4) elective
        Travel4/11 (40.0) elective
      Does your program provide formal teaching sessions on global health issues? (yes)
        Academic half-day sessions/lectures7/11 (63.6)
        Rounds6/11 (54.5)
        Guest lecturers9/11 (81.8)
        Journal club2/11 (18.2)
        Bedside rounds2/11 (18.2)
        Clinics5/11 (45.5)
        Organized resident global health interest groups3/11 (27.3)
      Are the following topics (as they relate to GWH as defined at the outset of this survey) part of your formal academic curriculum? (yes)
        HIV/AIDS/Prevention of Mother-to-Child Transmission9/11 (81.8)
        Unsafe abortion5/11 (45.5)
        Adolescent pregnancy5/11 (45.5)
        Contraception/family planning8/11 (72.7)
        Cervical cancer prevention and treatment8/11 (72.7)
        Maternal morbidity and mortality7/11 (63.6)
        Sexual/domestic violence6/11 (54.5)
        Female genital cutting7/11 (63.6)
        Women's mental health4/11 (36.4)
        Aboriginal women's health7/11 (63.6)
        Millennium Development Goals3/11 (27.3)
        Cultural sensitivity/competence5/11 (45.5)
        Ethics7/11 (63.6)

      Attitudes and Perceptions

      Respondents' attitudes towards the importance of global health training and the adequacy of current curriculum content are outlined in Table 2. Most PDs and residents felt that an understanding of GWH issues was important for all Canadian obstetrics and gynaecology trainees, with 90% of PDs stating that prospective residents interviewing for their program had inquired about global health opportunities. Few PDs and residents felt that their programs currently offered sufficient education in global, immigrant, refugee, and Aboriginal women's health. In programs without a GWH curriculum, none of the PDs and 7.7% of residents felt that their programs offered sufficient education in these issues. However, even in programs with a GWH curriculum, only one quarter of PDs and residents felt that their programs offered sufficient GWH education. Although a majority of PDs and residents agreed that residents in their program have benefited from their international electives, fewer felt that an international elective should be strongly encouraged as a part of residency training. A higher proportion of both PDs and residents felt that an immigrant/refugee-focused elective (40% of PDs, 54.4% of residents) and an Aboriginal health-focused elective (50% of PDs, 60.8% of residents) should be strongly encouraged.
      Table 2Attitudes and perceptions
      Program directors vs residentsProgram directors with and without a GWH curriculumResidents with and without GWH curriculum
      Program directors n/N (%)Residents n/N (%)With GWH curriculum n/N (%)Without GWH curriculum n/N (%)With GWH curriculum n/N (%)Without GWH curriculum n/N (%)
      Agree or strongly agreePAgree or strongly agreePAgree or strongly agreeP
      Prospective residents interviewing for our program through CaRMS have inquired about global health opportunities within our program.9/10 (90.0)51/78 (65/4)0.164/4 (100.0)5/6 (83.3)0.9915/18 (83.3)28/52 (53.8)0.05
      An understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees.9/10 (90.0)68/79 (86.1)0.994/4 (100.0)5/6 (83.3)0.9916/18 (88.9)44/53 (83.0)0.72
      Our program currently offers sufficient education in global/immigrant/refugee/Aboriginal women's health.1/10 (10.0)11/79 (13.9)0.991/4 (25.0)0/6 (0)0.405/19 (26.3)4/52 (7.7)0.05
      Residents in our program have benefited from their international electives.8/10 (80.0)51/80 (63.8)0.483/4 (75.0)5/6 (83.3)0.9917/19 (89.5)26/53 (49.1)<0.01
      An international elective should be strongly encouraged as a part of residency training.3/10 (30.0)44/79 (55.7)0.183/4 (75.0)0/6 (0)0.0313/19 (68.4)25/52 (48.1)0.18
      An immigrant/refugee-focused elective should be strongly encouraged as a part of residency training.4/10 (40.0)43/79 (54.4)0.512/4 (50.0)2/6 (33.3)0.999/19 (47.4)27/52 (51.9)0.79
      An Aboriginal health-focused elective should be strongly encouraged as a part of residency training.5/10 (50.0)48/79 (60.8)0.522/4 (50.0)3/6 (50.0)0.9910/19 (52.6)31/52 (59.6)0.60

      Barriers to Participating in or Implementing Global Health Curricula

      Respondents' perceptions of barriers are shown in Table 3. Almost 73% of PDs felt that residents in their program could easily identify and arrange international electives. However, residents with a GWH curriculum were more likely to agree than residents without a GWH curriculum (84.2% vs. 37.3%, P < 0.001). Only 57.7% of residents believed that their programs offered scheduling fexibility for these electives (P < 0.01) and few respondents felt that their program offered financial support for international electives. Approximately half the respondents noted restrictions on the amount of time that residents are allowed out of the province or country during their residency training. Lack of malpractice and disability insurance did not appear to be a major barrier to planning an international elective. There were major differences in access to an ongoing global health program at an international site where a resident could schedule an elective; most programs with a GWH curriculum, but few programs without a GWH curriculum, had ongoing global health programs at an international site where a resident could schedule an elective. Finally, responses to the question of whether or not a resident would still learn about GWH throughout residency if he or she chose not to undertake an international elective differed between programs with and without a GWH curriculum (Table 3).
      Table 3Barriers
      Program directors vs residentsProgram directors with and without a GWH curriculumResidents with and without a GWH curriculum
      Program directors n/N (%)Residents n/N (%)With GWH curriculum n/N (%)Without GWH curriculum n/N (%)With GWH curriculum n/N (%)Without GWH curriculum n/N (%)
      Agree or strongly agreePAgree or strongly agreePAgree or strongly agreeP
      Residents in our program can easily identify and arrange international electives.8/11 (72.7)41/78(52.6)0.333/4 (75.0)5/7 (71.4)0.9916/19(84.2)19/51 (37.3)< 0.001
      Our program is supportive of residents wanting to do international electives.11/11 (100.0)64/78(82.1)0.204/4(100.0)7/7(100.0)0.9918/19(94.7)38/51 (74.5)0.09
      Our program offers scheduling flexibility to residents wishing to pursue international electives.11/11 (100.0)45/78 (57.7)<0.014/4(100.0)7/7(100.0)0.9913/19(68.4)28/51 (54.9)0.42
      Our residents are financially supported by our program to undertake international electives.3/11 (27.3)10/78(12.8)0.202/4 (50.0)1/7(14.3)0.493/19(15.8)4/51 (7.8)0.99
      Lack of malpractice and disability insurance is a significant barrier to planning an international elective.4/11 (36.4)11/78(14.1)0.081/4(25.0)3/7 (42.9)0.993/19(15.8)8/51 (15.7)0.99
      There are restrictions from my university or province on the amount of time that 1 am allowed to be out of province or out of country on elective/ research during my residency.6/11 (54.5)39/78 (50.0)0.992/4 (50.0)4/7(57.1)0.9911/19(57.9)25/51 (49.0)0.60
      Our program has ongoing global health programs at international site(s) where I can schedule an elective.6/11 (54.5)31/79(39.2)0.354/4(100.0)2/7 (28.6)0.0614/19(73.7)11/52(21.2)< 0.001
      If a resident chooses not to do an international elective, he/she will still learn about GWH throughout residency.6/11 (54.5)25/77 (32.5)0.193/4 (75.0)3/7 (42.9)0.5412/19(63.2)9/50(18.0)< 0.001

      Future Directions of Global Health Curricula Within Programs

      A majority of PDs and residents felt that more emphasis should be placed on GWH in the obstetrics and gynaecology residency curriculum (Table 4). Most respondents agreed that their program would be interested in new initiatives regarding GWH. Ninety percent of PDs and 68.8% of residents felt that a GWH educational module, developed by APOG, could be incorporated into their current residency curriculum.
      Table 4Future directions
      Program directors vs residentsProgram directors with and without a GWH curriculumResidents with and without a GWH curriculum
      Program directors n/N (%)Residents n/N (%)With GWH curriculum n/N (%)Wthout GWH curriculum n/N (%)With GWH curriculum n/N (%)Wthout GWH curriculum n/N (%)
      Agree or strongly agreePAgree or strongly agreePAgree or strongly agreeP
      More emphasis should be placed on GWH in the obstetrics and gynaecology resident curriculum.6/11 (54.6)48/77 (62.3)0.742/4 (50.0)4/7 (57.1)0.9914/18 (77.8)29/51 (56.9)0.16
      Our program would be interested in new initiatives regarding GWH.8/11 (72.7)50/77 (64.9)0.743/4 (75.0)5/7 (71.4)0.9914/18 (77.8)29/51 (56.9)0.16
      A GWH educational module (approximately 6 hours, developed by APOG) could be incorporated into our current resident curriculum10/11 (90.0)53/77 (68.8)0.174/4 (100.0)6/7 (85.7)0.9910/18 (55.6)37/51 (72.5)0.24
      APOG: Association of Academic Professionals in Obstetrics and Gynaecology

      DISCUSSION

      As hypothesized, a minority of Canadian obstetrics and gynaecology residency programs were found to have a formal GWH curriculum, faculty with funding to allow protected time for global health activities, or a global health chairperson. Furthermore, the majority of programs did not have a dedicated global health budget.
      Despite this current lack of formal support, most PDs and residents agreed that GWH education is important for all trainees, and many programs currently do provide formal teaching on a number of GWH topics. Residents and PDs (even those who identified themselves as part of a program with a GWH curriculum) largely believed that their programs did not offer sufficient GWH education. While the majority of PDs and residents felt that residents benefit from their international electives, the number of PDs who would strongly encourage a GWH-related elective was highest for an Aboriginal health-focused elective, followed by an immigrant/refugee-focused elective, and lowest for an international elective. This trend may relate to a recognition that global health should be expanded to include low-income communities at home and a sense of responsibility towards local marginalized populations.
      • Loh L.C.
      • Rhee D.S.
      • Heckman J.E.
      • Chae S.R.
      Not just more global health—smarter global health.
      It may also relate to the challenge of planning and providing international elective experiences, a barrier that was highlighted by resident respondents across Canada. Many residents are conscious of the ethical concerns surrounding international medical electives and want to participate responsibly.
      • Gupta A.
      • Talavlikar R.
      • Ng V.
      • Chorny Y.
      • Chawla A.
      • Farrugia M.
      • et al.
      Global health curriculum in family medicine: resident perspective.
      The need for accredited global health experiences in medical training, with a focus on inter-institutional partnerships, sustainability, program support, and well-developed goals and objectives, is increasingly recognized as a priority in global health education.
      • Drain P.K.
      • Holmes K.K.
      • Skeff K.M.
      • Hall T.L.
      • Gardner P.
      Global health training and international clinical rotations during residency: current status, needs, and opportunities.
      ,
      • Loh L.C.
      • Rhee D.S.
      • Heckman J.E.
      • Chae S.R.
      Not just more global health—smarter global health.
      ,
      • Cherniak W.A.
      • Drain P.K.
      • Brewer T.F.
      Educational objectives for international medical electives: a literature review.
      In this survey, the majority of residents and all PDs from programs with a GWH curriculum identified global health programs at international sites where residents could schedule an elective. In programs without a GWH curriculum, this was only the case for approximately 30%. Evidently, the presence of ongoing global health programs and having a GWH curriculum are associated. Likely, faculty members who develop and participate in these programs subsequently act as leaders in GWH education within their programs. The importance that international electives currently play in providing GWH education was demonstrated by the fact that only a minority (18%) of residents in training programs without a GWH curriculum felt that a resident would still learn about GWH if he or she chose not to (or was unable to) participate in an international elective. This specific survey finding suggests that the majority of residents are not receiving adequate GWH training.
      Residents also identified a lack of financial support, limitations on the amount of time allowed out of province or country during residency training and scheduling flexibility as barriers to participating in an international elective. These are common challenges identified in surveys of residents in every medical specialty surveyed thus far, and are important factors to address in supporting greater access to GWH electives.
      • Drain P.K.
      • Holmes K.K.
      • Skeff K.M.
      • Hall T.L.
      • Gardner P.
      Global health training and international clinical rotations during residency: current status, needs, and opportunities.
      The results of this survey support a call for better, broader, and more collaborative GWH education in obstetrics and gynaecology residency training. Residents and PDs across the country were interested in new initiatives in GWH and felt that they could integrate an APOG-developed six-hour GWH educational module into their current curriculum. This module would be a first step in a nationwide demonstration by obstetrics and gynaecology training programs that teaching principles of GWH is a priority, and that equity in health for women should be a focus of all practitioners in this specialty. The larger goal should then be that the principles of global health (including social accountability, recognizing determinants of health, sustainability and advocacy) become the underpinnings of all accredited training programs, rather than being only an “add-on” lecture or an “elective” clinical experience. While this larger goal is already in progress in some areas and is espoused by individual practitioners across the country, improved national collaboration is needed to make this a universal priority. At the 2015 FIGO World Congress in Vancouver, the proposed APOG GWH module will be presented as part of a workshop on GWH education. The goals will be not only to improve the proposed module, but also to begin a dialogue aimed at forming a national GWH Working Group. This Working Group would then function through APOG or the SOGC to reach trainees across the country, with the goal of continuing to expand GWH education and sharing electives and opportunities.
      This survey's findings were limited by the number of participants (34% of residents and 69% of PDs). The results may therefore reflect a selection bias towards the opinions of those who are more interested in GWH and more likely to complete the survey. No parameters were applied to the definition of a GWH curriculum, so that participants' interpretations of this may have been inconsistent, leading to inaccurate group allocations used for comparison. Finally, Aboriginal health was included as one area of GWH but was not explored in detail. This was done purposefully to be consistent with an inclusive and exhaustive definition of global health that included all marginalized populations locally and globally. However, Aboriginal Canadians face unique health challenges as part of their history, and it has been demonstrated that Aboriginal health education is also lacking in obstetrics and gynaecology residency training.
      • Jumah N.A.
      • Wilson D.
      • Shah R.
      A Canadian survey of postgraduate education in Aboriginal women's health in obstetrics and gynaecology.
      In 2009, the Indigenous Physicians Association of Canada and the Royal College of Physicians and Surgeons of Canada developed a curriculum for culturally competent care in obstetrics and gynecology, with a focus on Aboriginal health.
      • Jumah N.A.
      • Wilson D.
      • Shah R.
      A Canadian survey of postgraduate education in Aboriginal women's health in obstetrics and gynaecology.
      ,
      • The Indigenous Physicians Association of Canada and the Royal College of Physicians and Surgeons of Canada
      Culturally competent care in obstetrics and gynecology: a curriculum for obstetrics and gynecology residents and physicians.
      Any future GWH curricula, including the APOG module currently under development, should be developed to be separate from but consistent with Aboriginal health priorities and curricula.

      CONCLUSION

      Senior residents and PDs of Canadian obstetrics and gynaecology residency programs agree that an understanding of GWH issues is important for all trainees. They also agree that the current education in these issues is insufficient, regardless of the curricula that exist in some of their programs. These findings are consistent with the published principles and priorities for global health education, and offer an opportunity to move forward with national curriculum development as well as expanded national collaboration in the pursuit of GWH. The fundamental goal is to train obstetrician-gynaecologists whose clinical practice is informed by GWH principles, and, in doing so, to produce equity in health for all women, both locally and globally.

      ACKNOWLEDGEMENTS

      The authors would like to thank Dr. Kellie Murphy for her assistance with data analysis, the Association of Academic Professionals in Obstetrics and Gynaecology of Canada for their support of this endeavor, and the survey respondents for taking the time to contribute.

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