Abstract
Introduction:
This study sought to determine pharmacy students’ self-assessment of their level of competency in specified global health statements across various schools. It also evaluated attributes associated with competency and perception of importance, as well as explored students’ perspectives on how best to incorporate global health content into pharmacy education.
Methods:
Cross-sectional survey administered online to pharmacy students from three pharmacy schools in the United States.
Results:
The self-assessed competency of pharmacy students in global health topic areas was low. Current or prior exposures outside of the PharmD curriculum to the global health content presented in the survey were significant indicators of self-assessed competency scores. Within individual participating schools, demographic characteristics such as gender, age category, speaking a non-English language, and progression through the PharmD curriculum were also significantly associated with competency scores reported. Most respondents (96%) agreed that relevant global health education should be incorporated into the pharmacy curriculum.
Conclusions:
Pharmacy students generally perceive global health competencies to be of great importance in practice, but acknowledge their deficiencies in this area. The current burden of global health education at the schools surveyed relies on individual student experience rather than curricular support. Ensuring that future pharmacists understand their role in global health teams and are able to achieve the necessary level of competency to function in interdisciplinary initiatives will require more strategic incorporation of relevant content into the curriculum.
Keywords: Global health, Pharmacy, Global health competency, Public health, PharmD curriculum
Introduction
Global health has been defined in many ways - sometimes differentiated, while other times interchanged, with public health and international health.1,2 Global health is broadly defined as “an area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.”3 Global health is an area of study that is highly interdisciplinary, achieving competencies relevant to health sciences and beyond. Engagement in global health initiatives has been associated with increased cultural sensitivity, higher interest in volunteerism and public health education, increased likelihood to take career opportunities in underserved communities or multicultural settings, and more effective communication skills for interdisciplinary collaborations.4–6
Pharmacists are among the diverse list of health professionals that can contribute significantly to improving global health.3,7 In order to optimize their unique knowledge and skill set for global health initiatives, pharmacists and other health professionals must be competent in their role when working within an interdisciplinary team. To ensure that pharmacy professionals achieve a level of competency and understanding specifically in global health, efforts have been made to document best practices for global experiential and didactic education in pharmacy programs from various perspectives.8,9 Progress has also been made in documenting available opportunities for exposure of pharmacy students to global health topics.10–12 In order to develop the relevant skill set and knowledge needed to adapt and take on the expanding global health role of pharmacy professionals, global health courses and experiences must become more available in doctor of pharmacy (PharmD) curriculums. This is especially important with respect to standardization of educational outcomes across colleges of pharmacy and competency building in the face of rapid expansion of global health interests in health professional programs.
While a variety of activities have been successfully implemented, there is still some dissonance on how global health education is provided across pharmacy schools and colleges.13–18 The three colleges of pharmacy that participated in this study offer varying amounts and types of global health exposure to pharmacy students. Global health education at the Arnold & Marie Schwartz College of Pharmacy & Health Sciences at Long Island University (LIU) is both advocated through a student organization, as well as provided through the formal curriculum (three-credit) and experiential (five-credit) elective courses. The University of Minnesota, College of Pharmacy (UMN) offers elective international advanced pharmacy practice experiences (APPEs) (five-credit), in addition to international excursions that are offered via student organizations rather than embedded in the curriculum. At the University of North Carolina at Chapel Hill Eshelman School of Pharmacy (UNC), an elective on global and rural health (one-credit) is offered in addition to opportunities to participate in an elective APPE through the college’s office of global engagement. Overall, curricular content, pedagogy, and the nature of the affiliations with foreign institutions are often dependent on faculty interest, level of knowledge, and connections to relevant agencies. These dependencies make it quite challenging to create competency statements that can be measured across PharmD graduates in this area. The importance, if any, that students place on this content area could become a tool to push for further standardization across pharmacy programs.
The objectives of this study were to1 determine students’ self-assessed confidence in global health competency statements and perceptions of importance to pharmacy practice2; identify attributes associated with confidence and perceptions of importance; and3 explore students’ perspectives on how best to incorporate global health content into pharmacy education.
Methods
To the best of our knowledge, there are currently no global health competencies specific to pharmacy.19–23 However, the Consortium of Universities for Global Health (CUGH), an interprofessional organization, has developed global health competencies that may be applied to all health professions. The 2015 CUGH Interprofessional Global Health Competencies specify 13 competencies across eight domains that should be met to achieve the most basic level of global health competency.24 The first stage of competency is termed the “global citizen” level and is defined as a competency set that may be required of all post-secondary students pursuing any field with bearing on global health. The 13 “global citizen” competency statements were considered most relevant for inclusion in the study survey. The Global Health Competency (GHC) survey for health professionals, developed by a multidisciplinary group in Canada and validated in 2013, includes 19 questions that evaluate learners’ needs related to global health, which were also considered relevant to the current study survey.25 Both tools were adapted with permission and modified to address study specific questions and fit the pharmacy context (Appendix 1).
The survey was divided into four parts. In part 1 (Knowledge in global health and health equity), students self-rated level of confidence in meeting the 13 “global citizen” CUGH competency statements using a 4-point scale (0 = Not at all confident; 3 = Very confident). Part 2 (Learners’ needs about global health) included 19 global health topic areas adapted from the GHC survey. Students rated the importance of each statement in relation to their pharmacy career using a 5-point scale (0 = Not at all important; 4 = Extremely important). Part 3 (Global health in the PharmD curriculum) explored students’ current exposure to content presented in part 1 and 2 of the survey, as well as students’ perceptions on how best to incorporate this subject matter into the PharmD curriculum. Part 4 (Demographics) requested relevant demographic information from respondents.
Data collection and analysis
This study was conducted as a cross-sectional online survey administered to pharmacy students in three colleges of pharmacy. The finalized survey was sent to pharmacy students via Qualtrics and Campus lab interface. Students received an email with a brief explanation of the study and a link to access the survey anonymously. Students in all four years of the PharmD program at UMN and UNC, and students in the first three years of the PharmD program at LIU, received the survey. Data was collected between March and May 2018. This study was approved by the Institutional Review Boards of the three participating institutions, respectively.
Descriptive data analysis was by frequencies, percentages, and means. Significant associations (p < 0.05) between demographic characteristics and1 self-assessed confidence levels or2 perceptions on importance of global health topic areas were determined using analysis of variance (ANOVA) and linear regression analysis. Independence testing was done using Fishers Exact test. Missing data was omitted from the analysis. Since only a proportion of students from each school answered all the survey questions, sample size differed per item. All analyses were conducted in R version 3.4.0.26
Results
Four hundred and eighty-seven students participated in the survey, with 312 from LIU, 89 from UMN, and 86 from UNC. Mean response rate was approximately 26% (LIU 51%; UMN 13%; UNC 14%). Table 1 shows relevant demographic characteristics of survey respondents. Respondents were predominantly Caucasian (50.1%), female (70.4%), born in the United States (US) (70.2%), and had at least one experience travelling outside the US (76%). Mean age was 22.9 years. The majority of respondents from UMN and UNC were monolingual. Respondents from LIU were predominantly bi- or multi-lingual (81.7%). Demographic characteristics of participants in each school were representative of the respective school’s overall demographic breakdown. For the demographic variables that differed significantly between the three schools (see Table 1), the pairwise differences are significant when LIU is compared to either UMN or UNC, but are not significant when UMN is compared to UNC.
Table 1.
Demographics of pharmacy student participants.
| All students n = 487a | LIU n = 312a | UMN n = 89a | UNC n = 86a | p-value | |
|---|---|---|---|---|---|
| Frequency (%) | Frequency (%) | Frequency (%) | Frequency (%) | ||
| Gender | 0.002b | ||||
| Female | 323 (70.4) | 213 (68.9) | 59 (73.7) | 51 (72.9) | |
| Male | 136 (29.6) | 96 (31.1) | 21 (26.3) | 19 (27.1) | |
| Age(years) | <0.001b | ||||
| <20 | 10 (2.6) | 10 (3.2) | 0 | 0 | |
| 20–24 | 286 (61.8) | 228 (73.1) | 26 (32.5) | 32 (45.1) | |
| 25–29 | 125 (27.0) | 53 (17.0) | 40 (50.0) | 32 (45.1) | |
| 30–34 | 28 (6.0) | 17 (5.5) | 8 (10.0) | 3 (4.2) | |
| >35 | 14 (3.0) | 4 (1.3) | 6 (7.5) | 4 (1.4) | |
| Year in school | 0.30 | ||||
| Y1 | 191 (41.6) | 165 (53.1) | 16 (20.0) | 10 (14.1) | |
| Y2 | 45 (9.8) | 8 (2.6) | 24 (30.0) | 13 (18.3) | |
| Y3 | 166 (36.2) | 135 (43.5) | 13 (16.3) | 18 (25.4) | |
| Y4 | 57 (12.4) | 27 (33.7) | 30 (42.3) | ||
| Race/ethnicity | <0.001b | ||||
| African American/Black | 25 (5.4) | 16 (5.1) | 3 (3.8) | 6 (8.5) | |
| American Indian/Alaska Native | 1 (0.2) | 1 (0.3) | 0 | 0 | |
| Asian American | 122 (26.3) | 95 (30.4) | 10 (12.5) | 17 (23.9) | |
| Caucasian | 232 (50.1) | 129 (41.7) | 61 (76.3) | 42 (59.2) | |
| Latino/Hispanic | 16 (3.5) | 12 (3.9) | 3 (3.8) | 1 (1.4) | |
| Native Hawaiian/Other Pacific Icelander | 3 (0.6) | 3 (1.0) | 0 | 0 | |
| Other | 64 (13.8) | 56 (18.1) | 3 (3.8) | 5 (7.0) | |
| Country of birth | <0.001b | ||||
| Non-USA | 135 (29.8) | 117 (38.7) | 7 (8.7) | 11 (15.5) | |
| USA | 318 (70.2) | 185 (61.3) | 73 (91.3) | 60 (84.5) | |
| Language spoken | <0.001b | ||||
| At least one other language | 302 (66.8) | 246 (81.7) | 27 (33.8) | 29 (40.8) | |
| English only | 150 (33.2) | 55 (18.3) | 53 (66.3) | 42 (59.2) | |
| Travel outside US | 0.23 | ||||
| No | 107 (23.9) | 78 (26.4) | 14 (17.5) | 15 (21.1) | |
| Yes | 340 (76.1) | 218 (73.7) | 66 (82.5) | 56 (78.9) | |
| Prior exposure to survey content area | <0.001b | ||||
| No | 316 (71.3) | 232 (79.5) | 44 (55.0) | 40 (56.3) | |
| Yes | 127 (28.7) | 60 (20.6) | 36 (45.0) | 31 (43.7) | |
Y1 = 1st year in PharmD program; Y2 = 2nd year in PharmD program; Y3 = 3rd year in PharmD program; Y4 = 4th year in PharmD program; LIU = Arnold & Marie Schwartz College of Pharmacy & Health Sciences at Long Island University; UMN = University of Minnesota College of Pharmacy; UNC = University of North Carolina at Chapel Hill Eshelman School of Pharmacy; USA = United States of America; PharmD = doctor of pharmacy.
Frequency indicates the number of respondents; not all participants represented by “n” answered every question; percentages are for those who responded to the question.
Significant difference in demographic variable is not observed in pairwise comparison between UMN and UNC.
The self-assessed confidence scores of pharmacy students for the statements associated with CUGH’s 13 “global citizen” level knowledge are presented in Table 2 (Survey part 1). Students’ self-assessed score was highest for “acknowledging one’s limitations in skills, knowledge, and abilities within a global health team.” Students assessed themselves to be least competent in “describing the major causes of morbidity and mortality around the world”, “describing the major public health efforts to reduce disparities in global health”, and “describing the roles and relationships of the major entities influencing global health.” On average, LIU students responded with “very confident3” 21.6% of the time across Survey part 1 questions (standard deviation (SD) = 4.6), compared to UMN and UNC students’ responses that were 14.7% (SD = 10.4) and 12.3% (SD = 7.3), respectively. Similarly, on average, LIU students responded with “not at all confident (0)” 5.9% of the time (SD = 1.9), while the UMN and UNC counterparts were respectively 9.6% (SD = 7.5) and 16.1% (SD = 8.6). The mean self-assessed confidence scores (maximum possible score of 39) were highest among students at LIU (mean score = 23.41) compared to students at UMN (mean score = 21.04; p < 0.001) or UNC (mean score = 18.41; p < 0.001).
Table 2.
Students’ self-assessment of global health confidence scores (Survey part 1).
| Competency statementsa | Average competency scores on a scale of 0–3b |
|||
|---|---|---|---|---|
| All students n = 487 | LIU n = 312 | UMN n = 89 | UNC n = 86 | |
| Describe the major causes of morbidity and mortality around the world | 1.49 | 1.70 | 1.19 | 1.06 |
| Describe the major public health efforts to reduce disparities in global health | 1.37 | 1.58 | 1.10 | 0.87 |
| Describe how travel and trade contributes to the spread of communicable diseases and chronic diseases | 1.72 | 1.84 | 1.51 | 1.50 |
| Describe cultural context and how it influences perceptions of health and disease | 1.78 | 1.85 | 1.78 | 1.52 |
| List major social and economic determinants of health | 1.79 | 1.89 | 1.75 | 1.45 |
| Describe the relationship between access to and quality of water, sanitation, food, and air on health | 1.84 | 1.92 | 1.81 | 1.59 |
| Exhibit inter-professional values and communication skills | 1.87 | 1.88 | 2.00 | 1.67 |
| Acknowledge one’s limitations in skills, knowledge, and abilities within a global health team | 2.00 | 1.99 | 2.09 | 1.92 |
| Demonstrate an understanding of common ethical issues and challenges that arise when working within diverse economic, political, and cultural contexts | 1.83 | 1.94 | 1.80 | 1.49 |
| Articulate barriers to health and health care in low-resource settings locally and internationally | 1.68 | 1.74 | 1.66 | 1.47 |
| Demonstrate a basic understanding of the relationships between health, human rights, and global inequities |
1.81 | 1.93 | 1.73 | 1.43 |
| Demonstrate a commitment to social responsibility | 1.70 | 1.81 | 1.56 | 1.48 |
| Describe the roles and relationships of the major entities influencing global health | 1.48 | 1.75 | 1.07 | 0.97 |
LIU = Arnold & Marie Schwartz College of Pharmacy & Health Sciences at Long Island University; UMN = University of Minnesota College of Pharmacy; UNC = University of North Carolina at Chapel Hill Eshelman School of Pharmacy.
Abbreviated competency statements, complete statements found in Appendix 1.
Average score of students’ self-perceived knowledge for each competency statement (item scale: 0 = Not at all confident; 1 = Slightly confident; 2 = Moderately confident; 3 = Very confident).
In all three schools, there were significant associations between prior exposure to global health content and confidence in the competency statements. Table 3 describes the association between students’ views on the adequacy of their non-curricular exposure to the global health content presented in this survey and higher overall confidence scores, for each school and overall. Relative to the students who strongly agreed, students who less strongly agreed that their non-curricular exposure to global health content was adequate, had significantly lower confidence scores on average. Further breakdown of results by individual participating schools show slightly different factors associated with significantly higher confidence scores in part 1 of the survey. Male gender in LIU (p = 0.012) and UNC (p = 0.004), those speaking a non-English language in UMN (p = 0.019) and UNC (p = 0.019), participants aged 20–24 years or 30–34 years in LIU (p = 0.01), and upper level pharmacy students (year 3 and 4) in UNC (p = 0.02), were more likely to have a higher overall confidence score.
Table 3.
Relationship between students’ views on the adequacy of their non-curricular exposure to global health content and their overall confidence scores in 13 global health competency statements.
| Estimatea | p-value | |
|---|---|---|
| All students | Ref. | |
| Strongly agree | Ref. | |
| Agree | −5.74 | <0.001 |
| Neither | −9.03 | <0.001 |
| Disagree | −10.61 | <0.001 |
| Strongly disagree | −13.13 | <0.001 |
| LIU | ||
| Strongly agree | Ref. | |
| Agree | −5.77 | <0.001 |
| Neither | −8.53 | <0.001 |
| Disagree | −9.83 | <0.001 |
| Strongly disagree | −11.75 | <0.001 |
| UMN | ||
| Strongly agree | NA | NA |
| Agree | Ref. | |
| Neither | −3.76 | 0.032 |
| Disagree | −5.12 | 0.002 |
| Strongly disagree | −10.02 | <0.001 |
| UNC | ||
| Strongly agree | Ref. | |
| Agree | −2.88 | 0.536 |
| Neither | −9.39 | 0.049 |
| Disagree | −8.22 | 0.076 |
| Strongly disagree | −11.58 | 0.047 |
Ref. = Reference category; NA = Not available; LIU = Arnold & Marie Schwartz College of Pharmacy & Health Sciences at Long Island University; UMN = University of Minnesota College of Pharmacy; UNC = University of North Carolina at Chapel Hill Eshelman School of Pharmacy.
A more negative estimate indicates that students who gave that response had lower overall confidence scores relative to the students who strongly agreed.
Students’ perceptions on the importance of various global health topics relative to their learning needs are presented in Table 4 (Survey part 2). Respondents primarily indicated that all the topic areas were at least moderately important. The majority of respondents from all schools perceived cultural competency and interprofessional communication skills as being highly important. Fewer respondents perceived “development of research and scholarly activities related to global health”, “peer education on global health topics”, and “having a mentor for global health training” as being extremely or very important. Further analysis show that Caucasians (p = 0.003) and those who identified with “other” (p = 0.02) race categories had significantly lower total scores for part 2 of the survey. On the other hand, speaking a non-English language (p < 0.001) or having “strongly agreed” to obtaining non-curricular global health content exposure (p < 0.001) were associated with higher scoring of importance compared to the rest of the survey population.
Table 4.
Pharmacy students’ perceptions on the importance of 19 global health topic areas (Survey part 2).a
| Statements assessing the importance of specified topic areas (n = 487a) | Extremely & very important | Moderately & slightly important | Not at all important |
|---|---|---|---|
| Freq. (%) | Freq. (%) | Freq. (%) | |
| Knowledge about how travel and trade contribute to the spread of communicable diseases | 314 (67.5) | 148 (31.8) | 3 (0.6) |
| Knowledge about how travel and trade contribute to the spread of communicable diseases | 314 (67.5) | 148 (31.8) | 3 (0.6) |
| Relationship between health and social determinants of health, and how social determinants vary across world regions | 345 (74.4) | 117 (25.2) | 2 (0.4) |
| Health risks associated with travel and migration, with emphasis on possible risks and appropriate management, including referrals | 325 (71.0) | 129 (28.2) | 4 (0.9) |
| Having training in the social determinants of health and the health issues associated with poverty | 346 (74.9) | 113 (24.5) | 3 (0.6) |
| Knowledge about how global health institutions influence health in different world regions through funding and policy | 303 (65.6) | 156 (33.8) | 3 (0.6) |
| Knowledge of major public health efforts to reduce disparities in global health | 321 (69.8) | 136 (29.6) | 3 (0.7) |
| Cultural competency; understanding how cultural background, socioeconomic status, and language barriers can influence access to care and health outcomes | 374 (81.0) | 86 (18.6) | 2 (0.4) |
| Inter-professional values and communication skills | 367 (79.4) | 94 (20.3) | 1 (0.2) |
| Relationship between access to clean water, sanitation, and nutrition on individual and population health | 350 (76.3) | 106 (23.1) | 3 (0.7) |
| Understand the relationship between health and human rights | 352 (76.2) | 109 (23.6) | 1 (0.2) |
| Understand common ethical issues that arise when working within diverse economic, cultural, and political context to address global health issues | 355 (76.3) | 109 (23.4) | 1 (0.2) |
| Development and implementation of research and scholarly activities related to global health | 288 (62.5) | 163 (35.4) | 10 (2.2) |
| Accessing resources to keep up to date with global health issues | 330 (71.1) | 128 (27.6) | 6 (1.3) |
| Having peer education such as student led seminars and journals clubs on global health issues | 281 (60.8) | 165 (35.4) | 16 (3.5) |
| Having a mentor for global health training and knowing who the local global health champions are | 273 (58.8) | 172 (37.1) | 19 (4.1) |
| Having pharmacist supervision on international electives | 337 (72.8) | 121 (26.1) | 5 (1.1) |
| Having feedback during the learning process related to global health competencies | 303 (65.7) | 153 (33.2) | 5 (1.1) |
| Having clinical rotations that enable work with disadvantaged or marginalized populations either domestically or internationally | 353 (76.1) | 104 (22.4) | 7 (1.5) |
| Having a learning guide to help develop and self-evaluate personal global health competencies | 310 (66.7) | 146 (31.4) | 9 (1.9) |
Freq. = Frequency.
Frequency indicates the number of respondents; not all participants represented by N answered every question; percentages represent those who responded to the question.
Students were further asked to provide information regarding the adequacy of their exposure to global health topics (described as the content provided in parts 1 and 2 of the survey) within or outside their current formal PharmD curriculum (Table 5 Survey part 3). More respondents at LIU “agreed” or “strongly agreed” to having been exposed to global health content outside the PharmD curriculum (43.5%) compared to respondents at UMN (32.5%) or UNC (32.4%) (p < 0.001). In analyzing the preferred placement of global health content within the PharmD curriculum, 96.3% of the respondents indicated that it should be a part of a required or elective course. Further breakdown shows that 21.6% of the respondents indicated it should be a part of a required course, 50.6% preferred it as an elective course, and 24.0% indicated it should have both required and elective components. There was no agreement on the optimal way to incorporate this material, as 34.8% indicated it should be provided in a specified course, 34.2% thought is should be spread across various courses, and 31% indicated that both should occur.
Table 5.
Pharmacy students’ perception of exposure to global health (GH) content and PharmD curricula best fit (Survey part 3).
| All students n = 487a | LIU n = 312a | UMN n = 89a | UNC n = 86a | |
|---|---|---|---|---|
| Freq. (%) | Freq. (%) | Freq. (%) | Freq. (%) | |
| Adequate exposure to GH content in formal PharmD curriculum (formal curriculum or experiential) | ||||
| Agree & strongly agree | 187 (40.7) | 143 (46.4) | 28 (35.0) | 16 (22.5) |
| Neither agree nor disagree | 141 (30.7) | 101 (32.8) | 18 (22.5) | 22 (31.0) |
| Disagree & strongly disagree | 131 (28.5) | 64 (20.8) | 34 (42.5) | 33 (46.5) |
| Adequate exposure to GH content outside formal PharmD curriculum | ||||
| Agree & strongly agree | 183 (39.9) | 134 (43.5) | 26 (32.5) | 23 (32.4) |
| Neither agree nor disagree | 144 (31.4) | 106 (34.4) | 21 (26.3) | 17 (23.9) |
| Disagree & strongly disagree | 132 (28.8) | 68 (22.1) | 33 (42.3) | 31 (43.7) |
| Teaching of GH content in the PharmD curriculum | ||||
| Required | 100 (21.6) | 69 (22.2) | 21 (26.2) | 10 (14.1) |
| Elective | 234 (50.6) | 175 (56.3) | 28 (35.0) | 31 (43.7) |
| Neither | 17 (3.7) | 17 (5.5) | 0 | 0 |
| Both | 111 (24.0) | 50 (16.1) | 31 (38.8) | 30 (42.3) |
| Placement of required GH content in the PharmD curriculumb | ||||
| In a specified course | 155 (34.8) | 125 (42.5) | 16 (20.0) | 14 (19.7) |
| Spread across various courses | 152 (34.2) | 90 (30.6) | 36 (45.0) | 26 (36.6) |
| Both | 138 (31.0) | 79 (26.9) | 28 (35.0) | 31 (43.7) |
Freq. = Frequency; LIU = Arnold & Marie Schwartz College of Pharmacy & Health Sciences at Long Island University; UMN = University of Minnesota College of Pharmacy; UNC = University of North Carolina at Chapel Hill Eshelman School of Pharmacy; PharmD = doctor of pharmacy.
Frequency indicates the number of respondents; not all participants represented by “n” answered every question; percentages represent those who responded to the question.
Note that the denominator for percentage calculation for this item excludes participants that responded with “neither” in previous question.
Discussion
The minimal amount of global health content offered by the participating pharmacy programs as electives rather than required courses, may account for students’ low levels of confidence in their knowledge of global health topic areas. On a scale of 0–3, the mean confidence levels for participants in all three colleges ranged from 1 to 1.7, a score at which the student would be considered “slightly” confident. This finding is consistent with results showing low levels of confidence in global health competencies among medicine residents, physiotherapy/occupational therapy students, and nursing students in five universities across Ontario, Canada.27,28 Minimal curricula provision of global health content was ultimately identified as the major contributor for the low competency observed in these Canadian universities.
In all three schools, participants were most confident with competencies addressing their ability to acknowledge one’s limitation in skills and knowledge, understand cultural context, exhibit interprofessional values, and communication skills. One reason for this may be that curriculum offerings in interprofessional values and cultural competency have been on the rise in many pharmacy programs.29 In 2011, the Accreditation Council for Pharmacy Education (ACPE) addressed the need to incorporate training on interprofessional practice across pharmacy colleges in order to maintain or achieve accreditation status.30 Other pharmacy organizations, like the American Association of Colleges of Pharmacy (AACP), have also issued official statements in support of incorporating structured interprofessional education into PharmD curriculums.31 In the 2016 ACPE Standards, a sense of responsibility is forged within pharmacy schools to increase curricular offerings related to cultural competency and communication with diverse populations by asserting the importance of these student learning outcomes to graduating practice-ready pharmacists.32 As the widespread uptake of these content areas into the PharmD curriculum seems to have translated into high levels of students’ self-assessed competence, it follows that further curricular expansion of relevant global health topics would do the same for global health competencies. Other studies have shown that exposure to more traditional global health topics via activities such as international experiential education leads to increase in self-assessment of confidence.33
When all three schools were combined, reported exposure to global health content outside of the PharmD curriculum was strongly associated with likelihood of having a higher confidence score. Students at LIU reported higher confidence in a majority of the global health competency statements compared to their UMN and UNC counterparts. As previously noted, exposure to global health content at all three schools were minimal; however, there are differences seen with the student demographic makeup between LIU and the other two schools. Findings suggest that due to low curricular inclusion of global health topics across all three colleges, students must rely on their own experiences and upbringing to become competent global citizens. Students from LIU in the New York Metropolitan area may come from or be exposed to stronger cultural and global influences, which may explain the consistent, significant difference between LIU and the other two pharmacy programs. This further emphasizes the need to increase content availability in the curriculum and standardize it across PharmD programs. Doing so will shift the burden of global health education from the student to the curriculum by ensuring all pharmacy students have equal opportunity to receive relevant exposure. Other factors identified in each individual school such as age, gender, language spoken, and progression through the pharmacy program, which correlated with significantly higher overall confidence in the subject matter require further analysis to understand the basis of this association. With combining participants from all three schools, these associations weakened suggesting it may not be easily generalizable.
Many respondents in all three schools identified the various global health topic areas presented in part two of the survey as important for their career. Over 96% of the participants also agreed that these topic areas should be incorporated into the PharmD curriculum in some form. Given the relatively high ratings of importance assigned to these topics by students, as well as their reported support of formal curricular inclusion, pharmacy programs would do well to begin the push for curricular amplifications in this area. A similar call for enhanced opportunities and training in global health has already been made for other health professional schools, meaning pharmacy students may be at risk of falling behind their interdisciplinary colleagues if curricular adaptations are not pursued.34,35 In the meantime, pharmacy programs may consider better indicating which courses, rotations, or co-curricular activities include relevant global health opportunities for students who seek such exposure. Organizations like the CUGH provide guidance to educators on ways to incorporate content from these global health competency statements into the curriculum. An updated version of the “CUGH global health education competencies tool kit” can be utilized as one tool for interested faculty members.36
In evaluating the optimal way to incorporate global health content into the PharmD curriculum, participants were split on whether this should occur as a specific, required course for all students or be offered only as an elective. In order to see progress, it may be necessary for pharmacy colleges to adapt an approach similar to what has been done to incorporate cultural competency and interprofessional education across curriculums by including required courses and activities.
Our study has its strengths and limitations. This is the first study to look at pharmacy students’ self-rated confidence in their ability to achieve global health competency statements. As interest in global health continues to grow, it is valuable to understand how equipped the pharmacy profession is to meet the challenges of this unique field in healthcare. This study also incorporated multi-institutional perspectives by including three different schools with diverse student bodies and curricular offerings related to global health. One limitation of the present study is that more than half of the overall participants were students from LIU, although LIU also has a higher number of overall students. This could have introduced population sample bias. Due to timing of survey collection, it was also not possible to include fourth year students from LIU. We reported our findings per school, to minimize this potential bias. Additionally, the representation of students in different years of the PharmD program (year one to year four) was not evenly distributed. As fourth year students in LIU were not included, we are not able to determine if a student’s progress in pharmacy school has a significant effect on confidence rating. Furthermore, the voluntary nature of students’ participation and the subjective nature of self-assessed confidence in global health competency statements could have introduced selection bias, as well as self-reporting bias to the study findings. Finally, by using a combined survey tool that has not been validated for use in pharmacy students, we run the risk of measurement error. This was managed by adapting our survey from a validated tool used in health professional students.25,37 We also urge for further studies to develop and validate specific global health competency assessment measures for pharmacy students and professionals.
Conclusions
Our findings suggest that relevant global health topic areas may be lacking in the pharmacy school curricula in the three colleges of pharmacy included in this study. This finding is in stark disagreement with the rising interest in global health engagement for future health professionals. Incorporating relevant education and training can potentially improve global health competency in graduating pharmacists. Among respondents who had exposure to global health topics outside the PharmD curriculum, there was significantly more confidence in competency statements. We advocate for additional research in this area and that schools and colleges of pharmacy join efforts alongside other health professional programs to incorporate standardized global health education into the curriculum so that pharmacists are confident in their expanding roles in public health.
Supplementary Material
Acknowledgements
Data analysis for this publication was supported by the National Institutes of Health Clinical and Translational Science Award Program, grant number UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.cptl.2020.01.012.
Disclosures
None.
Declaration of competing interest
None.
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