Visiting Trainees in Global Settings: Host and Partner Perspectives on Desirable Competencies

B A C K G R O U N D Current competencies in global health education largely reflect perspectives from high-income countries (HICs). Consequently, there has been underrepresentation of the voices and perspectives of partners in lowand middle-income countries (LMICs) who supervise and mentor trainees engaged in short-term experiences in global health (STEGH). O B J E C T I V E The objective of this study was to better understand the competencies and learning objectives that are considered a priority from the perspective of partners in LMICs. M E T H O D S A review of current interprofessional global health competencies was performed to design a web-based survey instrument in English and Spanish. Survey data were collected from a global convenience sample. Data underwent descriptive statistical analysis and logistic regression. F I N D I N G S The survey was completed by 170 individuals; 132 in English and 38 in Spanish. More than 85% of respondents rated cultural awareness and respectful conduct while on a STEGH as important. None of the respondents said trainees arrive as independent practitioners to fill health care gaps. Of 109 respondents, 65 (60%) reported that trainees gaining fluency in the local language was not important. C O N C L U S I O N S This study found different levels of agreement between partners across economic regions of the world when compared with existing global health competencies. By gaining insight into host partners’ perceptions of desired competencies, global health education programs in LMICs can be more collaboratively and ethically designed to meet the priorities, needs, and expectations of those stakeholders. This study begins to shift the paradigm of global health education program design by Funding for this study was provided by Child Family Health International. Dr. William Cherniak was supported by a Sommer Scholarship at the Johns Hopkins Bloomberg School of Public Health while he completed the initial manuscript and data analysis. All authors had access to the data and a role in writing the manuscript. From the Bridge to Health Medical and Dental and University of Toronto, Department of Family and Community Medicine, Division of Emergency Medicine at the Markham-Stouffville Hospital, Toronto, Ontario, Canada (WC); University of Wisconsin, Madison, WI (EL); Trinity Western University, Langley, British Columbia, Canada (BA); Kigezi Healthcare Foundation/Mbarara University of Science and Technology, Mbarara, Uganda (GA); Blue Roof Life Space, Durban, South Africa (TB); Child Family Health International, Quezon, Philippines (JB); Johns Hopkins University, Baltimore, MD (MD); Universidad San Francisco de Quito, Quito, Ecuador (KD); Vanderbilt University and Consortium of New SubSaharan Medical Schools, Nashville, TN (QE); University of Namibia, and Consortium of New Sub-Saharan Medical Schools, Windhoek, Namibia (MH); Rosalind Franklin University of Medicine and Science, North Chicago, IL (CM); Child Family Health International, Accra, Ghana (CN); Yale University, New Haven, CT (KS); Child Family Health International/University of California, San Francisco, CA (JE). Address correspondence to W.C. (w.cherniak@mail.utoronto.ca) A n n a l s o f G l o b a l H e a l t h a 2 0 1 7 I c a h n S c h o o l o f M e d i c i n e a t M o u n t S i n a i . P u b l i s h e d b y E l s e v i e r I n c . A l l r i g h t s r e s e r v e d . V O L . 8 3 , N O . 2 , 2 0 1 7 I S S N 2 2 1 4 9 9 9 6 / $ 3 6 . 0 0 h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . a o g h . 2 0 1 7 . 0 4 . 0 0 7

K E Y W O R D S global health, short-term experience in global health, education, competencies, ethics, international rotations

I N T R O D U C T I O N
There has been a rapid increase of students from all disciplines engaging in global health (GH) training. This includes international electives, fieldwork, volunteering, service learning, and internships. 1-4 Predominantly, trainees from high-income countries (HICs) travel to a low-or middle-income country (LMIC; also referred to as the "Global South") for a short-term experience in global health (STEGH). 5 Trainees may go abroad on STEGH through a program organized by a nongovernmental organization (NGO), academic institution, local ministry of health, 6 or an ad hoc experience.
Such programs generate controversy as to whether they do more harm than good, as noted by mainstream media (such as The Guardian, CNN, Huffington Post, The New York Times, and Al-Jazeera). [7][8][9][10][11] From an academic perspective, STEGH have been examined along many dimensions, including reciprocity in relationships between participants, 12 the concept of partnership engagement models, 5 and overall benefits and drawbacks for host communities and trainees. 13,14 Building on this work, there has been a push to develop more specific competencies and pedagogies for STEGH, and GH training more broadly. 2, 14 It must be noted that not all STEGH takes place abroad. Appropriately, there is an increasing emphasis on local GH, or "glocal." 15 This idea recognizes that the traditional model of international experiences defining GH should be expanded to focus on the health disparities and needs of low-resource communities within highresource nations. 15 Recently, a list of 7 key themes representing GH and local health were released. 15 Although a topic of pressing concern, this study focuses on STEGH where participants are traveling outside their country of residence.
A seminal set of competencies from the Consortium of Universities for Global Health (CUGH) proposed 4 levels of global health (GH) proficiency that corresponds to degrees of experience and professional commitment. CUGH's Global Citizen and Basic Operational Program-Oriented Levels of proficiency are characterized through 39 competencies across 11 domains. These competencies encompass skills, knowledge, and attitudes ranging from descriptions and understanding of social and environmental determinants of health to ethics, professionalism, health equity, and social justice. 14 They represent substantial progress in current thinking about the aims of GH training. However, the peer consensus process that developed this competency set was without significant input from LMIC stakeholders. Eichbaum cogently argued "the process of developing GH competencies is often insufficiently inclusive of input from host country health professionals and furthermore fails to take adequate account of local health contexts." 16 Therefore, we created an online survey and distributed it to faculty, staff, and community members who supervise and mentor visiting trainees open to individuals from all regions of the world. The primary objective was to obtain their unique perspectives and incorporate them into existing GH frameworks.

M E T H O D S Survey
Design. An 85-item survey, based mainly on the CUGH interprofessional competencies and some additional competencies, was developed. 2, 14 The initial survey was developed through a collaborative editing process among co-investigators from 8 HIC and LMIC countries, including Canada, the United States, Uganda, the Philippines, Ecuador, Namibia, Ghana, and South Africa. To help ensure content and face validity (as well as cross-cultural clarity), the survey was piloted with 5 respondents from LMIC settings. We incorporated this feedback into the final survey. By design, the final version asked first about respondents' own beliefs about competencies in an open-ended fashion before asking them to evaluate specific competencies along a Likert scale. We used a 4-point Likert scale with 1 representing not important and 4 representing very important. One of the co-investigators translated the original English survey into Spanish, with grammar and spelling double-checked by a second native Spanish speaker from the funding organization, both approved by the institutional review board. Survey Distribution. Because no discrete sample of STEGHs existsdand because the aim was for a broad representation from LMICsdwe chose a combination of convenience and snowball sampling and conducted the survey online. Participants and co-investigators forwarded the survey link to GH partnerships and other colleagues. The online survey was open from September 1 to December 31, 2015. The Western Institutional Review Board reviewed and approved the study. The requirements for participation were >18 years of age, consent, and interaction with trainees from other countries. Specifically, at the beginning of the survey respondents were asked, "What best and most specifically describes your role in relation to visiting students from other countries (also referred to as 'international visiting students')?" Respondents had to select 1 of the following: A. I oversee, supervise, or teach international students at my workplace or institution; B. I work alongside and interact with international visiting students, but I do not have responsibilities toward them; C. I host or interact with international students while they are in my community or my home, but not in my workplace; or D. I do not interact with any international visiting students who are in my community.
Respondents who selected D were excluded from analysis. Data Analysis. Microsoft Excel and STATA version 14.1 were used to analyze survey results. Simple descriptive statistics were carried out on demographic and program-related information. To compare responses between HIC and LMIC respondents, we used the 2015 World Bank economic regions for respondents' country of residence. 17 Chi-square analysis was used to determine initial relationship between responses for questions and economic region. If this analysis suggested a relationship, we performed logistic regression and calculated odds ratios across our defined economic regions and the respondents' role in their organization. For the regression, we collapsed the original Likert-scale categories of important and very important into one variable (and did so similarly for somewhat important and not important).

R E S U L T S
Demographics and Program Information. After excluding 67 individuals who did not respond to questions despite giving consent and 33 who answered only the question about level of student interaction, our final sample included 170 respondents, with 132 participating in English and 38 in Spanish. Respondents represented 38 countries (Table 1) and 22 primary languages (Table 2), with the most common countries being China, the United States, and Ecuador (Table 1). The 2 most common primary languages spoken were English (n ¼ 87; 51%) followed distantly by Spanish  Perspectives on Competencies for Trainees (n ¼ 36; 21%; Table 1). Less than half were from an upper middle-income nation (n ¼ 74; 44%; Table 2). The vast majority was responsible for supervising trainees (n ¼ 129; 76%), and worked at nonacademic centers (n ¼ 126; 74%; Table 2). Although nearly two-thirds (n ¼ 99; 61%) reported a clinical background, one-fourth (n ¼ 37, 23%) reported being administrators, home-stay hosts, public health workers, and NGO staff.
We asked respondents about their experience with trainees. In terms of number of trainees per year, the most common responses were 1 to 5 (n ¼ 54 of 148; 36%) and >20 (n ¼ 54 of 148; 36%), a nearly bimodal distribution. The reported average length of time trainees spent in the host community was 4 weeks (n ¼ 45 of 145; 31%), and the most commonly encountered level of trainees were undergraduates ( Figure 1).
Although most respondents were from an urban setting, based on logistic regression we found that respondents from low-income regions were more likely to be in a rural setting (odds ratio [OR], 5; P ¼ .021). Additionally, nonclinical respondents and NGO staff were more likely to be from a rural setting (OR, 7.3; P ¼ .001; and OR, 15; P ¼ .005, respectively) compared with doctors and nurses. Predeparture. More than 50% of 138 respondents said that trainees were satisfactorily prepared before arriving for their STEGH (n ¼ 80; 58%; Table 3). They rated trainees possessing the ability to demonstrate humility as being more important than confidence (94 of 127; 74% versus 62 of 128; 48%). In all 111 of 128 respondents (87%) overwhelmingly said that demonstrating an understanding of the influence of culture on patients and health care was important. The ability to speak the local language in advance of arriving for a STEGH was not of great importance to 41 of 128 respondents (32%); however, practicing introspection and reflection was rated important by 87 respondents (68% ; Table 3).
After performing logistic regression, the lower middle-income group had higher ORs of reporting a previous knowledge of local language as being not important compared with the high-income group (OR, 16.3; P ¼ .001). Intraexperience. The intraexperience competencies were divided into those that were generally applicable to all STEGH, those that were health related, and those specific to clinical activities. In the general objectives, 88 or 112 respondents (79%) said that it was equally as important for trainees to learn about the local culture as medical conditions. Sixty-five of 109 respondents (60%) said it was not important to have trainees become fluent in the local language (Table 4). Additionally, >70% of respondents rated understanding health workforce issues, cultural awareness and sensitivity, cultural effects of behavior and treatment, the link between health and human rights, and the influence of culture on health care and perception of disease as being important ( Table 4). There was no significant difference in the rated importance of these competencies across economic categories. From a health standpoint, some of the most important competencies (rated as being important by 90% of respondents) were exhibiting interprofessional values and communication skills that demonstrate respect for all types of professionals and groups working in health, as well as recognizing personal limitations (Table 5). Nearly as important (rated as being important by 75% of respondents) were appreciating human resource limitations, and demonstrating professionalism and respect of the entire team, including the local knowledge, culture, and practices. Logistic regression detected no significant differences between economic categories or respondents with different roles in the health care organization.
Clinically, <33% of respondents rated the ability to perform surgical procedures, or to manage diseases rarely seen in the trainee's home country, as important. Logistic regression did not detect significant differences between respondents in rural areas, from different income categories, or across the respondents' role in the health care organization. Interestingly, with 55 of 90 respondents (61%) in agreement, the competency that was rated as least important in this survey was the ability to manage patients without supervision. The most important clinical competencies (rated as being important by >75% of respondents) were being able to work collaboratively with all members of the health care team to advance health care in a low-resource setting, and demonstrating an awareness and recognition of all members of the health care team, including nontraditional and lay providers ( Table 6). There was no significant difference found between groups during logistic regression. Postexperience. Ultimately, 75 of 105 local mentors (71%) said that they engaged in a debriefing with trainees after their STEGH (Table 7), and 75% said they received feedback from trainees after completion of the experience. None of the respondents indicated that they would want to have fewer trainees visiting their community (Table 8).
There was a nearly equal divide of wanting more versus satisfaction with current volume. Interestingly, none of the respondents believed that trainees came entirely as practitioners. Only 13 of 140 (9%) agreed that trainees give more than they receive during the experience (Table 8). Ninety-four of 104 (90%) said they wished trainees would stay more in touch after completion of the STEGH, and 80 of 102 (78%) indicated that <50% of trainees actually did stay in touch after their experience. Eighty-four of 103 respondents (82%) indicated that only 0 to 25% of trainees returned after their initial experience.

D I S C U S S I O N
To our knowledge, this is the first survey of STEGH competencies to focus on perspectives of host community members and mentors. The 170 responses encompassed numerous nationalities, languages, geographic/economic regions, and professional backgrounds (Tables 1 and 2). Very interesting trends emerged along the lines of program development, competencies, and host perspectives on GH experiential learning (Tables 1-8).
Of additional interest is that 14% of respondents were from rural areas, and 33% were from nonclinical backgrounds or engage in research activities. A specific goal of using a convenience sampling and snowball method was to allow the individuals who might be missed by traditional sampling methods to provide their input. Additionally, 65% of STEGHs are 4 weeks, which fits well with the current literature on international programming. 18 Nearly one-fourth of respondents said that their programs had a community-based outreach component (37 of 170; 22%). Programs that accepted >20 Although using convenience sampling had great advantages as described previously, a limitation of this study was that it made it difficult to capture a response rate, and it had a response bias toward those engaged in networks with the research group and HIC entities. Additionally, the use of a webbased survey instrument has limitations that introduce additional response, social acceptability, and culture bias, such as not being accessible to those with limited Internet, not being a culturally acceptable form of divulging information, and lack of trust between researchers and subjects. Based on Table 2, we are confident that we obtained a wide and   diverse subset of individuals. However, additional studies with mixed methods are needed. Predeparture. In assessing the predeparture competencies, it was reassuring that none of the respondents believed that visiting trainees were completely unprepared, and that 58% felt that they were at least "satisfactorily prepared." Although positive, it should be noted that nearly equal numbers rated trainees as being "less than satisfactorily prepared" as they did "well prepared" (20% and 22%, respectively). This is a clear sign that the work to date on predeparture training (PDT) is having a positive effect, but that there is still much to do in ensuring consistency and preparation of trainees in advance of STEGH. Additionally, respondents valued a trainee arriving with a well-developed sense of humility, and would value confidence more if the 2 came together. Confidence on its own was not a highly rated trait. More than half of the respondents (59%) rated understanding the realities of working and living in a low-resource setting as being important, although 100% of respondents from LMIC settings and 57% from HICs rated it as being important. HICs contain homeless and impoverished populations, aboriginal and first nation communities, and other marginalized regions that involve working and living in a low-resource setting. Building a greater understanding of this competency for trainees in HICs is proposed as an important consideration moving forward.
It is telling that the most highly ranked predeparture competencydwith 87% rating it importantdwas an awareness of how culture influences patients and health care. This is in stark contrast to only 32% valuing a previous knowledge of the local language as being important. Language is widely regarded as a key component of cultural sensitivity, 19 yet this was not highly valued by the respondents in the present study. These results support an expanded emphasis on ensuring trainees are being prepared for the importance of cultural awareness and calls into question the role of intense language training, particularly for STEGH where most trainees are not expected to return to the host community and are there for a relatively short period of time.
As a consideration, we do not know if the majority of respondents were from areas where visiting trainees already had well developed fluency in the local language on arrival, and so respondents may have felt that learning language was less important.  Intraexperience. Similar to PDT, during the STEGH, learning about local medical conditions was valued equally to learning about local culture. This supports new findings and challenges the beliefs of health science trainees and faculty that STEGH are intended primarily to enhance clinical skills. 20 A large majority of respondents resonated with the importance of learning about cultural sensitivity, the effect of culture on patient behavior, on health care, and on perceptions of disease as well as understanding health and human rights and workforce issues. This is a sobering reminder to trainees and faculty planning STEGH to be prepared, and plan for, time to explore areas outside of clinical settings. It also supports institutions valuing such learning with academic credit and related valuations.
In the clinical competencies included in the present study, respect and collegiality for all allied health staff were regarded as critically important, as were being able to recognize personal limitations and human resource limitations. Learning "hard skills" such as how to conduct research, performing    surgical procedures, maintaining and reviewing data entry logs, and learning to describe the local health care system were rated as being much less important. From a practical standpoint, developing communication and collaborative skills and behaviors even in clinical settings, is as or more important for the trainee than honing clinical skills. Additionally, the present study highlights the importance of trainees being able to appreciate the context of the international setting, and the human condition they are encountering. It underscores how essential it is both for trainees to recognize their own limitations, and to act on this recognition, so they do not attempt clinical practice beyond their level of mastery, or without adequate supervision. These findings fit with recent literature that draws a distinction between "acquired" competencies and approaches to learning that predominate in the individualist cultures of HICs, and "participatory" competencies (such as collaboration, teamwork, communication, cultural sensitivity) and approaches to learning that arise out of dynamic social situations in collectivist cultures of LMICs. These approaches to learning and competency development each require different methods of evaluation and assessment. 21 Postexperience. There has been less pedagogy developed around the postexperience period and reinforcing of learning that occurs abroad. However, 2 that are the most described in the literature target self-reflection and debriefings. 14,22 In the group surveyed, 71% of respondents said they engaged in a debriefing session with trainees, but only 35 identified that they had them complete a reflective activity. Self-reflection, particularly critical reflection, has proven very important in maximizing the personal and professional development during STEGH. 14,22 It is important to note that there are still many host mentors who are not engaging with trainees in these ways, perhaps in accordance with different cross-cultural valuations and levels of comfort in the practice of reflection. The fact that no respondents said they would like to receive fewer trainees is very encouraging. Equally as important, of 142 respondents, none felt that trainees were coming to their sites as already capable practitioners to practice without additional learning, and only 13 of 140 (9%) thought that trainees gave more than they received from the STEGH. This is a strong sign that host mentors do not expect trainees engaging in STEGH to fill critical health care gaps, but rather are being allowed to come to communities to learn from them.
Unfortunately, very few trainees seem to stay in touch with the host community members after they depart, and even fewer return to the community. This underscores that trainees often are getting a viewpoint of GH at one moment in time in one community and not necessarily appreciating a longitudinal viewpoint of a community and its dynamic realities over time. It is clear that the individuals mentoring the trainees in host communities would like this to change, as 90% of respondents reported that they wished more trainees would stay in touch after completion of the STEGH.

C O N C L U S I O N S
To those generous partners hosting and supervising trainees during STEGHdoften without any substantial remunerationdteaching competencies such as cultural sensitivity, and continuing to demonstrate and develop humility and teamwork skills were clearly more important than acquiring and learning clinical or technical skills. This is in stark contrast to the goals and objectives being put forth by many GH programs in HICs. It is our hope that this data will begin a dialogue to build collaboratively developed learning objectives and competencies for STEGH, which will ultimately create stronger education for trainees, and enhance mutual respect between partners.

A C K N O W L E D G M E N T S
Dr. John McGready provided support and guidance around statistical analysis of the study. Dr. Cherniak was supported by a Sommer Scholarship at the Johns Hopkins Bloomberg School of Public Health while he completed the initial manuscript and data analysis.