Consensus on global health competencies for Korean medical students using a modified Delphi method

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Korean J Med Educ. 2023;35(4):389-405

Publication date (electronic) : 2023 December 1

doi : https://doi.org/10.3946/kjme.2023.275

Songrim Kim¹, Sun Young Kyung², Ie Byung Park², Kwi Hwa Park^,3

¹Office of Medical Education, Gachon University College of Medicine, Incheon, Korea

²Department of Internal Medicine, Gachon University College of Medicine, Incheon, Korea

³Department of Medical Education, Gachon University College of Medicine, Incheon, Korea

Corresponding Author: Kwi Hwa Park (https://orcid.org/0000-0002-0008-2400) Department of Medical Education, Gachon University College of Medicine, 38-13 Dokjeom-ro 3beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82.32.458.2635 Fax: +82.32.421.5537 email: ghpark@gachon.ac.kr

Received 2023 September 15; Revised 2023 October 13; Accepted 2023 October 19.

Abstract

Introduction

In 2020, the world experienced an unprecedented crisis due to the coronavirus disease 2019 (COVID-19) pandemic. The world realized not only that failure to effectively deal with the infectious-disease-induced healthcare crisis would have a detrimental impact on the healthcare system but also that one country’s healthcare problems were not limited to that country because of the rapid spread of the virus across continents. There are no boundaries between countries in terms of diseases, and interstate or global cooperation is important to manage such diseases, which is one of the reasons for the emphasis on global health education (GHE) [1,2]. Since the COVID-19 outbreak, joint response and quick and effective cooperation among countries to prevent the spread of the virus have become more necessary than ever for medical personnel [3]. The participation of doctors in international organizations is significant not only in terms of contribution to the international community but also in protecting the rights and interests of patients by identifying medical policy trends in the international community. Doctors can share each country’s experiences and expertise and participate in establishing medical systems and policies in underdeveloped countries. International exchange and cooperation also provide an opportunity to contribute to developing medicine and healthcare systems both at home and abroad. After the COVID-19 pandemic, there may be an increasing demand for doctors who can protect global health and contribute to the international community [4]. Global health competency is one of the social constructs for understanding social trends and changes, adapting to the changes in the medical environment, and contributing to the healthcare of the international community [5]. To promote the health of mankind, it is necessary to not only know what policy strategies and cooperation systems are in place but also develop a global sense in the medical field. It has been reported that students who have experienced GHE better understand disease patterns, perform more comprehensive clinical skills, have excellent cultural sensitivity, and are more likely to choose a career in global health after graduation and practice medicine in diverse cultural environments [6]. Moreover, medical students consider global health to be essential for working in a globalized world [7]. Therefore, sufficient understanding and education about global health problems are required for medical students to actively fulfill their roles in global health.

A competency-based approach is important in developing GHE curriculums. Competency-based education is intended for learners to successfully apply the knowledge, skills, and attitudes required in certain specialized fields to actual worksites, which is why it is accepted as a more important concept in healthcare, including in medical education. A competency-based education model would provide a more complete picture of GHE in medical school curriculums. For the smooth progress of these curriculums, a series of essential global health competencies are needed to prepare for various global health issues that medical students may face. Thus, continued efforts have been made to determine or integrate global health competencies in various studies. Notably, 14 competencies were derived after reviewing 32 domestic and international works on global health competencies and GHE: skills to better interface with different populations, cultures, and healthcare systems; an understanding of immigrant health; primary care within diverse cultural settings; understanding healthcare disparities between countries; an understanding of the burden of global disease; an understanding of travel medicine; developing a sense of social responsibility; appreciating contrasts in healthcare delivery systems and expectations; humanism; scientific and societal consequences of global change; evolving global governance issues; cost of global environmental change; taking adequate patient histories and physical examinations in resource-poor settings; and using physical diagnosis without high technological support [8]. Another study argues that the core components of GHE are fostering the ability to be engaged in interdisciplinary teams and work with all global health practitioners in a respectful and collaborative manner and developing equitable partnerships with shared leadership and stated, common goals [9]. According to the graduation competencies related to global health suggested by the General Medical Council in 2018, graduates must have knowledge and skills in areas such as population health; improvement and development of health; equity and sustainable healthcare; health service policy and economics; and ecological, environmental, and occupational hazards in ill health and their mitigation [10]. As such, with the increasing diversity of contents and methods addressed in global health and the growing demand for the standardization process, a subcommittee of the Consortium of Universities for Global Health (CUGH) in 2013 began to publish and regularly revise a tool kit that includes 38 competencies in 11 domains [11,12]. This toolkit specifically provides the competencies that must be developed in 11 domains: namely, global burden of disease; globalization of health and healthcare; social and environmental determinants of health; capacity strengthening; collaboration; partnering and communication; ethics, professional practice, health equity, and social justice; program management; sociocultural and political awareness; and strategic analysis.

Meanwhile, the core competencies of global health for nursing students have been defined in healthcare in Korea [13]. Further, 24 competencies were derived in six domains; global burden of disease; health implications of migration, travel, and displacement; social and environmental determinants of health; globalization of health and healthcare; healthcare in low-resource settings; and health as a human right and development resource. However, no research has been conducted thus far on global health competencies in medical education. In medical school education, global health is defined in the “2014 Korean Doctor’s Role” as the role and competency that medical students must have as social accountability [14]; the Basic Medical Education Accreditation Standards of KIMEE 2019 (ASK2019) [15] also recommend medical schools to include content related to global health and healthcare in their mission (H.1.1.1) and graduation outcomes (H.1.3.1). Consequently, global health is one of the fields that must be addressed to achieve graduation outcomes in medical education. To this end, global health competencies must be derived before developing a GHE program. Reaching a consensus on global health competencies would help all medical students be exposed to similar basic levels of education. Medical schools seeking to establish GHE programs and activities must start by defining the desired competencies. However, even though it is important to integrate international competencies into GHE for medical students, finding sources or studies with consensus on specific global health competencies that must be included in medical education is difficult. Therefore, this study aims to define the global health competencies of medical students in Korea through consensus among experts.

Methods

2. Research subjects

This study selected 13 experts (61.9%) who have majored in global health, have experience related to GHE, or are affiliated with institutions or organizations related to global health, as well as eight medical education experts in medical schools (38.1%) as the panel of experts for the Delphi survey (Table 1). The total number of panel members was 21, and they all participated in every round without dropping out.

Table 1.

Demographic Characteristics of the Respondents

Results

1. Results of the first-round Delphi survey

The results of the first-round Delphi survey were analyzed according to the CVR threshold (0.37 or higher), degree of convergence (0–0.5), and degree of consensus (0.75 or higher); descriptive opinions such as integration or exclusion of each competency were all reflected (Table 2). Thus, 52 competencies in 12 domains were restructured to 30 competencies in eight domains.

Table 2.

Content Validation Index of the Global Health Competencies and Experts’ Consensus in the First Round

Specifically, “globalization of health and healthcare” and “global migration and health” were integrated into “globalization of health and healthcare,” and “collaboration and communication” was integrated into “cultural diversity and health.” Meanwhile, three domains－“professional practice,” “global health research,” and “program development and management”－were excluded, and some competencies in these domains were modified and included in other domains. Moreover, “participation in global health activities” related to participation in global health programs was newly added.

In “global burden of disease,” two out of seven competencies were excluded, and one competency was integrated, and thereby it was modified into a total of four competencies. “Globalization of health and healthcare” had three competencies but was modified into five. One competency was excluded from the initial three, and two competencies that had been incorporated in “global migration and health” were included in this domain. In addition, “can explain global trends and efforts at national and regional levels to achieve health-related Sustainable Development Goals (SDGs)” was added as the new competency. “Determinants of health” had three competencies, but two of them were integrated into one competency, and one other competency was added, ultimately becoming modified into three competencies. The competency added was “can explain the concepts and levels (micro, macro, and so forth) of determinants of health.”

“Healthcare in low-resource settings” had six competencies, but three were excluded, two were integrated into one, and one was added, ultimately becoming modified into a total of three competencies. The competency added was “can see epidemiological situations in low-resource settings and apply them to diagnosis.” “Global health governance” had four competencies, but one was excluded, and thus it was modified into three competencies.

“Human rights and ethics” had 10 competencies, but four were excluded, and thus it was modified into six competencies. “Cultural diversity and health” had five competencies, but three were excluded. As it was integrated with the “collaboration and communication” domain, two competencies were included; thus, it was modified into four competencies in total.

Finally, “participation in global health activities” was added as a new domain with two competencies. The competencies that were added included “can identify the status of global health activities at home and abroad using all kinds of data” and “can perform one’s role by participating in global health programs at home and abroad.”

2. Results of the second-round Delphi survey

The responses from the second-round Delphi survey showed that no competencies met the standards (Table 3). However, the competencies were modified according to the descriptive opinions of the panel members about each competency; as a result, 30 competencies in eight domains were restructured into 24 competencies.

Table 3.

Content Validation Index of the Global Health Competencies and Experts’ Consensus in the Second Round

“Global burden of disease” was modified into three competencies, while the remaining competency was integrated into “globalization of health and healthcare,” which maintained five competencies with some changes to clarify the meanings of the competencies. “Determinants of health” was modified into two competencies, and competency 3 was integrated with competency 2. “Healthcare in low-resource settings” was modified into two competencies, and competency 3 was integrated with competency 2.

“Global health governance” maintained three competencies with some changes to clarify the meanings of the competencies. “Human rights and ethics” was renamed “Health as a human right” and modified into four competencies. “Cultural diversity and health” was modified into three competencies, integrating the ones with redundant meanings and making some changes to clarify the meanings of the competencies. “Participation in global health activities” maintained two competencies with some changes to clarify the meanings of the competencies.

3. Results of the third-round Delphi survey

The results of the third-round Delphi survey were analyzed in light of the agreement and additional opinions on global health competencies organized according to the results of the second round. The panel members agreed on the final version of global health competencies and provided a few opinions on modification. Words or texts in four competencies (competency 5 in “globalization of health and healthcare,” competencies 1, 2, and 3 in “cultural diversity and health”) to clarify their meanings. The global health domains and competencies for medical students were finalized through this consensus process (Table 4, Appendix 1).

Table 4.

Final Consensus of Global Health Domains and Competencies for Medical Students

Discussion

Health problems are occurring increasingly beyond national borders. Notably, GHE is becoming more important in solving these problems. Korea has not yet reached a consensus on global health competencies that can be potential resources for medical schools in developing their own GHE programs. This study was the first in Korea to derive global health competencies that must be included in undergraduate medical curriculums using a Delphi method for medical students to obtain global health competencies.

Accordingly, 52 competencies in 12 domains summarized in previous studies [11-13,17,18] were finalized into 24 competencies in eight domains after three rounds of the panel consensus process. Out of the eight domains in this study, “global burden of disease,” “determinants of health,” and “health as a human right” were among those that had also been commonly suggested in previous studies. “Global burden of disease” was most frequently mentioned in the literature review on global health competencies [8] and was proposed as one of the three major global health competencies that medical students must have [22]. This indicates that it is an important basic domain of competencies in global health. In “global burden of disease,” medical students must know the burden of disease, risk factors for that burden, and how these things vary across populations to understand and solve global health problems. They must also understand the indicators explaining health status and how they vary by region or country.

As “determinants of health” has been reported as the most valid global health domain for not only medical students but also nursing students [13], it is an essential domain of competency required for all students in medical and health departments. The competencies included in this domain identify the social, economic, and environmental factors (determinants) of health and how they affect the key health status indicators, such as the prevalence of diseases, mortality, and life expectancy. These competencies are required to resolve health disparities and gaps in quality of life, as well as to encourage action to achieve health equity [23]. “Health as a human right” also showed the highest ratio of consensus vis-à-vis having the most important competencies in health and healthcare [13]. The SDGs set by the United Nations also emphasize that health is a mandatory requirement of development resources, as well as a basic human right [24]. Therefore, medical students must be able to comprehend the relevance of health as a human right and present their own views on various ethical issues related to global health. If medical students can use GHE as a learning venue for medical ethics education so that they can cognize human rights and health inequalities and gain ethical and philosophical perspectives on healthcare [25], students’ competencies can be cultivated in this domain.

“Globalization of health and healthcare” and “global migration and health” were integrated into “globalization of health and healthcare,” ultimately deriving five competencies. This domain consisted of competencies related to the impact of changes incurred by the globalization in progress and the common migration between countries on global health and healthcare. The competency to understand and analyze the relevance between globalization and healthcare is so important that it is suggested as one of the 11 common competencies of global health for medical personnel [11,12]. Changes in healthcare in each country due to globalization are also factors affecting population health problems [26]. In a study on nursing students in Korea, “globalization of health and healthcare” showed relatively low validity. This study also revealed that this domain had the lowest validity among eight domains, except for “participation in global health activities.” In other words, this domain has global health competencies required for medical personnel and yet shows relatively lower validity compared with other domains.

“Collaboration and communication” was integrated into “cultural diversity and health.” Global health initiatives recommend medical students to have cultural sensitivity to provide holistic and comprehensive care for the gradually increasing immigrant population [22]. The aforementioned CUGH also includes communication skills and cultural awareness at the global citizen level as competencies [11,12]. The number of foreign residents and patients is also increasing in Korea [27]. Medical students must be able to interact effectively with people from different cultures and have the cultural competency to respect and respond to the health beliefs and cultural needs of diverse populations [28]. Medical students must identify their own beliefs and cultural identities about people or patients from diverse backgrounds and introspect and have critical self-awareness.

Meanwhile, “professional practice,” “global health research,” and “program development and management” were excluded in the first-round Delphi survey. The panel members did not include these competencies because they were not related to those at the medical student level and were a burden on medical school curriculums. In the process of reaching a consensus on competencies, the CUGH assigned the competency levels according to the intent of education to the global health citizen level, which is the basic preparation level for pursuing and contemplating a future in any field related to global health, and the basic operational program-oriented level, which is the discipline-specific level for a career in global health. The basic operational program-oriented level has 38 competencies in 11 domains, which include the global citizen level with 13 competencies in eight domains [11,12]. This shows that discipline-specific level domains and competencies beyond the medical student level are also excluded in this study. This might be because the competencies at the basic operational program-oriented level were also included when initially developing the Delphi survey items. Other studies have also claimed that policy development, analysis, and program management are global health competencies for specific professional groups, which are included within the scope of competencies at the postgraduate education level [29]. For this reason, this study added a new domain called “participation in global health activities.” This domain has competencies at the medical student level, which include searching for information necessary for global health activities and voluntarily participating in various global health programs.

As in previous studies, “global burden of disease,” “determinants of health,” and “health as a human right” emerged as core competencies. Unlike previous studies, “global health research” and “program development and management” were not included as competencies in Korea. Even if these competencies are limited at the undergraduate level, they should be considered as necessary competencies for students considering majors or careers in global health. Furthermore, cultural competency should be emphasized in the future in the Korean context, where population migration and globalization are accelerating and the patient population from different cultures is increasing.

The limitations of this study are as follows: as the items for the first-round Delphi survey were developed on the basis of the review of a few representative works in the literature, this study might not include all domains and competencies. The adequate levels of CVR, degree of convergence, and degree of consensus were all considered in the analysis process, but as the additional opinions described by the panel members were also reflected, this might have unintentionally affected the results in a subjective manner. Therefore, it is necessary to verify and supplement the validity of the current competency framework on the basis of continuous research. Global health competencies in this study are limited to only those at the medical school level, thus underscoring the importance of establishing a competency framework in each step by expanding to the postgraduate education level. Moreover, it will be possible to expand the scope of application by conducting a follow-up study that establishes a guide to reach each competency, such as the content and method of education, and evaluation.

Notwithstanding the growing demand for global health competencies as graduation outcomes, there is still a lack of consensus on global health competencies that must be acquired by medical students in Korea. This study is significant in terms of reaching a consensus among experts in this situation. The results of this study are expected to be used as the basic data for the development of GHE programs for medical students in the future.

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