How do Ontario family medicine residents perform on global health competencies? A multi-institutional survey.

BACKGROUND
There is an increased interest in global health among medical students, family medicine residents, and medical educators. This paper is based on research to assess confidence in knowledge and skills in global health in family medicine residents in five universities across Ontario.


METHODS
A web-based survey was sent to 166 first-year family medicine residents from five universities within Ontario. Descriptive statistics were used to analyze residents' confidence in their knowledge and skills in global health. The strength of association between each of the self-perceived knowledge and skills variables was assessed by the Spearman correlation coefficient.


RESULTS
The response rate ranged from 29% to 66% across the five universities. Self-perceived knowledge scores revealed that 34.3% of the respondents were very confident, 51.9% were somewhat confident, and 13.8% were not at all confident about their global health knowledge. Participants' confidence scores were lower in relation to knowledge of access to health care for low income nations (44.3%), and were better on their global health skills related to working in a team (70.9%) and listening actively to patients' concerns (64.6%).


CONCLUSIONS
The global health competency scale has identified key areas of strengths and weaknesses of family medicine programs in global health education. This can be used to evaluate and analyze progress over time.


Introduction
There is a marked increase in interest in global health among medical students, family medicine residents and medical educators; 1,2 they are demanding more emphasis on global health teaching and international opportunities in medical school. 3,4 In these times of globalization, 5 it is important that family physicians feel competent in contributing meaningfully to reducing inequalities, both in their own practice and in the global context with determinants of health such as socioeconomic, environmental and political factors. Hence, global health training should be part of the residency program curriculum and be adapted to the requirements of each specialty. 6. Global health training may further stimulate students to develop a commitment to community health as well as provide an opportunity to work with socially disadvantaged populations. Additional benefits of global health training include an opportunity to learn or improve a foreign language. 7 A key component of global health are the social determinants of health identified by the World Health Organization. In Canada, health disparities are related mainly to ethnic background, gender, education level, income, geographic location, and other characteristics that can bring disadvantages in accessing health care for some groups compared to others. 8 Family physicians have a crucial role to play in providing effective primary health care for disadvantaged populations, and primary care has been shown to be an effective strategy to promote health equity in both high-income and low and middle-income countries. 9 The quality of education for family medicine residents plays an important role in the effectiveness of primary care. 10 Improving family physicians' knowledge about global health and health equity may help to reduce health care disparities, address the inequities related to treatment and access to health care for socially disadvantaged populations, 11 and achieve effective primary care. Canadian health system policies put family medicine central in delivering comprehensive community-based health care. Canada is large, ethnically diverse, has indigenous health inequalities, a universal health care system that covers the entire population, and has primary care as a priority area in health.
Therefore, improving education in global health and health equity for family medicine residents has a huge potential to enhance family medicine residency programs and consequently improve the effectiveness of primary care services for socially disadvantaged populations. This study is part of a larger assessment of global health competency in students in healthcare. This study aims to describe global health competency in family medicine residents in Ontario in order to understand their perceived knowledge and skills in global health as well as learning needs in major global health topics.

Sample
In 2011, a total of 452 family medicine residents in five Ontario universities were invited to participate in the survey. The criteria for inclusion in this study were: being 18 years or older; being in a program from the following participating universities: University of Ottawa, University of Toronto, Queen's University, Western University and McMaster University; and must be a 1 st year resident in a family medicine residency program.

Design
A cross-sectional study.

Data collection
Residents who were eligible to participate were identified by the directors or coordinators of their program. They received an electronic e-mail invitation with a web link to access the online survey and consent form. Reminders were sent at two-week intervals. The data were collected using a web-based tool, Survey Monkey (http://www.surveymonkey.com).

Instrument
The instrument was adapted from: (a) a validated questionnaire used to measure actual and perceived resident physicians' knowledge of underserved patient populations in the United States and adapted to the Canadian population, 12 (b) items from a global health competency survey for medical students, 13 and (c) Canadian Medical Education Directives for Specialists (CanMEDS) competencies. 14 The instrument was assessed for validity, reliability and pretested in a previous study. The survey consisted of 30 questions subdivided into four categories: 1) Knowledge of global health and health equity (selfassessment); 2) Global health skills for working with patients who have different linguistic, educational, socioeconomic, and cultural backgrounds (selfassessment); 3) Learning needs about global health; and 4) About you -socioeconomic and demographic questions. This survey was previously validated and demonstrated good internal consistency and validity with a Cronbach's alpha > 0.8. 15 The responses to the questions were: 'not at all confident', 'somewhat confident' or 'very confident'. These were coded as 0 (not at all), 0.5 (somewhat) and 1 (very). Thus, by averaging all respondents' answers to a given question and multiplying that average by 100, each question could be summarized by a number between 0 and 100, with 0 representing an overall complete lack of confidence and 100 representing a perception of being very confident. This approach to measuring confidence was previously used by Wieland et al. 16

Ethical considerations
The study was approved by the University of Ottawa, the Ottawa Hospital research Ethics Board, and the University of Western Ontario.

Data analysis
The data were analyzed with descriptive statistics using the Statistical Package for the Social Sciences Software (SPSS, version 19). Descriptive statistics were used to analyze residents' self-perceived knowledge and skills in global health. The strength of association between each of the global health knowledge and skills variables was assessed with the Spearman correlation coefficient.

Demographic characteristics
Surveys were completed by 166 residents. The overall response rate ranged from 29% to 66.35%. Respondents were predominantly female (68.7%), median age was 29 years, white background (58.4%), raised by parents with family income of $80,000 or more per year (44.6%), and able to speak only one language (42.8%) ( Table 1). four languages or more 16 (9.6)

Self-perceived knowledge
Self-perceived knowledge in global health topics revealed that 34.3% of the respondents were very confident, 51.9% were somewhat confident, and 13.8% were not at all confident. Regarding all topics, residents' average score percentages were higher for confidence in their knowledge of the relationship between income and health (79.52%), relationship between socioeconomic position and impact on health (75.30%), and relationship between work and health (70.90%). Their average score percentages were lower for access to healthcare for low income nations (44.24%), mechanisms for why racial and ethnic disparities exist (44.58%), and racial stereotyping and medical decision making (46.39%) (item scale: 0 = not at all confident; 0.5 = somewhat confident; 1 = very confident) ( Table 2).  (Table 3).

Correlation between self-perceived knowledge of global health and global health skills
As shown in Table 4, several variables from selfperceived knowledge of global health were significantly correlated with global health skills variables. The major positive significant correlations were found for: 1) residents' knowledge of racial and ethnic disparities and skills in keeping up to date in global health (0.38); 2) knowledge of racial stereotyping and clinical decision making and skills in keeping up to date in global health skills (0.35); 3) knowledge of gender and access to health care and skills in keeping up to date in global health (0.34).

Discussion
Our results show that family medicine residents' confidence in their knowledge of global health was generally low. These results were corroborated by the findings of a survey of US residents on actual and perceived knowledge of underserved populations which also showed low self-perceived knowledge ( 18 This survey includes two residents from each family medicine program across Canada and intends to compare programs nationally. 18 There is a need to improve global health education across programs in Canada as well as global health skills related to other CanMEDS competencies, such as expert, manager, health advocate, scholar and professional. All these competencies are essential for a family physician to provide effective care to disadvantaged populations locally and internationally.
Although we found small correlations among selfperceived levels of knowledge of global health and self-perceived global health skills, all self-perceived knowledge variables have a correlation with the global health skills, which highlights the importance of the use of this survey to evaluate and track changes in global health skills of family medicine residents.

Conclusion
This study attempted to describe self-perceived knowledge of global health and global health skills in family medicine residents in Ontario. The findings of this study demonstrate clearly that there is a need to improve global health curricula in family medicine residency programs in Ontario universities. Overall, the self-perceived knowledge of global health score was below 60% for six out of the twelve items. Residents scored below 60% in eight out of eleven global health skills. It is imperative to use and improve this survey tool designed to measure global health competencies. It is also important to evaluate global health knowledge and skills over time to be able to track improvements in the curricula. Therefore, upon review of the survey data, workshops, training and courses can be developed in the short term to address areas of weakness in knowledge and skills in terms of global health competence, considering local and international settings.