The complex relationships involved in global health: a qualitative description

Background Growing numbers of medical trainees now participate in global health experiences (GHEs) during their training. To enhance these experiences we sought to explore expectations inherent in the relationships between GHE stakeholder groups. Methods 20 open-ended, semi-structured interviews probed participant perceptions and assumptions embedded in GHEs. A fundamental qualitative descriptive approach was applied, with conventional content analysis and constant comparison methods, to identify and refine emerging themes. Thematic structure was finalized when saturation was achieved. Participants all had experience as global health participants (10 trainees, 10 professionals) from an urban, academic, Canadian medical centre. Results We identified three stakeholder groups: participants (trainees and professionals), host communities, and sponsoring institutions. During interviews, four major themes emerged: (i) cultural challenges, (ii) expectations and perceptions, (iii) relationships and communication, and (iv) discordant objectives. Within each theme, participants recurrently described tensions existing between the three stakeholder groups. Conclusions GHE participants frequently face substantial tensions with host communities and sponsoring agencies. Trainees are particularly vulnerable as they lack experience to navigate these tensions. In the design of GHEs, the needs of each group must be considered to ensure that benefits outweigh potential harms. We propose a conceptual model for developing educational objectives that acknowledge all three GHE stakeholder groups.

Part Two is a needs' assessment in which we will focus on several key themes of global health and ask you to describe your own experiences. Your responses will be used to inform the development of a global health curriculum. In this section, I will be audio recording your answers. This part of the interview is a conversation-style answer and response. So at times, I may at ask you to further expand on your experiences. Please note, that this portion of the survey will be entirely anonymous, and remain separate from part one, above. The anonymous audio-recordings will be transcribed and only the transcriptions will be used for data analysis.
If you require any clarification of a question(s), please stop and ask prior to responding and I will better explain the question.
We will now begin. We will now commence the needs' assessment portion of the survey. I remind you that this section is entirely anonymous and your responses will be audio-recorded and transcribed. I encourage you throughout this section to please describe in your own words, the experiences that you think are most relevant. Do you have any questions before we begin?

CONTACT INFORMATION
1. Please describe the most significant challenges/barriers you have encountered in your Global Health work.
a) Related to the example(s) above, can you please describe how these issues were coped with or resolved?
b) Are there any other significant challenges that you would like to discuss that we have not covered?
2. Please describe some noteworthy successes you experienced during your global health work that were not included in question #1.
3. Please describe any resources that you found most beneficial during your Global health project(s). This may be prior to your departure, when you were abroad and/or when you returned home. (If asked for clarification of the term "resources"; PROMPT: "for example, resources might include courses, funding, contacts, debriefing opportunities") a) Follow up question: Can you think of resources that you wish you had had available?
4. Why do you go abroad, and what drives you to continue your work?
5. Have your experiences impacted your practice and/or life? Please expand.
6. Are there any topics or themes that you believe to be essential in the field of global health such that they should be taught to all medical students regardless of whether they will have future involvement in the field? If so, please specify. These topics or themes may be presented in the context of PBLs, a mandatory course or general inclusion throughout the curriculum.
7. Another topic we're interested in exploring is your experiences of interprofessional collaboration in your Global Health activities. And we understand that the idea of 'interprofessional' may be very different for in your global health work than in your Canadian practices. Could comment on your experiences of collaborating with other healthcare professionals in global health settings? Maybe compare these to your experiences here in Canada?
8. Please tell me about the perceptions of the impacts your GH work had on individuals and/or communities in the host country. These perceptions can be your own or those from people of the host country.
b) What does medical tourism mean to you? Have you encountered it? 9. We have had a chance to talk about some of the aspects of your global health activities.
There may be issues that haven't been addressed yet, can you describe to me any other issues and themes that you would like to address.
10. Please describe any advantages or disadvantages that you could foresee in establishing a network of information sharing & resource pooling amongst Global Health contributors through the Global Health Initiative?
11. During your global health experiences, were there any occasions in which you or other trainees were involved in situations where you were concerned about patient safety? a) Can you give me an example or a story about such an experience?
12. While you were abroad, were there any clinical situations where you were concerned about your own or another trainee's personal safety? a) Can you describe that situation for me?
13. During your global health experiences, were there any instances where you or another trainees were asked or felt pressured to perform above your clinical competency or skill level? a) Can you give an example or a story?
14. While you were abroad, were there any clinical situations that you would describe as ethically questionable either involving you or other trainees? a) Can you tell me about that situation?
This concludes the needs' assessment portion of our survey. I would like to thank you very much for taking the time to aid us in building a stronger global health community. Your time is greatly appreciated.