Global health education in medical schools (GHEMS): a national, collaborative study of medical curricula

Background Global health is the study, research, and practice of medicine focused on improving health and achieving health equity for all persons worldwide. International and national bodies stipulate that global health be integrated into medical school curricula. However, there is a global paucity of data evaluating the state of global health teaching in medical schools. This study aimed to evaluate the extent of global health teaching activities at United Kingdom (UK) medical schools. Methods A national, cross-sectional study assessing all timetabled teachings sessions within UK medical courses for global health content during the academic year 2018/19. Global health content was evaluated against a comprehensive list of global health learning outcomes for medical students. Results Data from 39 medical courses representing 86% (30/36) of eligible medical schools was collected. Typically, medical courses reported timetabled teaching covering over three-quarters of all global health learning outcomes. However, a wide degree of variation existed among granular global health learning objectives covered within the different medical courses. On average, each learning outcome had a 79% [95% CI: 73, 83%] probability of being included in course curricula. There were a number of learning outcomes that had a lower probability, such as ‘access to surgeons with the necessary skills and equipment in different countries’ (36%) [95% CI: 21, 53%], ‘future impact of climate change on health and healthcare systems’ (67%) [95% CI: 50, 81%], and ‘role of the WHO’ (54%) [95% CI: 28, 60%]. Conclusions This study served as the first national assessment of global health education and curricula within UK medical schools. Through a formalised assessment of teaching events produced by medical schools around the country, we were able to capture a national picture of global health education, including the strengths of global health prioritisation in the UK, as well as areas for improvement. Overall, it appears broad-level global health themes are widely discussed; however, the granularities of key, emerging areas of concern are omitted by curricula. In particular, gaps persist relating to international healthcare systems, multilateral global health agencies such as the WHO, global surgery, climate change and more.

before [2] and have become an ever increasing threat to global security [3]. HCPs are key workers for mitigating and managing disease threats to maximise human safety and survival. In order to prevent and prepare for future pandemics, it is key that all HCPs are given the training to understand international disease epidemiology and trends. Equally, a better understanding of whole population health and an appreciation of the complex relationships between certain communities, ill health and health inequities is essential for effective healthcare leadership in service planning [4]. Moreover, it is the ethical responsibility of HCPs, as health advocates, to learn from one another transnationally to improve health around the world [5]. The aforementioned concepts are core principles of medical practice [6,7]. Therefore, these professional values must be fostered and encouraged at an early stage of medical training [8].
There have been repeated calls for more robust global health education within medical training programmes from students [9][10][11] and faculty alike [5,[12][13][14]. International legislative voices, such as the World Health Organisation (WHO) now insist that global health be included in medical school curricula [15][16][17]. Many medical schools incorporate global health education into their curriculum through student selected (optional) modules or through intercalated Bachelor of Science degrees [6,14]. However, global health principles have been mandated to be included in medical school curricula as essential, non-elective modules [12,[18][19][20][21]. Documents from a regulatory body for medical professionals in the United Kingdom (UK) detail specific global health learning outcomes and competencies that medical students are expected to achieve by graduation [18][19][20].
However, it is unclear whether medical schools have integrated global health learning outcomes into their compulsory syllabi. This is because there is a paucity of data evaluating the current state of global health teaching in medical schools. In particular, there is limited data on curricula, teaching methods and quantity of global health education outside of the United States (US) [22]. The Global Health Education in Medical Schools (GHEMS) study is a UK based, multicentre, collaborative study that aimed to characterise global health education and curricula within UK medical schools. The primary aim of this study is to formally map the extent of timetabled global health teaching activities within UK medical schools. This information can be used by medical schools and regulators to ensure that an adequate global health education is being provided to all medical students.

Study design and participants
The study was conducted as per the previously published study protocol [23]. This was a national study evaluating global health education within UK medical school curricula during the academic year 2018/19. Medical schools were eligible to participate if they were recognised by the General Medical Council (GMC) as being able or being under review to award a UK medical degree in 2019. Data variables were based on a list of global health learning outcomes published by the Global Health Learning Outcomes Working Group (GHLOWG) [12]. This list was developed through consultations with a consortium of global health stakeholders, comprising universities, the public, the Royal Colleges, and other professional, educational, and civil society bodies, with discussions focused on the targeted outcomes listed in guidelines published by the GMC. For the purposes of this study, the list was amended following consultations with the lead author of the GHLOWG publication [12] and a board of cross-specialty advisors comprised of educationalists and global health professionals. The list was modified to improve interpretability for students and to add a learning objective (LO) related to global surgeryrecently added as a mandatory LO to the national undergraduate curriculum in surgery [24] to produce the final list of 42 LOs (Appendix 1).
Two collaborators were recruited at each participating centre by utilising existing networks of national and local bodies interested in global health. All collaborators attended a training and support session delivered by the GHEMS steering committee. Following the training session, collaborators ensured the correct departmental approval had been achieved prior to collecting data. The GHEMS steering committee maintained regular contact with all data collectors in order for collaborators to receive prompt clarifications regarding project uncertainties and provide feedback on local issues or questions raised by their institution. The authorship of this paper was modelled according to previous collaborative publications [25].

Data collection
Collaborators obtained timetables for all curricular years of medicine at their institution for the academic year 2018/19. Separate timetables were obtained for undergraduate and graduate-entry medicine course curricula as timetabled teaching often differs between courses within the same university due to differences in courselength: undergraduate courses are typically five to six years in length, while graduate-entry courses are usually four to five years in length. Each collaborator identified global health curricular events from the timetables and independently coded them to populate a standardised data collection template formulated by the steering committee as per the study protocol (Appendix 2) [23]. Collaborators were advised not to discuss institution results with each other during the data collection phase. Following data collection, the data points in agreement (90% of all data points) between collaborators at the same institution were recorded. For the 10% of data points encountering disagreement, conflicts were resolved by mutual agreement or through a member of the GHEMS steering committee reviewing the evidence and making the final judgement. All final decisions were relayed back to the collaborators and feedback was sought from medical leadership to ensure that coding accurately represented the state of global health teaching within their medical school. Following this, permission was obtained from selected participating centres to utilise the global health content taught at their institution to create an amalgamation of frequently discussed topics (Appendix 3).

Study variables
Variables pertaining to characteristics of the timetabled learning eventcourse year, undergraduate/graduate-entry course, and style of teaching -were collected. The assigned LOs for each timetabled event were recorded. The duration of time that each timetabled event spent on a global health LO was not recorded. Timetabled events for student selected modules and intercalated years were excluded from further analysis. Variables pertaining to medical elective placements at each institution were also collected, including length of the elective and the year of study. The content and location of electives are likely to be highly variable from one student to another, and as such it was beyond the scope of this study to collect more granular data about electives.

Statistical analysis
Data was analysed using descriptive statistics to determine the proportion of LOs included in each UK medical course curriculum. For individual LOs, we calculated the proportion of medical schools reported to be delivering that LO. For groups of LOs (themes and sub-themes), we determined the median number, mean proportion, and range of LOs covered within that group across reporting schools. We used exact binomial methods to estimate 95% confidence intervals around proportions. We applied a multilevel Poisson model with robust variance to compare coverage of individual and grouped LOs to average coverage using dummy variables, modelling variance between medical schools as a random effect. We also used this approach to assess differences between LO coverage between undergraduate and graduateentry medical courses. Where reported, confidence intervals were 95% and p-values were two-tailed. LOs and sub-themes that were covered by fewer than 80% of participating centres have been highlighted, and divided into those that are covered by some medical courses (60-80%), and those that are covered by few medical courses (< 60%).

Ethical considerations
Advice on ethical approval was sought from King's College London Research Ethics Committee and Oxford Medical Sciences Inter-Divisional Research Ethics Committee. Both committees stated this study did not require ethical approval.

Role of the funder
The author(s) received no financial support for the research, authorship and/or publication of this article.

Characteristics of timetabled teaching sessions
Eighty-three percent of eligible UK medical schools were represented in this study (30/36). Eligible centres were excluded due to an inability to recruit collaborators or a lack of permission granted by the prospective institution. Among consenting institutions, 23 were located in England, five in Scotland, two in Wales and none in Northern Ireland. Data was extrapolated based on the type of medical course offered within the institution: undergraduate and/or graduate-entry course. Overall, data from 39 medical courses was collected: 28 undergraduate medical courses and 11 graduate-entry medicine courses. A range of teaching styles were employed by each medical course to deliver LO content. Undergraduate and graduate-entry courses had a similar distribution of pedagogical techniques (Fig. 1). The majority of teaching (74%) was delivered via lectures in both undergraduate (72%) and graduate-entry (83%) courses. The remainder of the teaching was provided via small group teaching (13%; undergraduate:14%; graduate-entry: 10%), problem-based learning (8%; undergraduate:9%; graduate-entry: 0.1%), case-based learning (2%; undergraduate:1%; graduate-entry:6%), and self-directed learning (4%; undergraduate:4%; graduate-entry:1%). Theme one: global burden of disease All medical courses (n = 39) included timetabled content pertaining to the 'global burden of disease' theme. Nested within this theme, the following three sub-themes: 'the health of populations', 'migration and disease' and 'pandemics' were offered within the teaching of 100% (39/39), 100% (39/39), and 90% (35/39) of medical courses, respectively. The three sub-themes were further subdivided into 11 global health LOS that were included in 89% (35/ 39) [95% CI: 74, 96%] of medical courses. Moreover, all medical courses documented the inclusion of 'principles of disease prevention and control in a global setting' and 'diseases commonly seen in certain communities' into timetabled teaching ( Fig. 3 and Table 2). In addition, 'mortality and morbidity statistics between countries' and 'nutrition on health' was covered by all undergraduate medical courses and all graduate-entry medical courses, respectively. There was a significant difference between the proportion of undergraduate medical courses that reported they had scheduled teaching on 'global, national, and local efforts to control pandemics' (27/ 28,96%) and the proportion of graduate-entry medical courses that reported they had timetabled teaching on this LO (8/11, 73%) (p = 0.0326).

Coverage of Global Health LOs by UK medical courses
Theme two: socio-economic, cultural, and environmental conditions All medical courses documented inclusion of the theme 'socio-economic, cultural, and environmental conditions' as part of timetabled teaching. The six sub-themes that formed this broader theme: 'effects of violence and war on health', 'health inequity' and 'socioeconomic factors affecting health', 'political factors affecting health', 'environmental and occupational hazards and ways to mitigate their effects' and 'future impact of climate change on health and healthcare systems' were included in timetabled learning opportunities of 62% (24/39), 100% (39/ 39), 100% (39/39), 90% (35/39), 85% (33/39), and 67% (26/39) of courses, respectively ( Fig. 3 and Table 2). On average, all six global health LOs within this theme were reported to be included in the timetabled teaching of 85% (33/39) [95% CI: 67, 100%] of medical courses.  Table 2). Three LOs were not included in any teaching sessions by the majority (> 50%) of medical courses: access to surgeons with the necessary skills and equipment in different countries ( Fig. 3 and Table 2). This mean was skewed left by the relatively few medical schools that had timetabled teaching about 'how to communicate with someone who does not speak English' (26/39, 67%). Of note, all graduate-entry medical courses reported inclusion of 'being informed of cultural differences from people from that culture', 'sociology and psychology of the varied responses of groups and societies to disease', and 'health behaviours and outcomes of specific backgrounds' into their timetabled teaching.

Medical electives
The average length of elective opportunities offered at each UK medical course was 6.8 weeks. The length of the elective opportunities ranged from four weeks to ten weeks. Overall, 13 medical schools (43%, 13/30)offering undergraduate and/or graduate entry medical coursesreported compulsory pre-elective timetabled teaching for medical students, with topics ranging from appropriate vaccinations to respecting local cultures. Two medical schools held post-elective face-to-face reflection sessions with students.

Discussion
This study affirms that the majority of learning outcomes produced by the GHLOWG are being taught as part of timetabled teaching within the majority of UK undergraduate and graduate-entry medical courses. The pedagogical method utilised by the majority of the teaching sessions are lectures. Broad-level themes and subthemes are well-covered within curricula; however, there is considerable variation when it comes to more specific global health LO opportunities. For instance, while all medical courses delivered teachings on the structure and function of the National Health Services (NHS), broader discussions surrounding healthcare systems and the dynamic involvement of the private and charitable sectors were neglected. Similarly, it was estimated that only over half of medical courses provided teachings on the WHO's framework and role, leaving much to speculate regarding students' education of international global health surveillance and security. Further, few medical courses included content on highly topical global health issues, such as global surgery and climate change. Trends were largely similar between undergraduate and graduate-entry courses; however, graduate-entry courses were less likely to cover content pertaining to pandemics. Finally, although medical schools offered approximately seven weeks of elective time, there were minimal learning opportunities pertaining to elective preparation or debriefing.
By gaining a greater understanding into global health topics exposed to UK medical students, we were able to ascertain the key lessons being instilled in the future NHS workforce. The inconsistent coverage of certain LOs between medical schools, indicates distinct differences in standards of global health education across the UK. Translational topics including awareness of cultural  differences, the ethics of healthcare delivery and diseases commonly seen in certain migratory communities, are universally applicable to all students' future careers as NHS clinicians. However, less frequently discussed topics such as healthcare systems, global health security and surveillance, global surgery and climate change also necessitate attention in order to ensure these needs do not go unmet [26,27]. In particular, the emergence of the novel coronavirus pandemic reinforces these essential global health lessons. A thorough understanding of not just the hierarchy of the NHS, but also the structure and functioning of international healthcare systems affords students a greater opportunity to understand global health security and pandemic preparedness [28]. When the Ebola epidemic spread across West Africa, there was an acute need for medical professionals to adopt less traditional roles and new knowledge. A renewed spotlight was placed on the need for comprehensive health systems models, with integrated global health security [29]. Our study noted that few medical courses included teaching about the WHO, marking a major gap in education surrounding global multilateral health agencies. The WHO plays a vital role in preventing and addressing disease around the world, and many argue that the coronavirus pandemic has reinforced the importance of this role [30]. Overall, as future clinicians, medical students are in the unique position to harness the lessons of pandemic response to step into professional roles that mitigate disease threats [31]. Developed by the American Medical Association (AMA), health systems science (HSS) is a novel approach designed to challenge medical curricula to include regular, interdisciplinary, health systems teaching [32]. Trialled by a few medical schools in the US, HSS calls for timetabled emphasis on healthcare policy, health information technology, systems thinking and more [32]. Authors of the HSS movement caution that such reform must be accompanied by addressing student-perceived barriers such as the basic science-focused design of formal medical assessments and additional stressors [33]. In addition to the above global health needs, emerging topics such as global surgery and climate change were covered infrequently by medical curricula. In 2015, the Lancet Commission on Global Surgery released a landmark report detailing the needs of five billion people who lack access to safe, timely and affordable surgical care [34]. Advocates reinforced surgery as an "indivisible, indispensable part of health care," with moral and economic arguments for future investment by nations [34]. At a higher-tier in the UK, the Royal Colleges have affirmed their commitment to addressing inequities in surgical care, through dynamic collaborations with the College of Surgeons of East, Central and Southern Africa (COSECSA) and SURG-Africa, among others [35]. Moreover, global surgery has been ratified by the Royal College of England as an essential topic among surgical undergraduate curriculum [24]. With parallel calls for strengthening global surgery education at the traineelevel, learning opportunities pertaining to surgical inequities are crucial for inclusion in medical school curricula [36]. Similarly, as literature continues to emerge detailing the links between climate change and health, such issues must be discussed among the future health workforce [37]. Global temperature shifts, wildfires, changing tides, disrupted animal habitats and more, challenge the homeostasis of our existing disease patterns, including the presentation of novel infectious diseases. Given the topic relevance, medical students must be equipped with climate change knowledge, in order to serve as advocates and counsel for patient wellbeing [38]. The One Health approach may serve as a blueprint for schools looking to further consider the complex effect of human, animal and environmental health on emerging disease threats [39]. Finally, elective preparation and debriefing is an area of need that has been identified by GHEMS and others [11]. With 90% of UK medical students participating in a medical elective abroad, it is particularly important to ensure students are equipped with the necessary knowledge, awareness and cultural humility to meaningfully work in settings of varied resourcelevels as well as appropriately learn about other cultures and medical systems [40]. Given medical electives are a valuable opportunity for many students to consolidate and contextualise their global health teaching, it is a significant missed opportunity that only 40% of medical schools provide a mandatory timetabled preparatory course. The GHEMS study comprehensively captured data from 83% of eligible medical schools in the UK. This has been possible through collaboration amongst students. Such collaborative projects which are driven for students, by students, have been validated internationally and have a proven record of generating robust data [25,41]. Amongst participating medical schools, approximately 90% of centres had two collaborators independently coding all timetabled global health learning events, thereby increasing the reliability of the data. The consistency and reproducibility of the data was ensured by providing centralised training to collaborators and publishing an open access comprehensive study protocol [23]. Through the GHEMS study, local results were disseminated to institutional leadership to facilitate ongoing discussions surrounding educational quality improvement. This crucial link in the audit loop, ensures that participating centres can benefit from study results and identify strategies for global health education reform at their respective institution. Moreover, our study is timely, as several new medical schools (including the Universities of Sunderland, Lincoln and Edgehill) are currently developing their curricula. In addition, as the world combats a novel infectious disease pandemic, concerns arise surrounding the under-representation and variance of key LOs within medical school curricula. This warrants further investigation into the reasoning behind curricula development. Similar research has been conducted in both the US and Canada through formalised organisations such as the Global Health Education Consortium [22]. National recommendations have also yielded a diverse range of global health learning opportunities among American medical schools [11], suggesting the need for greater international reform of global health education. The results of GHEMS serve to guide schools in developing comprehensive curricula that addresses all recommended global health LOs. Finally, it is interesting to note that most global health LOs are being taught via lectures: the most base form of information transfer; these LOs are topics that lend themselves to in depth discussions between students. The paucity of small group teaching around global health may be an indicator that there has not been sufficient emphasis on global health to make it more of a "skill" than just knowledge.
The cross-sectional nature of our study restricted the depth of gathered curricular information. A continual audit cycle of global health teaching across multiple years would reveal the true nature of global health curricular progression within medical schools. In addition, data collection was limited to timetabled information found within institutional virtual learning environments and schedules. In this regard, authors were unable to ascertain whether planned teaching matched actual learning opportunities delivered to students. Although data pertaining to the length of each teaching session was collected, we believe this was not representative of the breadth of nuance of coverage afforded to each LO. For example, while a topic may have been listed within the learning points of a lecture, we were unable to ascertain what proportion of the total lecture time was spent on this area of interest. It is also important to acknowledge the various opportunities for external global health exposure afforded to medical students through summer projects, conferences and more. Such opportunities may depend on factors such as geographic region, local global health faculty and institutional global health funding, but nevertheless should be assessed in order to capture the variability of student experiences. Finally, this study did not evaluate institutional global health examination standards. Teaching without assessment will generally be viewed as noncompulsory, particularly by busy medical students, therefore efforts in this discipline should be directed towards robust global health educational examination as well.

Conclusion
This study serves as the first national assessment of global health education and curricula within UK medical schools. Through a formalised assessment of teaching events produced by medical schools around the country, we were able to capture a national picture of global health education, including the strengths of global health prioritisation in the UK, as well as areas for improvement. Overall, it appears broad-level global health themes are widely discussed; however, the granularities of key, emerging areas of concern are omitted by curricula. In particular, gaps persist relating to international healthcare systems, multilateral global health agencies such as the WHO, global surgery, climate change and more. To facilitate local strengthening of global health educational opportunities, collaborators reported local results to institutional leadership to initiate discussions regarding avenues for satisfaction of the topical gaps in content identified. With models such as GHEMS, we encourage national advocacy bodies and other stakeholders to conduct ongoing status reviews of compulsory global health teachings within their medical schools, with a view to highlight areas for improvement. To equip medical students in the UK with the knowledge to operate, thrive and care for communities in our ever-globalised world, medical schools must vigilantly upgrade current curricula to reflect expert-driven recommendations for global health education. Finally, we perceive and hope that the GHEM S framework will be replicated internationally in order to address the paucity of global health educational literature in medical schools and strengthen the opportunities afforded to students to learn, grow and serve future patient populations.

Complete List of Global Health Themes, Sub-Themes, and Learning Objectives
The full list of forty-two global health learning objectives is listed below. The forty-two global health learning objectives can be divided into seventeen sub-themes, which fit into five global health thematic elements. Each learning objective, sub-theme, and thematic element was cross-referenced with the GHLOWG learning outcome that it relates to.

Data Collection Template
Below is a sample of our data collection template. Each row represented a documented teaching session, while each column represented a variable of interest regarding that teaching session. The start of the form collected baseline data pertaining to the key characteristics of the teaching session, while later components were comprised of each learning objective subdivided by theme (e.g. Global Burden of Disease) and sub-theme (e.g. The Health of Populations). Collaborators identified "Yes" or "No" if the teaching sessions fulfilled or did not fulfil the learning objective.