When Global Becomes Virtual: A Survey of Virtual Global Health Education Activities During the COVID-19 Pandemic Among Pediatric Educators

Global health (GH) medical education has undergone substantial shifts with teaching innovations fueled by best practices for adult learners.¹  Improved virtual platforms and increasingly available curricula have increased GH content access.

The COVID-19 pandemic created a unique situation in which distance learning became the “new normal,”²  and GH track requirements necessitated adjustment.^3,4  The concept of virtual global health education (GHE) is not new, with existing virtual predeparture preparedness and simulation programs.^5-9  However, few studies examine faculty or trainee preferences for virtual GHE activities (VGHEAs), and a comprehensive report of virtual education offerings is lacking. Innovative VGHEAs could add to existing GH education curricula.

Educators from the Midwest Consortium of Global Child Health Educators (MWC)¹⁰  sought to assess the current landscape of VGHEAs. We hypothesized that the pandemic created logistical challenges in GH education. Additionally, we hypothesized that VGHEAs offered activity continuity for GH educators and trainees, while also posing new challenges to GH engagement, resulting in new types of education activities not previously offered.

We conducted a cross-sectional survey in February 2021 (provided as online supplementary data). Using convenience sampling, we invited GH educators (ie, GH track and center directors) and trainees (residents and fellows) from 8 MWC institutions via email to complete a voluntary anonymous survey in REDCap (Vanderbilt University).

The authors created a de novo 71-question multiple-choice and free text response survey via an iterative process, as no prior surveys were available and pilot testing was not conducted. The goals of the survey were to collect GH program characteristics, understand existing GHE activities and pandemic-related shifts to VGHEAs, and identify barriers and facilitators to VGHEAs.

Using SAS software, version 9.4 (SAS Institute Inc), we summarized descriptive data using frequencies for dichotomous and categorical variables and measures of central tendency for continuous variables. We obtained ethical board approval from the Colorado Multiple Institution Review Board and participant consent.

All 8 MWC institutions responded, with at least 1 GH educator and 2 trainees from each site. After excluding 2 incomplete surveys, we included 38 responses. Resident and chief resident physicians comprised 39% of respondents (15 of 38; Table 1). We combined faculty and trainee respondents, as there was no statistical difference between their responses.

GH education fund spending was affected by the pandemic. Pre-pandemic, most GH programs reported receiving funding (88%, 7 of 8) and administrative support (75%, 6 of 8). Most programs (75%, 6 of 8) saw no change in funding support during the pandemic; however, one program experienced decreased support while another reported increased support. Most funding was spent on GH programming and education at the home institution, followed by travel or elective support for trainees (Table 1).

Table 2 characterizes faculty and trainee interest in educational, clinical, and research-related VGHEAs and the landscape of virtual and in-person activities over time. The number of respondents ranged from 15 to 24 for each question. We found an increase in VGHEA utilization and development during the pandemic. Fifteen respondents reported that trainees had online access to GHE materials and curricula pre-pandemic, yet many (80%, 12 of 15) reported creating and expanding virtual content. Among 24 respondents who reported on virtual joint didactic medical education sessions with GH partners, 38% (9) created these sessions since the pandemic began or reported a plan to do so, while 63% (15) indicated interest without a plan.

Respondents reported transitioning to clinical VGHEAs within their community (60%, 9 of 15) or to domestic sites within US borders (40%, 6 of 15) during the COVID-19 pandemic. Only 27% (4 of 15) of respondents reported moving toward an international VGHEA, while 40% (6 of 15) indicated interest without a plan. Few respondents reported instituting virtual ward rounding with partner sites (13%, 3 of 23) or hosting trainees from a partner institution virtually (7%, 1 of 15) during the pandemic, despite significant interest in these activities. Similarly, despite high interest in virtual research opportunities (87%, 20 of 24), only one institution implemented this.

Lastly, participants identified the greatest benefits and challenges in VGHEA implementation (online supplementary data). The most commonly mentioned benefit was leveraging VGHEAs to maintain existing GH relationships (25%, 7 of 28). Other benefits of VGHEAs included: increased access to GH content (18%, 5 of 28); increased trainee participation (18%, 5 of 28); laying a foundation for future VGHEAs (14%, 4 of 28); promoting career advancement (7%, 2 of 28); and providing safer educational endeavors during the pandemic (7%, 2 of 28). Only one respondent (4%) described VGHEAs as a cost-effective GHE option.

The greatest barrier was a lack of reliable internet access in the United States and abroad (25%, 7 of 28). Additional challenges were a lack of knowledge or skills in developing VGHEAs (18%, 5 of 28) and adequate time for activities (13%, 4 of 28). Respondents acknowledged the challenges surrounding “Zoom fatigue,” virtual logistics, and the need for additional faculty time and support.

Our survey of GH educators and trainees at GH programs highlights key considerations in the development and implementation of VGHEAs. It uncovers important benefits of VGHEAs that align with GH and education principles. The most frequently cited benefit was the ability to maintain existing GH partnerships during the pandemic, a well-established education priority.¹¹  Respondents expressed interest in increasing virtual access to GHE activities and resources for low-middle income (LMIC) partners, a need persistently identified in high-income country (HIC)-LMIC collaborations.^12,13  VGHEAs may offer new opportunities to increase bidirectionality and decrease inequities in global North-South partnerships, a key tenet of ethical GH practices.^14,15  The most frequently cited challenges to VGHEAs included unreliable internet access and a perceived lack of knowledge and skills in facilitating VGHEAs. These findings agree with previously reported barriers, where LMIC participants struggled with connectivity issues and a need for training.¹⁶ 

Adequate funding is critical for maintaining GHE programming. GH experiences are associated with increased clinical/teaching/research skills, awareness of health systems issues and costs, and continued work with vulnerable populations at home.^11,17,18  Most programs reported no change in funding. VGHEAs may be a lower-cost option in pursuing GHE activities and reallocating scarce funds away from HIC travel logistics and toward LMIC partners' needs (stable internet connections and faculty development).¹⁹ 

Our findings have implications for US and international trainees. Respondent trainees indicated interest in pursuing virtual local or domestic GH electives (eg, refugee health, Indian Health Service). Such “glocal” electives may allow for hybrid in-person and virtual formats and offer an alternative to international rotations. Benefits of VGHEAs for international trainees who experience peer-to-peer learning with faculty mentorship include improved understanding of health systems, increased communication and collaboration skills, more interest in local volunteering and international electives, and even increased interest in less popular specialties. These outcomes may even alleviate health care workforce issues in HIC.^20,21 

Limitations of this study include the cross-sectional design and respondent homogeneity. Due to convenience sampling and voluntary responses, the sample size and responses to some questions were small. We were unable to calculate an individual-level response rate, as we did not have access to the specific number of participants at all MWC sites. While this may contribute to response bias, we chose a population active in GHE programming. This provides valuable baseline data during the COVID-19 pandemic, which will help guide future study and planning for VGHEAs.

Our survey of GHE trainees and faculty identified a significant change from traditional GH education activities to VGHEAs due to pandemic-related disruptions. Trainees and educators are interested in VGHEAs, which have their advantages and challenges in successful implementation.

The authors would like to thank Midwest Consortium for Global Child Health Educators and all who participated in the survey.