Developing Global Health Diplomacy-related Skills Using a COVID-19-like Epidemic Simulation as a Learning Strategy

INTRODUCTION

Global health diplomacy (GHD) is a nascent and fast-growing field that sits at the intersection of public health and foreign affairs, bridging these disciplines with other related fields such as management, law, and economics. ¹ Global health diplomacy can also be defined as the “multi-level and multi-actor negotiation processes that shape and manage the global environment for health.” ² GHD concerns itself with the global policy environment for health, ¹ which has produced international health-related binding agreements such as the International Health Regulations. ³ According to the International Health Regulations, the World Health Organization (WHO) has the capacity to declare a public health emergency of international concern when conditions on the ground warrant it. ³ Only a few instances of a public health emergency of international concern declaration have occurred since the adoption of the 2015 International Health Regulations, including the current coronavirus disease (COVID-19) pandemic. ^4,5 International agreements, such as the International Health Regulations, require the sophisticated work of public health professionals who master diplomacy (i.e., global health diplomacy professionals). In this work, we discuss the use of a COVID-19-like epidemic as a basis for a scenario-based activity to develop GHD-related skills that are linked to current global health competencies.

The Taxonomy of Educational Objectives (commonly known as Bloom’s Taxonomy) is a systematic framework that allows instructors to identify and classify statements of expectation regarding what students should learn as a result of instructional activities. ⁶ Analysis, evaluation, and creativity sit at the pinnacle of the revised Bloom’s Taxonomy. ⁶ The use of scenarios simulating real-world events can facilitate the achievement of these taxonomic levels by providing an opportunity to connect the knowledge learned in the classroom to the conditions that practicing professionals might face, which is something we refer to as contextual learning. Scenario-based activities could facilitate the development of required skill-based competencies. Leadership, communication, and systems thinking are part of the Council on Education for Public Health (CEPH) Master of Public Health (MPH) Foundational Competencies. ⁷ Consistently, public health practitioners are expected to develop and master leadership, negotiation, mediation (management), and communication skills, among others. ^7,8 In particular, global health practitioners need to be prepared to address public health emergencies in an international and multicultural context. Such professionals also need to understand the complex diplomatic processes that lead to international health-related agreements and instruments that have been negotiated to address increasingly complex global health scenarios. Therefore, GHD is an important component of both the knowledge base and skills that a global health professional should develop. We have identified four basic GHD-related skills: diplomacy skills, negotiation skills, communication skills, and the skills to address public health emergencies (DNCEs). Existing avenues for students to achieve these skills as a result of participating in an integrated and contextual activity with an emphasis on GHD-related processes are rather limited.

Problem-based learning, which is a student-centered model incorporating principles of the Adult Learning Theory, has increasingly been used as an educational approach in undergraduate, graduate, and postgraduate continuing education activities in public health and medicine. ^9–13 The problem-based learning model consists of small-group, active learning encounters that emphasize the “know-how,” as opposed to the “know all,” of traditional approaches. ^9,11,13 Scenarios simulating real-world events comprise an active-learning strategy ⁹ that could be used as an innovative extension of problem-based methods when training professional global/public health students. Real-world simulations have been used to master professional skills in other fields as well. ^13–15

Using problem-based learning as a framework, we have developed a simulated international health emergency scenario describing the outbreak of a rapidly spreading emerging respiratory viral disease. This scenario-based GHD activity encourages the use of an interdisciplinary perspective to reach a consensus for possible solutions. The aim of this activity is to provide an opportunity for the initial (i.e., it is one of the first opportunities) and early (i.e., during the student’s first semester in the MPH program) development of DNCEs among students in the Global Health Practice concentration of the University of South Florida MPH program. In addition, this scenario is meant to emphasize the roles of global health stakeholders and the need for culturally appropriate, interprofessional collaboration. We examined the practical and theoretical application as well as the effectiveness of scenario-based approaches to support the early and initial development of competencies associated with a professional public health degree with a focus on global health issues.

METHODS

RESULTS

Overall changes in self-reported skill-related Likert scale scores.

Figure 1 shows a cell plot matrix representing self-reported prescenario-based and postscenario-based activity Likert scale scores associated with each of the skills studied. Most participants reported a positive migration in the Likert scale between the preactivity and postactivity measurements (Figure 1). Moreover, the majority of strongly agree classifications were observed during the postactivity measurement. Conversely, disagree classifications were confined almost exclusively to the preactivity measurement.

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Cell plot matrix of pre-SBA and post-SBA measurements of the self-reported understanding of selected skills using Likert scale scores. SBA = scenario-based activity. For each skill, the preactivity assessment inquired about whether the participants believed that they had a thorough understanding of the skill itself and of how the skill relates to Global Health and Public Health practice. The postactivity statement inquired participants about their perceived improvement in the understanding of the selected skill (and its relevance to Global Health and Public Health practice) as a result of having participated in the SBA.

Citation: The American Journal of Tropical Medicine and Hygiene 105, 1; 10.4269/ajtmh.21-0155

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DISCUSSION

Global health issues have been recognized as a needed curricular element in medicine and public health by students and faculty alike. ^26–28 Global health issues are inexorably linked to economic development, health inequalities, political stability, security, and peace, ²⁶ whereas their socioeconomic, environmental, and political determinants are local occurrences that are interconnected on a global scale. ^26,28 Addressing these issues requires intense and complex diplomatic efforts ^29,30 ; therefore, the development and adoption of international health-related binding agreements, such as the 2005 International Health Regulations, have occurred. ³ Such agreements and regulations are crucial tools in our fight against global health threats, such as the one posed by the current global COVID-19 pandemic. For instance, the International Health Regulations give the WHO authority to declare a public health emergency of international concern, ³ a mechanism that was put in practice during the early days of the COVID-19 pandemic. ⁴ Major global events, such as COVID-19, may present themselves as cosmopolitan moments, ³¹ suggesting the need for a revision of current global health strategies that will require input from experts trained in GHD. Therefore, the development of a skill set for addressing global health issues, ²⁶ within a diplomatic context, should be an important curricular objective of global health programs.

Scenario-based approaches can be useful during the early development of foundational global health competencies, especially as they relate to diplomacy and negotiation. During this study, problem-based learning was used as a framework to create a scenario-based activity designed to support the early and initial development of DNCEs. The authors and designers of this activity cumulatively had more than 10 years of experience developing and implementing problem-based learning activities, including in international settings such as schools of medicine in Ecuador and the United States, schools of public health (including undergraduate and graduate-level courses) in the United States and Nepal, schools of nursing in Belize, workshops about Geographic Information Systems applied to health in Ecuador, Nepal, and India, and training and development activities with the Peace Corps in Togo, Cameroon, and Senegal, among others. This scenario-based activity places more emphasis on the process rather than on the outcome, thereby reducing the extraneous cognitive load associated with performance anxiety. ³² By virtue of being a motivating and engaging experience, the scenario-based activity may lead to further reductions in emotional loads. ³² The scenario-based activity’s briefing and debriefing sessions also reduced the cognitive load ³² These characteristics are likely to favor learning by helping to avoid surpassing the individual’s working memory capacity (i.e., avoiding overload). ³²

The scenario-based activity also draws from experiential education principles. Specifically, it is an experience that is supported by reflection, critical analysis, and synthesis that encourages students to take initiative and make decisions. ³³ This scenario-based activity may be an effective and efficient method of introducing students to the complex reality of international health regulations and global health actors that allows the acquisition and development of essential knowledge and skills required by global health practice competencies. For instance, participants reported significantly better responses (i.e., either agree or strongly agree) when asked about DNCE knowledge improvement after participation in the activity (P < 0.05 for all comparisons, Wilcoxon signed rank test). In addition, most participants either agreed or strongly agreed that their DNCE skills improved after participation in scenario-based activity (diplomacy = 55.6%; communication = 72.2%; negotiation = 66.5%; addressing emergencies = 72.1%). Therefore, the scenario-based activity effectively improved the self-reported understanding of DNCE knowledge and skills. Diplomacy and negotiation, as well as cross-cultural competency (another component incorporated in the scenario-based activity; see Methods section), are among the required global health diplomacy competencies that have been identified by experts and practitioners in the field. ¹

It is noteworthy that this scenario-based activity responds to the needs identified by students, faculty, and national professional and public health-accreditation bodies. For instance, students at our institution had indicated that they would prefer to have applied interdisciplinary team experiences early during their educational program. ³⁴ The scenario-based activity reported here is delivered during the first semester of the MPH program with a concentration in Global Health Practice. Similarly, our faculty had identified the need to develop an interdisciplinary, experiential, and cross-cutting MPH curriculum. ³⁴ Alumni and employers had also highlighted the need for the development of systems thinking, professionalism, and communication skills. ³⁴ In addition, the Framing the Future: The Second 100 Years of Education for Public Health report advocates for applied, skills-based, and interdisciplinary programs ³⁴ that translate to the MPH Foundational Competencies set forth by the CEPH, including leadership, communication, interprofessional practice, and systems thinking. ⁷ Accordingly, the University of South Florida’s MPH competencies list, among others, includes “… effective functioning within and across organizations and as members of interdisciplinary and inter-professional teams.” ^12,34 The scenario-based activity reported in this work is in alignment with these preidentified needs because it allows students to immerse themselves in the strategic thoughts and actions of different global public health stake holders and represent those actors in an interactive experiential learning opportunity.

In conclusion, the use of a problem-based, learning-informed, systems thinking-oriented, scenario-based global health diplomacy activity is an engaging strategy for the early and initial development of DNCEs in an introductory, required Global Health Practice class at our institution. Such activities should be encouraged and scrutinized for their effectiveness, especially in the long-term. Problem-based learning has been shown to induce long-term learning habits, increase long-term knowledge retention and recall (or prevent knowledge recall decay, at minimum), improve the transfer of concepts to new problems, integrate basic concepts into practical contexts, enhance intrinsic interest in the subject matter, improve confidence, and sustain self-directed learning skills. ^13,35 Importantly, learning about problems in the context in which they will be encountered during professional practice (contextual learning), might facilitate memory coding (at the moment of learning) and recall of knowledge (as a practicing professional). ³⁵ Some of the concerns raised regarding problem-based learning include increased demand for instructional resources, including teachers, and their corresponding investment and funding needs. ¹³ In addition, a critical review of problem-based learning effectiveness suggested that effects on educational outcomes are either small or moderate when they are significant. ¹¹ Further research is required to assess the mid-term and long-term impacts of the scenario-based activity on self-directed learning habits and knowledge recall and to evaluate the level of resources necessary. Borrowing and modifying a recent view of medical education, ¹³ it is important to recognize that high-quality global health education is central to high-quality global health practice.