The development and initial evaluation of http://ethicsandglobalhealth.org
presented here is, to our knowledge, the first attempt to design and evaluate an online, widely accessible, introductory curriculum focused on ethical issues trainees might face in short-term training and service programs in global health. It was developed in direct response to increasing recognition of the ethical issues arising in such programs, emerging consensus around best practice guidelines, and a perceived need to translate these guidelines into an accessible format, especially for trainees or those with little prior global health experience. Our findings have important implications for ethics education related to short-term global health programs specifically and online ethics education more generally.
For instance, our data support the belief that more ethics training is needed for individuals traveling abroad for short-term global health programs. Less than one-third of users who have been abroad before report having had ethics training directly related to short-term work. Only after more than five trips abroad do a majority of individuals report having had ethics training. About one-quarter of users reported that this curriculum would be their only ethics training.
In addition, our data suggest that the curriculum is meeting its goal of wide accessibility and use. First, the curriculum is reaching a diverse range of fields, including medicine, public health, and nursing. Individuals of various nationalities are using the curriculum, and it is being disseminated via personal referral and through training programs, with a number of users locating the curriculum via web search. These observations encourage curriculum developers to consider ongoing direct dissemination of curricula to colleagues (perhaps including social media) and to use proven strategies to improve their curriculum’s ranking on Google and other search engines. Third, the curriculum content is generally well received based on responses to our Likert scale questions, with users generally perceiving that it offered both new content and new strategies for navigating ethical issues in this setting. Fourth, a number of programs appear to be requiring the curriculum before travel abroad, reinforcing the usefulness and perceived necessity of ethics education.
Despite this progress, work remains to meet our other curriculum goals. We were surprised, for example, at the average age of users (37 years) and that half were already practicing in their fields. While this suggests the curriculum may be effectively reaching those not in training programs, it might also suggest a need to better reach or target younger trainees. Similarly, although cases were well-received, a few cases (“Developing Cultural Understanding,” “Exceeding Level of Training,” and “Ensuring Personal Safety”) were perceived as less “new.” While these cases are arguably fundamental to global health training programs, future iterations of curriculum content might be able to cover these issues in more depth.
From a broader perspective, the curriculum at http://ethicsandglobalhealth.org
is not the only online curriculum available. Other relevant online ethics resources that are freely available and directly related to short-term global health training (as opposed to global health ethics more generally) are shown in Table
. Each has unique features. For example, the Global Health Education Consortium (GHEC) has teaching modules available in Spanish. Both GHEC and Unite for Sight integrate their ethics and professionalism teaching within broader global health topics. The University of British Columbia site has a quite comprehensive curriculum, including a detailed conceptual framework and pedagogical resources for instructors.
Comparing freely available online curricula for short-term global health ethics
Our curriculum, however, was designed to meet a particular niche in light of known advantages and disadvantages of online ethics education [41
]. For example, some qualitative evidence suggests that teaching complex ethics concepts online is difficult [42
]. We chose an online format for several reasons. First, our introductory curriculum does not teach complex concepts but instead introduces individuals with little or no prior training to a broad range of issues. Second, we wanted the introductory curriculum to be free and widely available, without requiring a login and with accessibility at all times. Third, an online site allows training programs and educators to tailor the curriculum for their particular needs, including within more comprehensive ethics curricula [43
]. Our use of real life cases, for example, fits well within current models of medical ethics education [44
] and the high prevalence case- or problem-based methods for teaching ethics (e.g., at U.S. medical schools [45
]). Fourth, because some trainees organize and participate in short-term programs outside their training institution, we wanted the curriculum to be available independent of specific institutions or programs.
Our findings must be interpreted in light of several limitations. First, web statistics can be difficult to interpret, likely overestimate the number of unique visitors, and cannot track whether or to what extent visitors complete site content. The open user group may be subject to ascertainment or sample selection bias. For example, open users searching for a curriculum online may be less likely to have had ethics training in the past and hence desire to search for it. This prevents us from making broad claims about the general population of individuals who go abroad for short-term global health training. The use of open user data – unlike standard pre- and post-test methods [46
] – might nevertheless better represent the real-world and intended use of online curricula, which is particularly important for the heterogeneous group of individuals who travel abroad for short-term global health training and service. Second, because our curriculum is introductory, it cannot address ethical issues specific to every situation, such as unique issues that might arise within specific medical specialties (e.g., pediatrics or obstetrics) or specific locations (e.g., global health programs which include underserved areas in one’s own country). Finally, although WEIGHT and CUGH include individuals and institutions in LMICs, thereby informing the process, content was determined and evaluated predominantly by individuals from high income countries. This suggests a need to develop and implement future curricula with greater input from those abroad, especially those in LMICs or the “global South.”