The Nuts & Bolts of Developing a Global Health Course

impacted health care globally and has led to culturally diverse patient populations both domestically and abroad. The course must not only introduce its students to the multitude of conditions that can affect the health and wellness of individuals, communities, and populations’ world-wide, but should also provide an introduction to key concepts and constructs. For example, concepts that are defined and explored in depth within the course include capacity building, collaboration, cultural humility, cultural relativism, equality versus equity, host country ownership, partnerships, resource allocation, social justice, and sustainability [2-5]. It is important to provide students with a foundational knowledge of medical ethics, international humanitarian law and human rights law within the context of global health if they have not had exposure to these topics in prior coursework. A discussion of healthcare as a “right verses privilege” is also introduced to students at the start of the semester as the presiding viewpoint of powers that be within a country or geographic region will ultimately affect accessibility, acceptability, and accountability of services and providers to its citizens [6].


Introduction
The literature has become a repository for a variety of resources focused on global health and various efforts in academia to increase student's awareness of global health issues, concepts and constructs and in some cases provide experiential learning activities. While nursing and other interdisciplinary partners in health care may gleam knowledge and ideas from this literature, what they may find most valuable is a roadmap or guide to assist in the development and implementation of a global health course that includes a study abroad "hands on" sustainable program of primary care delivery.
Designing a course that examines the many issues that surround healthcare delivery to diverse populations through a global perspective can be challenging. Course facilitators should not use a broad "cookie-cutter" approach, but link its development to the mission and objectives of both the department in which the course is to be offered and the sponsoring institution. The course needs to support the curriculum. In the case of one State of New Jersey College in the United States of America, an overarching goal for all students is to become a global citizen. Within the Department of Nursing and the Department of Public Health where the course is cross-linked and offered, population health is integrated into the curriculum. The description of the course sets the stage for exploring quality healthcare and quality of life issues for all, but particularly vulnerable patients, communities and populations. Although the course is taught primarily by a doctorally prepared advanced practice nurse, it appeals to students from multiple academic programs such exercise science, health, international relations, nursing, pre-medicine sciences, psychology and public health. This interprofessional (IPE) mix of undergraduate students make for a rich discussion of topics from varying points of view. The faculty whom designed the course sought course approval not only from the departments' curriculum committee but also from the colleges' Liberal Learning Program. Liberal learning is part of the general education of all undergraduate students at the institution. This coursework, in addition to their major, assists students to learn fundamentals of reasoning and communication while supporting broad areas of human inquiry, civic responsibility and intellectual and scholarly growth [1]. The course was given a two-fold liberal leaning designation of "world views" and "global" as it was deemed to address both human inquiry and civic responsibility.

Course Design
In order for a global health course to be pertinent, it must be flexible and highlight how the mobility of society and social media has

Abstract
As society becomes more culturally diverse and diseases and other health risks continue to cross national and international borders, academic schools preparing future healthcare professionals will need to address the health and wellness needs of individuals and communities worldwide. This article provides an example of many aspects of course design,following an analogy of "nuts and bolts, " used by a nursing department to assist in the development and implementation of a global health course. The course in turn promotes student knowledge and skill in the delivery of culturally humanistic and sustainable healthcare services to populations across the world in their future practice.
to learning, knowledge and professional development" that in turn impacts the health of individuals globally (p. 517). They also allude to development of a collaborative partnership between academia, community members and volunteer organizations. Identification of a partner may take some investigation and fact-finding meetings on part of the college, university or its representatives to ensure that the goals of the partnering organization such as an NGO are compatible with those of the academic institution and its nursing or other interprofessional healthcare departments. It is extremely important that collaboration with a partner or agency does not lead to "harm" in the patients or population with whom it interacts. For example, an academic-NGO partnership needs to strike a balance between meeting the educational needs of students with the collective healthcare needs identified by members of the population being served, both of whom are additional stakeholders. This requires all partnering stakeholders to have a mission and value system that supports humanitarian healthcare outreach that is builds capacity and is sustainable.
Another "nut" in development of a global health course is identification and review of the evidence regarding service learning in the nursing curriculum. The Consortium of Universities in Global Health (CUGH) [8], The Global Advisory Panel on the Future of Nursing & Midwifery (GAPFON®) Report and the Global Nursing Caucus [9] are a few of many resources that can assist administrative and faculty planners by providing guidance in course development and implementation of an outreach opportunity that yields socially responsible outcomes in global health [10,5].
The American Association of Colleges of Nursing [11], professional values such as caring, human dignity, and social justice are also in line with the outcome variables of many global health outreach activities that involve undergraduate students.
Ensuring that the faculty involved in facilitating the didactic portion of the course and mentoring/supervising students during an outreach experience have a sound knowledge base related to global health and stay current through on-going professional and leadership development in the subject area is a third "nut. " Prior to course development, faculty should peruse the literature and identify a theory that can serve as the foundation for providing healthcare to a multitude of cultures. The theory of Culture Care Diversity and Universality [12] is one option. It addresses the dimensions of providing culturally congruent care to people and recognizes that there is not only cultural variations between cultures, but also within cultures. A second example is that of Community-based Learning: The Theory and Practice of Ethical Engagement at Home and Abroad [13]. Within this theoretical framework, it is recognized that community based learning and service, whether on a domestic or international level, is unpredictable yet transformative. Hartman, Kiely, Friedrichs & Boettcher [13] identify what they term "key drivers" e.g. cultural humility and exchange, power and privilege, reflective practice and seeking global citizenship that need to be taken into consideration to provide ethical engagement within health outreach or experiential learning setting. The faculty may also participate in global health conferences, webinars and workshops, cultural competency and sensitivity training, or gain first-hand experience by volunteering as a provider on a humanitarian healthcare missions.
The "bolts" are the components of a course found within a syllabus. They include the course description, objectives, content outline, instructional methods, grading criteria, and other information that supports student in their learning. The "bolts", with the aid of the "nuts" result in the assembly of the overall course. The first "bolt" is the course description. It provides an overview of the course. An excerpt from the course description may read as follows: Students will be exposed to ethical reasoning, philosophical views related to the human right to health and international humanitarian health law in order to understand the variety of issues that can affect the delivery of healthcare services within a global perspective. Emphasis will be placed on preparing students to engage in global health to improve access, quality of care for vulnerable patients and populations, and address health issues around the world using a patient and community-centered, culturally sensitive model of care.
Course objectives, the second "bolt, " lists expected outcomes a student should obtain by the end of a global health course. The United Nations Educational, Scientific and Cultural Organization (UNESCO) [14] proposed in 2017 that learning objectives be written in the cognitive, socio-emotional and behavioral domains related to education addressing the Sustainable Development Goals developed by the United Nations [15]. Using these domains as a guideline, an example of objectives within a global health course may state that upon completion of the course a student will: 1. identify key global health care issues and policies 2. discus show global health issues cross cultural and social boundaries 3. propose strategies to address a specific health need of a vulnerable population.
The course outline is the "bolt" that is links to both the course description and objectives. As previously noted, the outline focuses on exposure to global health concepts. These concepts should be discussed and applied to a variety of health conditions experienced by both developed and underdeveloped regions of the globe [16]. Specific health issues or epidemics pertinent to a geographic region may be studied. Data from seven regional meetings of GAPFON® held during 2014 through 2017 was analyzed to identify five global health priorities worldwide including "non communicable diseases, including chronic diseases, mental health in general, as well as secondary to substance abuse and to violence, communicable diseases, disaster preparedness and response and maternal-child health" (Sigma Theta Tau International Honor Society of Nursing, p 16). A discussion of these major topic areas in addition to health beliefs, social determinants of health and specific threats to health within different cultures and geographical areas can be found in a plethora of textbooks and journal articles currently available for adoption as primary and secondary course references. For example, Lymphatic Filariasis, a subtropical disease, targeted for eradication by the World Health Organization (WHO) prior to the earthquake of 2010 in Haiti was assessed and diagnosed by a student and his faculty mentor during an experiential learning study abroad trip in 2012. This communicable infection, was impacted by number of socioeconomic determinants of health e.g. poor infrastructure of the country, lack of access to healthcare, substandard housing in a tent city, etc. was shared first hand and in a published case study format by course faculty [17].
The course leader should also explore webinars and other information available from key resources and professional organizations such as the World Health Organization (WHO), the United Nations (UN), the International Council of Nurses (ICN) and other internationally based global health agencies and consortiums on their respective websites [18][19][20].
The overall context of a global health course appears to lend itself to blended or on-line delivery of content. Faculty can initiate student involvement by having students participate in a self-assessment that has them define global health and identify any prior experiences that may have influenced their knowledge of the topic. This type of assessment along with a pedagogic design that includes a variety of strategies such as case studies, discussion board postings, peer group activities, real-time web-based data and video links have been noted in the literature to increase student-centered learning and engagement [21][22][23][24].
Other teaching/learning methods to use within a global health course include, but are not limited to, reading assignments, student led presentations, and reflective assignments tied to experiential global health learning. The latter, according to Aaronson [25] can assist undergraduate students in "confronting both illness and injustice in health systems around the globe and their own expectations, ideals, biases, limitations, and ambitions" (p. xii). Reflective practice exercises incorporated into experiential learning appears to support students' personal growth as a global citizenship and professional relationship with a host community versus thought processes that emerge from experiencing global health study within an academic bubble.
As with any course, evaluation serves an important role in the feedback process. It is how faculty knows what worked and did not work in guiding students toward meeting the course objectives. The "bolt" of evaluation which can be objective or subjective, formative or summative. An objective measure used to evaluate students' comprehension of subject matter was a writing assignment that included a rubric for grading. Students submitted a paper that examined the role of key stakeholders' i.e. nursing or another member of the health profession in a global setting. This included inquiry into a chosen countries scope and regulation of practice which the student had to contrast and compare to their home country/state. A subjective evaluation assignment used a reflective approach. Reflection has historically been used to explore the impact of international nursing experiences in nursing education on student nurses' cultural awareness and competency [26][27][28]. It is supported as a critical component of community-based global learning by Hartman, Kiely, Friedrichs & Boettcher [13]. This strategy was used in a number of ways including encouraging student journaling and faculty-led debriefing of all team members on a daily basis during the service learning component of the course. A reflective essay on how participation in the global health course and its study abroad or community immersion experience impacted the student both personally and professionally was also a course assignment. Undergraduate nursing and public health students made the following comments in their reflective assignment related to participating in a primary healthcare immersion experience in Haiti; I cannot describe the trip to others because it was simple indescribable. Amazing, awesome, humbling, incredible, sad, rewarding, grateful -these are all words I have used in order to help describe the trip to my friends and family.
I have learned many lessons from an actual field experience -the main one being that the experience of actually being in a different country, caring for people is completely different from simply learning about a country and its healthcare challenges.

Discussion
The development of a global health course takes time and persistence in order for it to truly be a rewarding learning experience for students. It is recognized that there are many resources available that may enrich didactic and experiential learning. The true test is that the course and its content meet set learning objectives, expands a students' knowledge base related to the many facets of global health, opens their eyes to disparities in healthcare and the role nursing and other healthcare disciplines can play in global healthcare delivery and leadership. Kostovich & Bermele [29] shared that one of the don'ts of a study abroad trip is planning for every minute of the trip. As such, students involved in a course can be given a "cultural day" in the host country. As a group, students and faculty can visit a museum that displays the history of the host country or engage in some other activity that depicts the innate culture of its people. With provisions for safety and security, students may opt to join faculty members and translators and go onto the community to interact with local individuals from across the lifespan. These visits appeared to positively impact students' development of cultural humility by providing them first hand with an immersion opportunity in which they can assess the challenges that community members encounter related to the environment, economic stability, education, and other determinants of health as outlined in the Sustainable Development Goals [15]. These goals, appearing in the literature under the abbreviation SDGs, fall under a formal plan titled "Transforming our World: the 2030 Agenda for Sustainable Development" [30]. They are important content to include in a global health course. Students can use the SDGs as a framework for identifying quality of life and health issues in underserved populations and develop an action plan that is basic and sustainable to share with community members and leaders.
Developing and implementing a global outreach component within a course is not without challenges. Hurdles that may impact the elective may include language barriers, the political milieu of the country under consideration, housing and on-ground travel considerations and to a lesser degree cultural adaptation [31]. Cost associated with an experiential learning component within a global health course may pose a financial burden to students and limit their participation. Course faculty can share creative strategies used by prior students that assist in fund-raising or sponsorship. A course can be modified to offer a section that provides case based learning vs. the study abroad opportunity. It is anecdotally noted that course evaluations over a 3 year time frame completed by undergraduate generic and RN to BSN students when this option was offered by the author were equally positive as compared to those completed by a study abroad cohorts.

Conclusion
As society becomes more culturally diverse and diseases and other health risks continue to cross national and international borders, the global health arena can only continue to grow. Whether addressing the health and wellness needs of individuals and communities within their homeland or worldwide, healthcare professional disciplines will need to develop global health knowledge and competencies. It is prudent that this education process start early through development of a global health elective or other coursework that fits within the context of the curriculum, department, school and/or collegiate setting. Now more than ever the opportunity for academia to partner with organizations in their home as well as host country to engage in global health is ripe. Prior to any outreach, faculty is in a key position to educate themselves and their student body about the many facets of healthcare on a global level. It is acknowledged that student enrollment and completion of one course is not all inclusive. However, even an introductory course such as that described above will open the eyes and minds of students to not only the conditions and disease states that are of concern worldwide, but also to key concepts and constructs of global health that will assist them providing humanistic and culturally respectful care to individuals, communities or populations no matter where future provider chose to practice.