Being global in public health practice and research: complementary competencies are needed.

Cole, Donald C. ; Davison, Colleen ; Hanson, Lori 等

Public health practitioners, educators and researchers have long been involved in international health and now global health. Global health arose from the spaces where population and public health, health promotion, and international development converge. Although global health as a field is in a state of flux, (1,2) "global" captures the scope and interconnectedness of public health--transcending political borders and boundaries, in keeping with the Canadian Public Health Association's tagline "Across Canada and Around the World".

International colleagues (3) and the United States Association of Schools of Public Health (http://www.asph.org/) have taken the position that "Global health is public health." Public health researchers in Canada have advocated for global health research (4) and supported the Canadian Global Health Research Initiative (http://www.idrc.ca/ghri/). The Canadian Institutes of Health Research-Institute of Population and Public Health has been particularly inclusive of global health research (http://www.cihrirsc.gc.ca/e/documents/ipph_strategic_plan_e.pdf). Within this context of evolving and overlapping concepts and fields of practice and research are questions related to the necessary competencies, capacities, skill sets, or abilities to engage in global health practice and research.

The purpose of this commentary is twofold. First, it seeks to stimulate a constructive dialogue on key competencies for global health practice and research. Second, it seeks to ensure that those engaging in this emerging field are conscious of the distinct features of global health practice and research, e.g., historical context, international regimes that influence health globally, and international organizations that function on the global scale.

Competencies in public health

The core competencies for public health in Canada (CCPHC) have been put forward as a set of shared attitudes and values and competency statements in seven categories for Canadian public health practitioners (5) (see Box 1). Educators and practitioners have worked to extend this list to make them more specific to particular disciplines, such as those for public health epidemiologists. (6) No similar sets have reached consensus in public health research, global health, or global health research. Some public health graduate students have argued that public health competencies should necessarily include global health-related matters. (7)

Competencies in global public health

As graduate study of global public health in North America has become increasingly popular, academic institutions have taken the initiative to identify competencies that are either complementary to those for public health (e.g., University of Toronto (see Box 2)), or distinct for global public health (e.g., University of Washington (8)).

Competencies in public health research

While reserving research for consultant roles, the CCPHC define research as: "Activities designed to develop or contribute to knowledge, e.g., theories, principles, relationships, or the information on which these are based...." (ref. 1, p. 13). Relevant research competencies in doctoral training have been developed by health behaviour researchers in the USA and health services researchers. (9) In Canada, public health researchers have recognized that CCPHC are increasingly consonant with research funders' interest in key professional skills, such as those envisaged in the Tri-Agency Statement of Principles, e.g., communication [CCPHC Category 6] and interpersonal skills [CCPHC category 7], integrity, research management, and civic responsibilities through societal engagement [CCPHC category 4]. As well, the emphasis in the Canadian Health Services Research Foundation and the Canadian Institutes of Health Research on knowledge translation and exchange (http://www.cihrirsc.gc.ca/e/29418.html) is in keeping with the communication responsibilities and capacities of public health researchers.

Competencies in global health research

Members of the Canadian Coalition for Global Health Research (CCGHR) have responded to a thirst for training and mentoring among researchers new to global health. Global health research can be broadly defined as "research that prioritizes equity and improved well-being for all people worldwide." (http://www.ccghr.ca). Global health research examines transnational health issues, determinants and solutions; involves and collaborates with many disciplines within and beyond the health sciences; and is undertaken in order to inform (and be informed by) policy and practice at the local, national and global levels.

In keeping with a growing literature on fostering health research capacity for development, (10) the capacity development program area of CCGHR addresses capacities of individuals (researchers, small research teams, research-users, etc.), of institutions (nongovernmental organizations, universities, agencies, ministries, etc.) and of systems (national health research systems or cross-national networks). Correspondingly, CCGHR has developed "catalyst competencies" (see Box 3), involving more generic skills that complement discipline-based research methods and context-specific global health competencies.

Dialogue on competencies in global health and research

During a pre-conference workshop at the Canadian Public Health Association's Centennial Scientific Conference in June 2010, we explored competencies in addition and complementary to those in the CCPHC that were needed by global health practitioners and researchers. Participants were from a range of clinical, public and global health backgrounds, and at different stages of their careers, from undergraduate students to senior public health practitioners involved in competency development, global health promotion practice, and global health research. Many found it challenging to distinguish global health and public health initially, but agreed that global health is best understood as an extension of public health. One participant offered the concept of "epistemic communities" (11) that global health colleagues are seeking to construct, the same way that health promotion colleagues did in relation to broader public health some decades ago. Defining global health practice and research competencies is an important part of this self-identification process.

Box 1.

Categories of Core Competencies for Public Health
in Canada (CCPHC) (ref. 5, pg. 3)

1. Public Health Sciences

2. Assessment and Analysis

3. Policy and Program Planning, Implementation and Evaluation

4. Partnerships, Collaboration and Advocacy

5. Diversity and Inclusiveness

6. Communication

7. Leadership

Box 2.

Global Public Health Competencies, University of
Toronto Master of Public Health--Global Health
Concentration

Able to:

a) Understand the political economy of global health issues.

b) Bring a determinants-of-health and population health perspective
to problem analysis, policy development and project design.

c) Be cognizant of the linkages between local & global health
problems.

d) Work within the mandates, roles and approaches of international
organizations.

e) Build coalitions and work in partnership with the NGO sector and
local community organizations.

f) Be sensitive to cultural differences and adapt methods to local
contexts.

g) Understand broad ethical issues as they relate to equity globally.

h) Apply appropriate ethical approaches to international, country-level
and local projects.

i) Continue to advance knowledge, understanding and skills in
research or professional practice in the field of global health.

Box 3.

Canadian Coalition for Global Health Research
Catalyst Competencies

A. Global learning, mentoring and leadership--actively reflecting
upon, improving and shaping the research work of individuals,
institutions and systems in cross-cultural settings;

B. Global partnering and networking--coordinating, collaborating
and exchanging across countries and jurisdictions to help
individuals, institutions and systems work together on collaborative
research and training projects; and

C. Global level knowledge translation and exchange--from synthesis
of existing evidence, through engaging research-users in dialogue
and brokering, to dissemination and uptake of findings,
recognizing the limitations of resource-poor settings and
political-economic challenges in uptake across countries.

Participants emphasized that contexts (historical, cultural, resource, etc.) exhibit a more explicit or influential role when considered globally. Correspondingly, those active in global health need to understand and be able to engage in multiple contexts simultaneously. Global health practice and research require knowledge of political systems, health systems and social determinants of health with a greater diversity than one could expect within one nation. Those engaged in global health practice and research are also confronted with a plethora of international regimes, both bilateral and multilateral, that have direct and indirect impacts on global health. Participants also noted the challenges of working in what may be regarded as more extreme contexts, particularly with very limited resources, and the need to be highly flexible. While the group acknowledged that the slate of CCPHC competencies were applicable to global health practice, the discussion led to the generation of 14 additional global health practice, and public health and global health research competencies that coincide with each of the seven CCPHC categories (Table 1).

Workshop participants also considered several CCGHR global health research competencies generic to all public health research in an era of collaborative, respectful, practice-informed and action-oriented research. In particular, the need for transdisciplinary approaches, the ability to find 'entry points' for action, and the importance of research identifying "actionable determinants" were emphasized as competencies for both public and global health researchers. (12) Respect for cultural diversity which may impact upon research, particularly ethics provisions in different countries, and the ability to work in transnational teams on different kinds of health research were regarded as particularly important for global health researchers.

Important attitudes and values underlying the CCPHC and consonant with CCGHR's emphasis on equity include the commitment to equity, social justice (13) and sustainable development. The CCPHC's respect for diversity and self-determination was deemed crucial, as was the ability to self-reflect upon one's own social location and respond to others in theirs (Table 1, GH.8). The CCPHC approach to empowerment and community participation was also seen as key in partnership development for research, in keeping with CCGHR's Partnership Assessment Tool (see http://www.ccghr.ca/default.cfm?content=pat&lang=e&subnav=library). Some participants referred to the guidance that both CIHR and CCGHR have developed on conducting research and interacting ethically with Aboriginal communities as appropriate for both public health and global health researchers. (14)

Given the demands of understanding contexts, the need for enhanced capacities in self-reflection, and the requirements of flexibility and commitment, several participants reinforced the need for mentorship to develop these competencies. Mentorship for global health research leadership has received attention among nurses (15) and mentor development and training has been important in CCGHR's capacity development work (see mentorship modules at http://www.ccghr.ca).

DIRECTIONS

As global health practice and research develop as epistemic communities, we expect greater clarity on required competencies. The tremendous effort that has gone into developing the CCPHC is also needed in global health if we are to serve both our students and colleagues well. We will also need not only a parsimonious set of competencies, but corresponding methods to assess their demonstration in academic settings and their performance in global health practice and research. We hope this commentary initiates a constructive dialogue on the explicit identification of competencies held in common with the field of public health and those distinctly required of the subfields of global health practice and research.

Conflict of Interest: None to declare.

Received: November 25, 2010

Accepted: April 12, 2011

REFERENCES

(1.) Public Health Agency of Canada. Core Competencies for Public Health in Canada. Ottawa, ON: Public Health Agency of Canada, 2007.

(2.) Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al. Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet 2009;373:1993-95.

(3.) Beaglehole R, Bonita R. What is global health? Global Health Action 2010;3:5142 (DOI: 10.3402/gha.v3i0.5142).

(4.) Fried LP, Bentley ME, Buekens P, Burke DS, Frenk JJ, Klag MJ, Spencer HC. Global health is public health. Lancet 2010;375:535-37.

(5.) Neufeld VR, Spiegel J. Canada and global health research: 2005 update. Can J Public Health 2006;97:39-41.

(6.) Bondy SJ, Johnson I, Cole DC, Bercovitz K. Identifying core competencies for public health epidemiologists. Can J Public Health 2008;99(4):246-51.

(7.) Pringle J. Letter to the Editor. Canadian Society for Epidemiology and Biostatistics Bulletin. 2009;Spring-Summer:6-7.

(8.) Hagopian A, Spigner C, Gorstein JL, Mercer MA, Pfeiffer J, Frey S, et al. Developing competencies for a graduate school curriculum in international health. Public Health Reports 2008;123:408-14.

(9.) Forrest CB, Martin DP, Holve E, Millman A. Health services research doctoral core competencies. BMC Health Serv Res 2009;9:107 (DOI:10.1186/14726963-9-107).

(10.) Nuyens Y. 10 best resources for ... health research capacity strengthening. Health Policy Planning 2007;22:274-76.

(11.) Hass PM. Introduction: Epistemic communities and international policy coordination. International Organization 1992;46(1):1-35.

(12.) Stephen C, Daibes I. Defining features of the practice of global health research: An examination of 14 global health research teams. Global Health Action 2010;3:5188 (DOI: 10.3402/gha.v3i0.5188).

(13.) Edwards N, MacLean Davison C. Social justice and core competencies for public health: Improving the fit. Can J Public Health 2008;99(2):130-32.

(14.) Kishk Anaquot Health Research. Collaborative Research: An "indigenous lens" perspective. Ottawa: CCGHR, April 2008; 7 pp.

(15.) Edwards N. Webber J, Mill J, Kahwa E, Roelofs S. Building capacity for nurse led research. Int Nurs Rev 2009;56(1):88-94.

Donald C. Cole, MD, MSc, [1] Colleen Davison, MPH, PhD, [2] Lori Hanson, PhD, [3] Suzanne F. Jackson, PhD, [4] Ashley Page, BSocSc, [5] Raphael Lencucha, PhD, [6] Ritsuko Kakuma, PhD [4]

Author Affiliations

[1.] Associate Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[2.] CIHR Postdoctoral Fellow, Institute of Population Health, University of Ottawa, Ottawa ON

[3.] Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK

[4.] Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[5.] University of Ottawa, Ottawa, ON

[6.] Assistant Professor, Faculty of Health Sciences, University of Lethbridge, Lethbridge, AB

Correspondence: Dr. Donald C. Cole, Dalla Lana School of Public Health, 6th Floor, Room 676, Health Sciences Building, 155 College St., Toronto, ON M5T 3M7, Tel: 416-946-7870, Fax: 416-978-8299, E-mail: donald.cole@utoronto.ca

Table 1. Competencies for Public Health, Global Health Practice and
Research

                                      Our Proposed Complementary
                                      Competencies

Core Competencies for                 Global Health
Public Health Practice *              Practice ([dagger])

Category 1: Public Health Sciences    Demonstrate knowledge of:
                                      GH.1 historical and present
1.2 Demonstrate knowledge about       north-south power dynamics;
the history, structure and            social and political contexts
interaction of public health and      and determinants of health.
health care services at local,
provincial/ territorial, national     GH.2 linkages between local and
and international levels.             global health problems.

                                      GH.3 international
                                      organizations, their
                                      interactions and their effects
                                      on local actions for health.

Category 2: Assessment and Analysis

2.3 Collect, store, retrieve and
use accurate and appropriate
information on public health
issues.

2.4 Analyze information to
determine appropriate
implications, uses, gaps and
limitations.

Category 3: Policy and Program        GH.4 Work effectively and
Planning, Implementation and          responsibly in low-resource
Evaluation                            settings to promote sustainable
                                      interventions for global
3.3 Develop a plan to implement       health.
a course of action taking into
account relevant evidence,
legislation, emergency planning
procedures, regulations and
policies.

3.6 Evaluate an action, policy or
program.

Category 4: Partnerships,             GH.5 Foster self-determination,
Collaboration and Advocacy            empowerment and community
                                      participation in GH contexts.
4.1 Identify and collaborate with
partners in addressing public         GH.6 Actively recognize the
health issues.                        interaction between political
                                      and economic history, power,
4.2 Use skills such as team           participation and engagement
building, negotiation, conflict       globally.
management and group facilitation
to build partnerships.                GH.7 Contribute to improving
                                      health equity at multiple
4.4 Advocate for healthy public       levels, through systems changes.
policies and services that
promote and protect the health
and well-being of communities.

Category 5: Diversity and             GH.8 Critically self-reflect
Inclusiveness                         upon one's own social location
                                      and appropriately respond to
5.3 Apply culturally-relevant and     others in their diverse
appropriate approaches with people    locations.
from diverse cultural,
socio-economic and educational        GH.9 Communicate effectively
backgrounds, and persons of all       across disciplines and cultures.
ages, genders, health status,         GH.10 Demonstrate commitment to
sexual orientation and abilities.     global equity, social justice,
                                      and sustainable development.

Category 6: Communication             GH.11 Create social spaces for
                                      dialogue between stakeholders
6.3 Mobilize individuals and          across jurisdictions.
communities by using appropriate
media, community resources and
social marketing techniques.

Category 7: Leadership                GH.12 Demonstrate willingness
                                      to be mentored across borders.
7.4 Contribute to team and            GH.13 Mentor others and develop
organizational learning in order      long-term relationships of
to advance public health goals.       trust locally and globally.

7.6 Demonstrate an ability to         GH.14 Educate oneself about
build community capacity by           global health issues on an
sharing knowledge, tools,             ongoing basis.
expertise and experience.

                                      Our Proposed Complementary
                                      Competencies

                                      Public Health     Global Health
Core Competencies for                 Research          Research
Public Health Practice *              ([dagger])        ([dagger])

Category 1: Public Health Sciences    R.1 Demonstrate knowledge of the
                                      ways research has been
1.2 Demonstrate knowledge about       historically funded, generated
the history, structure and            and used in different contexts
interaction of public health and      and levels of the public health
health care services at local,        and the health care systems.
provincial/ territorial, national
and international levels.

Category 2: Assessment and Analysis   R.2 Critically analyze,
                                      synthesize and manage available
2.3 Collect, store, retrieve and      knowledge.
use accurate and appropriate
information on public health          R.3 Identify 'actionable
issues.                               determinants' or entry points
                                      for research to action.
2.4 Analyze information to
determine appropriate
implications, uses, gaps and
limitations.

Category 3: Policy and Program        R.4 Engage community members in
Planning, Implementation and          research planning within a
Evaluation                            framework of trust and respect.

3.3 Develop a plan to implement       R.5 Demonstrate proficiency in
a course of action taking into        the use of evaluation
account relevant evidence,            research methods.
legislation, emergency planning
procedures, regulations and
policies.

3.6 Evaluate an action, policy or
program.

Category 4: Partnerships,             R.6 Produce knowledge relevant
Collaboration and Advocacy            to users through well-managed,
                                      ethically informed research.
4.1 Identify and collaborate with
partners in addressing public         R.7 Identify and collaborate
health issues.                        with researchers from different
                                      disciplines and partners from
4.2 Use skills such as team           different cultures.
building, negotiation, conflict
management and group facilitation     R.8 Use research as an advocacy
to build partnerships.                tool; recognizing the
                                      appropriateness of different
4.4 Advocate for healthy public       strategies in particular
policies and services that            situations.
promote and protect the health
and well-being of communities.        R.9 Use knowledge exchange
                                      mechanisms in community action,
                                      program management and
                                      policy-making.

Category 5: Diversity and             GHR.1 Respect
Inclusiveness                         cultural diversity and
                                      values as they relate
5.3 Apply culturally-relevant and     to global health
appropriate approaches with people    research and
from diverse cultural,                interventions.
socio-economic and educational
backgrounds, and persons of all
ages, genders, health status,
sexual orientation and abilities.

Category 6: Communication

6.3 Mobilize individuals and
communities by using appropriate
media, community resources and
social marketing techniques.

Category 7: Leadership                GHR.2 Work in
                                      transnational teams
7.4 Contribute to team and            with a broad
organizational learning in order      understanding of
to advance public health goals.       health research.

7.6 Demonstrate an ability to
build community capacity by
sharing knowledge, tools,
expertise and experience.

* We have included competencies within the seven CCPHC categories
that we felt were relevant to global health
(www.phac.aspc.gc.ca/core_competencies).

([dagger]) These additional and complementary competencies were
developed with participants at a pre-conference workshop at the
2010 annual conference of the Canadian Public Health Association.