Globalization has become a key word in the 21st century and is defined here as “the ways in which nations, businesses, and people are becoming more connected and interdependent across national borders through increased economic integration, communication, cultural diffusion, and travel” [
Evidence shows that such calamities have progressively increased the number of deaths, illnesses, and disabilities and, therefore, the economic costs of treatment and rehabilitation [
Presently, there is an extraordinary interest in global health among students, health professionals, and educators [
Occupational therapists and physiotherapists have been participating in paid and unpaid work overseas as well as international internships as part of their educational programs [
Research on disability and health care suggests that people with impairments face noteworthy personal and cultural barriers to access healthcare facilities. The personal barriers are related to transportation, communication, finance, and insurance. The cultural barriers include misconceptions about people with disabilities, lack of respect, and reluctance to provide care for these populations [
An online cross-sectional survey was administered using SurveyMonkey online survey to physiotherapy and occupational therapy students registered in five universities in Ontario.
A forty-seven-item online global health education survey was firstly developed to gather information regarding self-perceived knowledge, skills, and learning needs in global health. The survey was developed by adapting three other instruments: (1) resident physicians’ knowledge of underserved patients, a validated survey used to measure actual and perceived resident physician’s knowledge of underserved patient populations in the United States done by Wieland and adapted by the research team for the Canadian population (17 items) [
The questions regarding self-assessed confidence in global health (part 01/04) asked respondents whether they felt “not at all confident,” “somewhat confident,” or “very confident.” The questions received the following code: 0 (not at all), 0.5 (somewhat), and 1 (very). Self-perceived skills in global health (part 2/4) could be answered by either “strongly agree,” “agree,” “neutral,” “disagree,” or “strongly disagree.” The questions received codes varying between 0 and 1 (item scale [0-1]—for negative questions: 1 = strongly disagree, 0.75 = disagree, 0.50 = neutral, 0.25 = agree, and 0 = strongly agree; for positive questions: 1 = strongly agree, 0.75 = agree, 0.50 = neutral, 0.25 = disagree, and 0 = strongly disagree). Therefore, by averaging all respondents’ answers to a given question and multiplying that average by 100, each question was given a number between 0 and 100. The score 0 represented a complete lack of confidence and 100 represented feeling completely confident. Learning needs in global health (part 3/4) could be answered by either “not at all important,” “somewhat important,” “neutral,” “important,” “very important,” or “extremely important.” The fourth part of the survey included demographic questions.
Students from five universities, within Ontario, Canada, were invited to participate in the study. Inclusion criteria were predefined as follows: 18 years or older or 1st year student from a master’s program in physiotherapy or occupational therapy program in one of the five participating universities in Ontario.
From May to October 2011, directors or coordinators of physiotherapy and occupational therapy programs were contacted to collaborate the survey. They were asked to send an e-mail invitation to all physiotherapy and occupational therapy students to invite the prospects to participate in the survey. Then, an e-mail containing a hyperlink to the survey and a consent form was sent to all students. Two reminder e-mails were sent at one and two week intervals.
Ethical approval was obtained for this study from the Ottawa Hospital Research Ethics Board, the University of Ottawa, and the University of Western Ontario.
The response rate was 23.7% and thus a total of 166 participants were included in the following analysis. Most of the participants were females, originally from Canada, from a higher socioeconomic background and were able to speak at least two languages.
All five eligible universities which offered both physiotherapy and occupational therapy programs in Ontario, Canada, were represented in this study. Table
Demographic characteristics of respondents (
Variables | Number (percentage) | |
---|---|---|
Physiotherapy students |
Occupational therapy students |
|
Sex | ||
Male | 13 (19.1) | 5 (5.1) |
Female | 55 (80.9) | 93 (94.9) |
Country (of birth) | ||
Canada | 59 (86.8) | 87 (88.8) |
United States | 0 (0.0) | 1 (1.0) |
Philippines | 1 (1.5) | 1 (1.0) |
India | 1 (1.5) | 0 (0.0) |
Honk Hong | 3 (4.4) | 3 (3.1) |
Pakistan | 0 (0.0) | 1 (1.0) |
Other | 4 (5.9) | 5 (5.1) |
Mean age | 26.47 (41) | 24.91 (59) |
Family background | ||
White | 52 (76.4) | 78 (79.6) |
Chinese | 7 (10.3) | 7 (7.1) |
South Asian | 3 (4.4) | 6 (6.1) |
Black | 0 (0.0) | 1 (1.0) |
Other | 6 (8.8) | 6 (6.1) |
Parent’s family income | ||
$20,001 to $30,000 | 8 (11.8) | 1 (1.0) |
$30,001 to $40,000 | 1 (1.5) | 3 (3.1) |
$40,001 to $50,000 | 4 (5.9) | 3 (3.1) |
$50,001 to $60,000 | 2 (2.9) | 8 (8.2) |
$60,001 to $70,000 | 4 (5.9) | 4 (4.1) |
$70,001 to $80,000 | 5 (7.4) | 10 (10.2) |
$80,001 or more | 23 (33.8) | 34 (34.7) |
Do not know | 21 (30.9) | 35 (35.7) |
Languages (spoken) | ||
One language | 26 (38.2) | 48 (49.0) |
Two languages | 31 (45.6) | 38 (38.8) |
Three languages | 8 (11.8) | 6 (6.1) |
Four languages or more | 3 (4.4) | 6 (6.1) |
Students were asked to rate their self-perceived knowledge in several global health and health equity topics. The self-perceived knowledge scores of physiotherapy and occupational therapy students in twelve domains of global health are presented in Table
Physiotherapy and occupational therapy students’ self-perceived knowledge in global health.
Domains of self-perceived knowledge | Physiotherapy students’ score* (%) | Occupational therapy students’ score* (%) |
---|---|---|
Language barrier and adverse impact on health and health care | 65.67 | 57.65 |
Access to health care for low income nations | 25.74 | 29.59 |
Relationship between income and health | 71.32 | 76.53 |
Relationship between work and health | 68.38 | 81.63 |
SEP and impact on health | 64.71 | 67.86 |
Environmental health and socioeconomic position | 47.06 | 53.06 |
Relationship between housing and health status | 55.15 | 54.12 |
SEP and food security confidence | 54.41 | 48.47 |
Health outcome discrepancies among different groups in Canada | 39.71 | 40.82 |
Mechanisms for why racial and ethnic disparities exist | 32.35 | 31.12 |
Racial stereotyping and medical decision making | 36.76 | 38.54 |
Gender and access to health care | 42.65 | 40.82 |
The scores of perceived global health skills of physiotherapy and occupational therapy students in eleven skills domains guided by the CanMEDS framework are presented in Table
Perceived global health skills for physiotherapy and occupational therapy students guided by the CanMEDS framework.
Skills | Physiotherapy students’ score* (%) | Occupational therapy students’ score* (%) |
---|---|---|
Communication skills | 60.00 | 54.34 |
Listening skills | 76.17 | 72.68 |
Able to understand patient with different background skills | 54.04 | 56.63 |
Address team disagreement skills | 52.69 | 42.89 |
Discuss sensitive issues skills | 49.62 | 48.95 |
Identify needs skills | 63.28 | 56.84 |
Helping patients achieve realistic goals skills | 55.68 | 47.83 |
Working in a team skills | 55.47 | 53.95 |
Clinical competency Skills | 69.62 | 67.11 |
Keep up to date in global health skills | 50.47 | 53.16 |
Active in global health skills | 33.09 | 33.42 |
Learning needs in global health for physiotherapy and occupational therapy students are presented in Table
Learning needs in global health for physiotherapy and occupational therapy students in Ontario, Canada.
Learning needs in global health | Physiotherapy |
Occupational therapy |
Pearson chi-square |
---|---|---|---|
Health risks associated with travel and migration, with emphasis on possible risks and appropriate management, including referrals | |||
Not important | 0 (0) | 0 (0) | |
Somewhat important | 16 (64) | 9 (36) | 0.12 |
Neutral | 7 (28) | 18 (72) | |
Important | 24 (40.7) | 35 (59.3) | |
Very important | 16 (40) | 24 (60) | |
Extremely important | 4 (36.4) | 7 (63.6) | |
Knowledge about how travel and trade contribute to the spread of communicable diseases | |||
Not important | 0 (0) | 0 (0) | |
Somewhat important | 9 (42.9) | 12 (57.1) | 0.86 |
Neutral | 9 (33.3) | 18 (66.7) | |
Important | 27 (45.8) | 32 (54.2) | |
Very important | 15 (45.8) | 20 (57.1) | |
Extremely important | 7 (38.9) | 11 (61.1) | |
Relationship between health and social determinants of health, and how social determinants vary across world regions | |||
Not important | 0 (0) | 0 (0) | |
Somewhat important | 3 (75) | 1 (25) | 0.03 |
Neutral | 5 (62.5) | 3 (37.5) | |
Important | 28 (53.8) | 24 (46.2) | |
Very important | 17 (32.7) | 35 (67.3) | |
Extremely important | 15 (31.3) | 33 (68.8) | |
Relationship between access to clean water, sanitation, and nutrition on individual and population health | |||
Not important | 2 (50) | 2 (50) | 0.03 |
Somewhat important | 4 (40) | 6 (60) | |
Neutral | 5 (55.6) | 4 (44.4) | |
Important | 18 (36) | 32 (64) | |
Very important | 9 (20.9) | 34 (79.1) | |
Extremely important | 30 (62.5) | 18 (37.5) | |
Understand the relationship between health and human rights | |||
Not important | 1 (50) | 1 (50) | 0.28 |
Somewhat important | 2 (66.7) | 1 (33.3) | |
Neutral | 4 (50) | 4 (50) | |
Important | 18 (43.9) | 23 (56.1) | |
Very important | 14 (27.5) | 37 (72.5) | |
Extremely important | 29 (47.5) | 32 (52.5) | |
Knowledge about how global health institutions (e.g., WHO, other United Nations agencies, and global institutions) influence health in different world regions through funding and policy | |||
Not important | 1 (33.3) | 2 (66.7) | 0.74 |
Somewhat important | 2 (50) | 2 (50) | |
Neutral | 6 (54.5) | 5 (45.5) | |
Important | 24 (46.2) | 28 (53.8) | |
Very important | 22 (35.5) | 40 (64.5) | |
Extremely important | 12 (36.4) | 21 (63.6) |
Almost 70% of the occupational therapy students reported that it is extremely important to learn about the relationship between health and social determinants of health and how social determinants vary across world regions compared to 31% of physiotherapy students (
Both physiotherapy and occupational therapy students (a total of 25 students) suggested additional topics that are important to learn in global health including (1) “understanding the different structures of health care around the world,” (2) “access to adequate healthcare services in less developed countries,” (3) “cultural perceptions of disability, work and health,” (4) “global health issues and social determinants of health,” (5) “language barrier and effective communication,” (6) “Potential cultural clash experiences of young immigrants, stereotyping based on religion, knowing the effects politics has on health in certain countries in the world,” (7) “the impact of climate change on the health of low socioeconomic classes,” (8) “specific education surrounding aboriginal people and the effects that their lifestyles have on them physically, psychologically, and emotionally,” and (9) “WHO millennium development goals.”
Our study identified several knowledge and skill opportunities relevant to global health and health equity for rehabilitation sciences students. These needs overlap with other primary health professionals but differ between professions, suggesting a need for both interprofessional and intraprofessional prioritization for education and policy relevance. Overall, both occupational therapy and physiotherapy students demonstrated limited competencies in global health. Few items received scores over 60%.
Most participants in our survey were females that spoke two languages and came from families with high socioeconomic status. The students’ sociodemographic profile is an important component for effective care in a global health context. The recent report by the Commission on Education of Health Professionals for the 21st century refers that in many countries the competencies of graduate students might not be aligned with the new challenges and the social, linguistic, and ethnic diversity of the populations [
Regarding gender, our findings were consistent with those of Cockrell and Peplau [
Gender balance in health systems is highly recommended, as a gender imbalance is a major obstacle for access to health care [
In our study, almost half of the physiotherapy student participants self-reported that they are able to speak at least two languages while half of the occupational therapy student participants reported that they are only able to speak one language. In addition, more than 60% of the physiotherapy participants reported self-perceived confidence related to language barriers and adverse impact on health and health care. According to the literature, one of the barriers to effective health care services is language [
On the other hand, our result in relation to the confidence in the “relationship between income and health” differs from the Wieland study. More than 80% of the occupational therapy students assessed themselves as confident in the “relationship between income and health,” while 57.4% of US family physician residents surveyed reported confidence in the topic. We believe that this difference is related to the main role of the occupational therapists. The occupational therapy profession in itself has a crucial role in training and offering advice on occupational performance, including self-care and productive and recreational activities [
Physiotherapy and occupational therapy students reported less confidence in “access to health care for low income nations,” “mechanisms for why racial and ethnic disparities exist,” and “racial stereotyping and medical decision making.” For these topics, our results were similar to the US students survey, where all of them scored less than 50% [
Overall, students from both programs reported less skill in “global health activity.” Physiotherapists and occupational therapists need to have extended knowledge and skills in global health in addition to their core professional training, to tackle the global burden of disease and disabilities in this multicultural world of the 21st century. The complexity of global health work demands physiotherapists and occupational therapists to have not only clinical and rehabilitation abilities, but also skill and knowledge regarding epidemiology, sociology, population health, geography, laws, and other disciplines. These disciplines are crucial for working in partnership with governmental and nongovernmental organizations.
Another point of emphasis is that in this globalized world occupational therapists and physiotherapists must build confidence to meet the demand and quality care of international citizens from all over the world, including immigrants and refugees, disabled people, victims of wars, and those who suffer from infectious diseases in order to provide equitable services. Furthermore, all the global health challenges will come to “knock on the door” of all health professionals wherever they are working in different settings sectors, such as clinics, rehabilitation centers, community health, or in hospitals.
This study begins to address important knowledge gaps that have appeared in global health literature and provides some global health relevant elements for the disciplines of physiotherapy and occupational therapy. It also highlights how future students of these disciplines can address the growing needs of global health effectively and equitably. Although the findings of this study are important, the results of this study should be interpreted with caution and should not be generalized for all populations because of the small sample size and the limited response rate. We used several strategies to improve the response rate such as e-mail and/or phone call communications with the coordinator and/or responsible for the health programs in the five universities in Ontario, in order to engage them in the research and two reminders were sent to the participants within two-week interval. Unfortunately, these strategies were not enough to minimize the low response rate already expected. Another limitation of the research was the availability of the survey only in English. Some health programs are offered only in French and even though we sent an e-mail invitation to the participants in French, it was not sufficient to motivate French speaking students to participate.
Areas for further research include the following. Assessing global health competencies with francophone students in Canada using a French version of the survey. The use of qualitative and quantitative methods to evaluate students’ learning needs in relation to global health knowledge, skills, and attitudes. Assessing the range of issues that relates to global health that affects PT/OT practice during their local/international training settings.
Based on our findings and the current literature, considerations for action to improve global health education for rehabilitation students include the following. Implementing and building on existing inter-professional global health curriculum and mentorship programs into, for example, the open access interdisciplinary Refugees and Global Health e-Learning Program [ Considering targeted admission policies to recruit students from different ethnic and language backgrounds over a range of socioeconomic status, as there is evidence that workforce diversity may lead to improved health care equity [ Providing opportunities for overseas global health training, seminars, and workshops that could improve students’ knowledge and language skills, relevant to global health.
In conclusion, this paper expands our understanding of the emerging knowledge and skills that occupational therapy and physiotherapy students may need to provide fair and equitable health care more effectively. It provides an invitation for physiotherapy and occupational therapy educators and students to be more involved in emerging interdisciplinary global health initiatives and considerations for the rehabilitation profession. In this globalized 21st century, it is essential for all health professionals to tackle determinants of health (e.g., socioeconomic, environmental, and political factors) and develop competencies to work with other disciplines and to be globally interconnected to help reduce health inequalities. Therefore, improving global health knowledge and skills of occupational therapists and physiotherapists on global health competency is essential not only to prove care for local socially disadvantaged and disabled populations, but also to play leadership roles in the field of interdisciplinary global health.
The authors declare that they have no competing interests.
Mirella Veras, Kevin Pottie, and Peter Tugwell contributed to the study conception, design, and methodology. Mirella Veras, Tim Ramsay, and Govinda P. Dahal performed the statistical analysis. Mirella Veras contributed to acquisition of data and initiated the first and final draft paper. Kevin Pottie, Debra Cameron, and Govinda P. Dahal helped to draft the paper. Kevin Pottie, Debra Cameron, Govinda P. Dahal, Vivian Welch, and Peter Tugwell commented and gave expert advice on the background, results, and discussion. All authors read and approved the final paper.
This study was supported by the Canadian Institutes of Health Research (CIHR) as a part of the Fall 2009 Doctoral Research Award Priority announcement in the Area of Primary Care (Grant agreement no. 200910DPC-216158-DRB-CECA-187516).