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Asset-Based Community Development as a Strategy for Developing Local Global Health Curricula

Published:February 07, 2018DOI:https://doi.org/10.1016/j.acap.2018.02.001

      Abstract

      Background

      A significant and growing proportion of US children have immigrant parents, an issue of increasing importance to pediatricians. Training globally minded pediatric residents to address health inequities related to globalization is an important reason to expand educational strategies around local global health (LGH).

      Methods

      We developed a curriculum in the pediatric global health residency track at the University of Wisconsin in an effort to address gaps in LGH education and to increase resident knowledge about local health disparities for global community members. This curriculum was founded in asset-based community development (ABCD), a strategy used in advocacy training but not reported in global health education.

      Results

      The initial curriculum outputs have provided the foundation for a longitudinal LGH curriculum and a community–academic partnership. Supported by a community partnership grant, this partnership is focused on establishing a community-based postpartum support group for local Latinos, with an emphasis on building capacity in the Latino community.

      Conclusions

      Aspects of this curriculum can serve other programs looking to develop LGH curricula rooted in building local partnerships and capacity using an ABCD model.
      There is significant globalization of communities within the United States; one quarter of US children have at least one parent who is foreign born.
      • Hernandez D.J.
      • Napierala J.S.
      Diverse Children: Race, Ethnicity, and Immigration in America's New Non-majority Generation.
      As a result, global health (GH) is becoming local health, and all pediatricians are increasingly expected to be familiar with diseases and challenges often thought to be limited to those who work in international settings.
      • Arnold L.D.
      Improving global child health: why all pediatricians must “be the change.”.
      Children of immigrant families experience disparities in rates of child mortality and are less likely to be covered by health insurance compared to those of nonimmigrant parents.
      • Hernandez D.J.
      • Napierala J.S.
      Diverse Children: Race, Ethnicity, and Immigration in America's New Non-majority Generation.
      Limited postgraduation data demonstrate that pediatric residents with GH training experience are particularly vital to the effort to eliminate health inequities for immigrant children, as they are more likely to care for underserved and resource-poor patient populations after graduation.
      • Haq C.
      • Rothenberg D.
      • Gjerde C.
      • et al.
      New world views: preparing physicians in training for global health work.
      In order to train globally minded pediatricians to successfully practice in these settings, residency educators must consider the importance of developing local GH (LGH) curricula.
      LGH is defined as “having a global perspective or understanding of transnational health issues, determinants and solutions and applying that perspective to address health care problems at the local level.”
      • Rowthorn V.
      Global/local: what does it mean for global health educators and how do we do it?.
      While LGH experiences, like international adoption clinics and immigrant screening, are common in GH residency training,
      • Butteris S.M.
      • Schubert C.J.
      • Batra M.
      • et al.
      Global health education in US pediatric residency programs.
      there are few published practical educational frameworks to help programs build LGH curriculum. This gap may in part be due to the history and evolution of pediatric GH education. While we do not know the full spectrum of experience and scope of expertise in pediatric GH education, we suspect that majority of GH education pioneers, like those leading the Association of Pediatric Program Directors GH Pediatric Education Group, came to GH education armed with experience in international GH and aimed to prepare pediatric residents to have successful and ethical international GH experiences. In recent years, the scope of GH education has broadened, with a growing number of globally minded pediatricians and trainees interested in participating in LGH. While many experts in the field believe that the skills obtained in international GH likely translate to LGH, there is a need to expand the tools and techniques used in LGH education to ensure that trainees and educators are well prepared.
      Because of this gap, we developed a LGH curriculum for residents in our GH program that simultaneously reflects an established community-based development strategy and asset-based community development (ABCD) while following recommended LGH educational components published by GH educators of the 2015 Consortium of Universities for Global Health (CUGH).
      • Rowthorn V.
      Global/local: what does it mean for global health educators and how do we do it?.
      The components of quality LGH education include community engagement, transferrable skills, focus on social justice and health disparities, bidirectional learning, experiential learning, interprofessional approach, and reflection. ABCD, a community development strategy, facilitates achievement of several of these 7 recommended elements and has long been used in community pediatrics and advocacy training.
      • Kretzmann J.P.
      • McKnight J.
      Building Communities From the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets.
      • Asset-Based Community Development Institute
      • American Academy of Pediatrics
      • Council on Community Pediatrics
      • Kuo A.A.
      • Etzel R.A.
      • Chilton L.A.
      • et al.
      Primary care pediatrics and public health: meeting the needs of today's children.
      • Baker I.R.
      • Dennison B.A.
      • Boyer P.S.
      • et al.
      An asset-based community initiative to reduce television viewing in New York state.
      • Hufford L.
      • West D.C.
      • Paterniti D.A.
      • et al.
      Community-based advocacy training: applying asset-based community development in resident education.
      While ABCD is well described for use in community pediatrics, we think it is important to bring this strategy to the forefront of GH education, where it can serve as a critical foundation on which global pediatricians can approach LGH work.
      We outline the key components of this curriculum, including the development of a bidirectional partnership with Centro Hispano, a local nonprofit, community-based organization whose mission is to empower Latino youth, strengthen families, and engage the community. Our hope is that this description can serve as a model for using the ABCD strategy, and asset mapping in particular, for other GH educators pursuing curricular collaborations with both local and global partners.

      LGH Partnership

      We wished to focus our curriculum on the local Latino population because of known health disparities and the rapidly growing proportion of Latinos in our county.
      • UW Applied Population Laboratory
      • University of Wisconsin Extension
      Latinos in Wisconsin: a statistical overview.
      Latinos make up 6.1% of the population in Dane County, and 44% are born in Wisconsin.
      • United Way
      An overview of the Latinx* community in Dane County.
      We reached out to Centro Hispano, and together we identified an overlapping priority. Centro Hispano sought a better understanding of reproductive health resources in the Latino community to inform an existing wellness initiative. This interest was in part due to known disparities in infant mortality and low birth weight for Latino infants in Dane County.
      • Healthy Dane
      Community health dashboards.
      This aligned with identified health priorities of the local community health care collaborative formed by the hospitals in which our residents work. A primary aim of Centro Hispano's wellness initiative was to train local Latina women to be community wellness workers, also referred to as community health workers (CHW), in GH work. The CHW, focused on reproductive health, was selected as an ideal area for bidirectional education and community development aimed at elimination of related health disparities.

      ABCD Strategy

      Needs assessments are a traditional approach to community development and typically begin with an outside group identifying a community's perceived needs and then attempting to fill these identified needs through outside funding, resources, and education. A criticism of this approach is that it creates a deficiency model that focuses on negative aspects of communities and threatens a host of unintended consequences (eg, community members perceiving themselves as a list of problems).
      • Kretzmann J.P.
      • McKnight J.
      Building Communities From the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets.
      To avoid these potential conflicts, we aimed to accomplish our LGH curricular goals in a manner that emphasizes established GH principles of sustainability and capacity building
      • Crump J.A.
      • Sugarman J.
      Working Group on Ethics Guidelines for Global Health T
      Ethics and best practice guidelines for training experiences in global health.
      by applying the strategies of ABCD.
      ABCD, pioneered by Kretzmann and McKnight,
      • Kretzmann J.P.
      • McKnight J.
      Building Communities From the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets.
      is as an innovative approach to community improvement rooted in local assets and capacity building. The basic tenet of ABCD is that in every community, there exist assets in numerous domains: individuals, associations, institutions, physical space, exchanges, and culture. Embracing the ABCD approach relies on connecting these assets to support the community from within. ABCD can therefore be used in partnership with communities to help support local capacity—working on priorities identified by the community through their own assets. We suggest that this approach is exceedingly valuable in LGH work, as it can help build connections for immigrant and refugee families, who may experience social, physical, cultural, and linguistic isolation. Moreover, the principles of ABCD can be applied in any community, allowing the curriculum to adapt as the local immigrant community evolves.

      Curriculum Design

      Our curriculum was guided by Kern's 6 steps for curriculum development.
      • Kern D.E.
      • Thomas P.A.
      • Hughes M.T.
      Curriculum Development for Medical Education: A Six-Step Approach.

      Step 1: Problem Identification

      Several residency programs report providing LGH experiences.
      • Butteris S.M.
      • Schubert C.J.
      • Batra M.
      • et al.
      Global health education in US pediatric residency programs.
      However, there is little published on how to educate trainees through these LGH experiences.
      • Asgary R.
      • Price J.
      • Ripp J.
      Global health training starts at home: a unique US-based global health clinical elective for residents.
      • McKinnon T.
      • Toms Smedley C.
      • Evert J.
      Service learning as a framework for competency-based local/global health education.
      Additionally, we were concerned about the potential burden these experiences place on local organizations. Although principles of ethical GH experiences exist in the literature, they are more specific to international GH.
      • Crump J.A.
      • Sugarman J.
      Working Group on Ethics Guidelines for Global Health T
      Ethics and best practice guidelines for training experiences in global health.
      • Loh L.C.
      • Cherniak W.
      • Dreifuss B.A.
      • et al.
      Short term global health experiences and local partnership models: a framework.

      Step 2: Gap Analysis

      During step 2 of curriculum development, identifying the gap the curriculum aims to fill, we examined our Fundamentals in Global Health Course, a 3-year longitudinal curriculum for residents in our GH track within the pediatric residency at the University of Wisconsin, which includes a 2-week required course in each year. During our yearly review of resident and faculty evaluations of the GH education program, we identified an explicit need to improve resident understanding of health disparities for LGH populations in our community and strategies to reduce these disparities. This feedback informed our decision to reach out to Centro Hispano to pursue a LGH partnership.

      Step 3: Goals and Objectives

      Our curriculum goals and objectives are outlined in the Table. We developed a broad set of 12 objectives, mapped to GH competencies and the CUGH consensus-based essential components of LGH training.
      • Suchdev P.S.
      • Shah A.
      • Derby K.S.
      • et al.
      A proposed model curriculum in global child health for pediatric residents.
      TableYear 1 Curriculum Objectives
      Data from Rowthorn V. Global/local: what does it mean for global health educators and how do we do it? Ann Glob Health. 2015;81:593–601.
      CompetencyObjectiveCUGH Essential Program Component for Local Global Health Training
      Community EngagementTransferable SkillsHealth DisparitiesBidirectional LearningExperiential LearningInterprofessional ApproachReflection
      Knowledge1. Analyze and discuss models of domestic CHW programs.
      2. Describe status of health and health inequities, emphasizing reproductive health for Latinos in our community.
      3. Apply key ABCD concepts of identifying and linking local assets specific to reproductive health in Dane County.
      Interpersonal and communication skills4. Demonstrate cultural humility while interviewing community members and institutional representatives.
      5. Present and collaboratively discuss project findings to community partners.
      Practice based learning and improvement6. Appraise benefits of ABCD as framework for local GH work.
      7. Recognize asset mapping as valuable first step toward agenda building for community-based development.
      8. Collaborate with community members and organizations to create agenda for community development.
      Systems-based practice9. Summarize connections between reproductive health services and Latino population.
      10. Recognize sociocultural factors affecting local Latino reproductive health.
      Professionalism11. Professionally navigate challenges of physician–community collaborations.
      12. Recognize potential cultural conflicts that arise when working in community-based setting.
      ABCD indicates Asset-Based Community Development; CHW, community health worker; CUGH, Consortium of Universities for Global Health; and GH, global health.

      Step 4: Educational Strategy

      The ABCD framework was the primary strategy we chose to achieve our objectives. Specifically, we chose asset mapping, a fundamental ABCD tool, as the focus for a resident project because it facilitates community engagement, experiential learning, and transferrable skills that can be translated into future GH work.
      • Kretzmann J.P.M.
      • McKnight J.
      Introduction to asset-mapping.
      • Dorfman D.
      Strengthening community education: the basis for sustainable renewal—mapping community assets workbook.
      To prepare residents for this self-directed project, we developed introductory readings and didactics on ABCD and asset mapping, the steps of which are outlined in the Figure.
      The asset-mapping project consisted of working with community members to identify assets in the area of reproductive health for Latinos in the community, and integrating the findings of the asset map into well-researched recommendations on training, evaluation, and implementation strategies for Centro Hispano's CHW program. We intended to facilitate interprofessional learning between residents, the community through the process of building the asset map, and sharing the resident's summary.

      Step 5: Implementation

      The curriculum was intended to become a permanent component of our Fundamentals in Global Health Course during the second week of the course annually. It was designed to parallel our 3-year longitudinal curriculum cycle.
      Seventeen residents, 15 pediatric and 2 family medicine, who participated in their residency program's GH track, were excused from clinical duties to participate in Fundamentals in Global Health during this curriculum's first year. The 5-day curriculum had 3 phases: 1) introduction to ABCD, 2) independent group work on the asset map, and 3) project presentation to Centro Hispano.
      Residents read introductory materials about ABCD before attending the course. On day 1, residents received the goals and objectives of the curriculum and didactics by faculty members with experience in CHW program development, ABCD, and asset mapping. Examples of ABCD projects were shared and discussed. On day 2, residents met at Centro Hispano to learn about the organization's wellness initiative and discuss Latino health demographics in Dane County. On days 2 to 4, residents self-organized into subgroups to do the work of asset mapping. GH faculty were available for guidance and consultation. Asset mapping activities included interviews with community members, leaders, and stakeholders identified by Centro Hispano. On the final morning, the residents presented their work to the faculty and leaders of Centro Hispano, followed by discussion and feedback. The residents also had time to share reflections about the curricular experience.

      Step 6: Evaluation and Feedback

      Resident evaluation of the curriculum was gathered from an anonymous electronic survey. Qualitative evaluation of the curriculum was accomplished using a focus group with residents and interviews with Centro Hispano leadership. Emergent themes from focus groups were identified using inductive content analysis of focus group and interview notes.
      The survey was completed by 15 (88%) of 17 residents. The majority of residents (67%) agreed that the experience was valuable to their education, and almost all (87%) felt they made a meaningful contribution to Centro Hispano's CHW program. Most residents (73%) expressed interest in collaborating with Centro Hispano in the future. Focus group themes included 1) difficulty adjusting to working in different cultures (sociodemographic and workplace), 2) need for clear expectations from the community partner, and 3) desire for a less compressed project timeline. Residents suggested a briefing in advance to prepare before the course. Additionally, while GH faculty and Centro Hispano leadership considered the output a success, some residents felt that the final product was not as robust or polished as they would have liked. Centro Hispano leadership felt the work and materials from the residents were valuable to the CHW program and used the resident products for organizational agenda building.

      Outputs

      Asset Map

      The residents prepared a narrative asset map. This outlined individuals and institutions providing reproductive health services in the community, and linked relationships within and across those organizations. For example, residents met with the director of the Division of Policy Planning and Evaluation from the Department of Health, a nurse coordinator for the local school district, a Latina CHW from Planned Parenthood, and Latino mothers and teens in the community. Key themes in the asset map addressed current perspectives on reproductive health status for Latinos, potential areas for local collaboration on reproductive health services, and barriers for Latinos in accessing reproductive and women's health services. A subgroup of residents researched US-based CHW programs and, integrating findings from the asset map, created specific suggestions for developing, implementing, and evaluating a CHW program at Centro Hispano. Because the asset map contains opinions and personal information about community members and organizations, we cannot publish the final resident product; however, sample asset maps and asset mapping tools can be found at the ABCD Institute (https://resources.depaul.edu/abcd-institute/Pages/default.aspx).
      • Kretzmann J.P.
      • McKnight J.
      Building Communities From the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets.

      Partnership

      The asset map set the agenda for the next steps in our partnership with Centro Hispano. We saw an opportunity to work together to develop, implement, and evaluate a postpartum support group led by the CHWs, which continues to fit with the model of ABCD by building capacity in the community. Since the first year of the curriculum, we have successfully obtained a partnership grant to continue to fund this community academic collaboration with Centro Hispano.

      Longitudinal Resident Curriculum

      By using the ABCD strategy and partnering with Centro Hispano, we were able to build a pilot curriculum based on the 7 essential components of LGH educational program as described by the CUGH.
      • Rowthorn V.
      Global/local: what does it mean for global health educators and how do we do it?.
      The development of the CHW-led postpartum support group has provided the foundation on which we have been able to build years 2 and 3 of the curriculum, which is focused on supporting many aspects of the program. Some of the previously identified obstacles have been mitigated, as senior residents mentor junior residents through the challenges of working on a community-based collaboration. Other modifications have included narrowing the scope of the resident project, briefing residents on the project earlier, and allowing more time for planning and execution of the residents' deliverables. The curriculum will continue to evolve with the changing priorities of the community and Centro Hispano, anchored in ABCD.

      Lessons Learned in Implementing This Curriculum

      ABCD provides an approach to transfer knowledge, attitudes, and skills that GH residents can use both locally and internationally to improve children's health at the community level.
      • Kretzmann J.P.
      • McKnight J.
      Building Communities From the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets.
      • Asset-Based Community Development Institute
      This curriculum was successful in part because the residents who participated were all in a GH track or pathway and therefore have protected time for the curriculum. For programs without this protected time, our approach might be modifiable to a longitudinal experience with several smaller portions of protected time, as the majority of the residents' time was spent working independently or in small groups. We note our residents had already received education about important GH themes, including longitudinal partnerships, cultural humility, and culture shock. Preparation likely contributed to success, and we recommend that residents receive similar training before engaging with a local partner to facilitate mutual benefit and minimize burden on the local partner. Importantly, despite preparation, residents struggled with frustration related to the challenges of community-based work. We consider this evidence of the importance of active preparation for LGH work. Experiencing these challenges in the supportive environment of residency allows for debriefing in a way that may help GH residents succeed in future community-based encounters.
      Finally, we acknowledge limitations of our work, including uncertainties about the influence of this experience on the current competencies and future practice of pediatric GH residents. Future work should aim to more deliberately assess achievement of curriculum elements recommended by CUGH and educational outcomes of such curricula.

      Conclusions

      Global pediatricians need effective skills, knowledge, and attitudes to address the health inequities experienced by immigrant and refugee children. Here we suggest one example of a longitudinal LGH curriculum for pediatric GH residents, using ABCD as a key strategy. We have found ABCD to be a model that can facilitate the development of an academic–community partnership, something we believe is vital to the development of a longitudinal, ethical LGH curriculum. We suggest the ABCD strategy be more broadly used in GH education to prepare residents for the changing landscape of GH work.

      Acknowledgment

      Supported in part by a Wisconsin Partnership Program Community Opportunity grant.

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