key: cord-0026043-75dc2rhm authors: Sharon E., Connor; Lauren J., Jonkman; Jordan R., Covvey; Abby A., Kahaleh; Sharon K., Park; Melody, Ryan; Michele, Klein-Fedyshin; Negar, Golchin; Regine Beliard, Veillard title: A Systematic Review of Global Health Assessment for Education in Healthcare Professions date: 2022-01-06 journal: nan DOI: 10.5334/aogh.3389 sha: 14ce067e31ae0c4dd98cb74238137e03cc6bbc69 doc_id: 26043 cord_uid: 75dc2rhm OBJECTIVE: Emphasis on global health education is growing, with schools/colleges developing relevant courses, areas of concentration, and other didactic content. Organizations such as the Consortium of Universities for Global Health (CUGH) provide guidance for competencies in global health, but evaluation strategies are lacking. Accordingly, the purpose of this study was to identify methods and tools utilized to assess knowledge, skills, and attitudes in global health courses for health science students. METHODS: A systematic review was conducted according to the PRISMA guidelines. The initial search was conducted using controlled vocabularies to screen PubMed, EMBASE, Global Health using Ovid, CINAHL, and ERIC from January 1997 to March 2020. Included articles detailed students in health professions, described a didactic educational intervention related to global health, and described assessment strategies and results. RESULTS: A total of 12,113 titles/abstracts were identified. Based on the study inclusion criteria, 545 full texts were reviewed, and 79 full-text articles were selected for qualitative synthesis. Findings of the research revealed that cultural competence (70.9%) was evaluated most often, followed by health disparities (26.6%) and global health itself (12.7%). Most articles used quantitative assessment methods (86.1%), with surveys being the predominant method. A total of 91.1% of studies assessed perceptions, attitudes, and beliefs, while fewer evaluated knowledge (43.0%) and skills (19.0%). The most common validated tool employed was the Inventory for Assessing the Process of Cultural Competence (IAPCC). CONCLUSIONS: Based of the results of this study, the majority of the assessment tools utilized for global health education focused on cultural competence. One of the important findings of this research is the lack of validated instruments to assess students’ skills in health disparities and global health. Given the recent global pandemic, these skills are essential for educating health care professionals to enhance global health. Although there are various definitions of global health, one that has become commonly accepted is "an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide [1] ." The demand for global health education within health sciences has grown considerably over the last several decades [2, 3] . Students are eager to participate in these experiences for a variety of reasons, including development of cultural competency, desire to reduce health disparities, interest in various cultures, and enhancement of their global health competencies prior to graduation [4] . There is a plethora of models that exist for global health education, ranging from didactic coursework to experiential opportunities abroad. While there has been considerable focus in the literature on experiential education, there have been fewer publications on the didactic approaches. Arguably, this latter format may have potential for the most impact. Given the considerable financial burden of higher education, many students are unable to travel and engage in immersion, For the students who do take advantage of opportunities abroad, baseline didactic engagement in global health should be viewed as a prerequisite, either separately delivered or as preparation prior to an international experience. An additional challenge to furthering knowledge in this area is the siloed nature of higher education, and accordingly, the scholarly assessments associated with global health. Studies describing global education initiatives tend to focus on a single healthcare profession and often are published in associated professional journals. The field of global health work is interprofessional, as are healthcare teams. This highlights the need for more inclusivity. While some fledgling work has been done to describe interprofessional global health education [5] [6] [7] [8] [9] , there is still a gap in the literature and few venues for publishing such work. Several organizations and programs have aimed to standardize educational experiences through the establishment of formal competencies [10] [11] [12] . Jogerst et al. described an effort through the Consortium of Universities of Global Health (CUGH) to establish a list of interprofessional global health competencies [11] . A finalized list composed of 13 competencies across eight domains at the "Global Citizen" level (those for post-secondary students pursuing any field with bearing on global health) has been developed. In addition, 38 competencies across 11 domains for the "Basic Operational Program-Oriented" level (those required for students aiming to spend a moderate amount of time working in global health) have been published. Despite standardization of these competencies, there is no method for assessment of students' performance to meet these competencies. In fact, Jogerst et al. specifically identified the need for more assessment tools in the area of global health education [11] . Additionally, Eichbaum suggests that lacking are comprehensive global health assessments to ensure learners are equipped with a full understanding of the factors that affect patient outcomes [13] . Given these findings in the literature, the purpose of this systematic review was to identify methods and tools utilized to assess knowledge, skills, and attitudes in global health courses for health science students. This research is a collaborative effort between faculty members at the American Association of Colleges of Pharmacy (AACP) and a clinical health sciences librarian. The systematic literature review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [14] . A search was performed to obtain all relevant publications regarding didactic global health education assessment within a ten-year timeframe among a selected set of diverse healthcare professional schools. The research protocol was written and registered in the International Prospective Register of Systematic Reviews (PROSPERO) [15] . The review process consisted of the following four phases: (1) an initial search to identify articles exemplifying the desired retrieval, (2) two sets of title/abstract reviews of the entire search results, (3) full-text review, and (4) narrowing the results to those articles that met the study objective. Articles were screened based on inclusion/exclusion criteria. The full-text articles that were included in this study described didactic education and associated assessment techniques to teach global health in US-based settings to healthcare professional students. For the purpose of the study, "didactic education" was defined as education delivered live or online in a formal educational environment in the United States, inclusive of higher education classroom training and service-learning opportunities. "Global health" included educational efforts specific to the term itself, as well as related efforts focused on health disparities (health difference that is closely linked with social, economic, and/or environmental disadvantage [17] ). Additional global health related terms included cultural competency (behaviors, attitudes, and policies that come together in a system or agency, or among professionals, and enable that system or agency or those professions to work effectively in cross-cultural situations [18] ). "Healthcare professional students" were defined as students in programs for medicine (including osteopathy and physician assistants), dentistry, nursing (including midwifery), and pharmacy [19] . "Assessment" included strategies used to measure learning, either focused on knowledge, skills, or attitudes/perceptions/ beliefs related to the topic areas of interest; these strategies were inclusive of standard tools (validated or not) as well as other informal methods/analysis. General exclusion criteria included the following: non-English articles and non-peer reviewed publications (case studies, editorials, reviews, commentaries, thesis, and summaries). Specific exclusions were articles that described experiential educational opportunities (without didactic components), those related to education based at non-US institutions, community-based efforts not centered within higher education, and analyses lacking quality descriptions of assessment methods and results. This last requirement expected that educational strategies were evaluated in a process that declared a formalized research objective (i.e., not merely a descriptive paper), adequately described the methodology and assessment, and that results of the evaluation were fully detailed. For instance, qualitative studies providing only summary and exemplar quotes from learners were not included in this systematic review, nor were generic course evaluations. Full-text articles assessed for eligibility (n=398 originally) (n=147 added with update) Full-text articles excluded, with (overlapping) reasons (n=466 original and update) ▪ Lacking health profession of interest (n=38) ▪ Not within definition of global health (n=55) ▪ Non-didactic education strategy (n=135) ▪ Curriculum-wide intervention (n=58) ▪ Non-US-based students (n=49) ▪ Low-quality methodology (n=91) ▪ Assessment not about global health (n=45) ▪ Lacking description of assessment (n=155) ▪ Lacking data from assessment (n=189) ▪ Non-peer-reviewed publication (n=35) ▪ Review article (n=18) ▪ Other (n=53) Studies Open-ended items for overall impression, experiences, and recommendations. Significant improvements from pre-to post-survey were seen for the skill development domain (p = 0.0001) but not for knowledge and attitudes (p = 0.14), role perception and career opportunities (p = 0.21), or instructional techniques used (p = 0.14), although numerical improvements were seen. Alexander-Ruff Knowledge increased from pre-to post-surveys (20.9 ± 5.5 to 26.7 ± 5.9, p < 0.001) with significant increases seen on all eight items. Comfort also increased for skills (29.6 ± 6.8 to 45.3 ± 5.9, p < 0.001) with increases on 10 of 11 items. Awareness increased (15.7 ± 3.6 to 19.4 ± 3.6, p < 0.001). Improvements were seen on all four abstract concept items as well (p < 0.05). Self-report; failure to measure actual behaviors; limited diversity (1) open discussions of differences between acute and community practice, (2) articulating skills and knowledge of population-focused practice, (3) reflection and debriefing, (4) clarifying the differences between community and acute care, (5) the trusting connection, (6) decision making in public health, (7) Overall changes from pre-to postincluded enhanced agreement on items for 'modify one's interview when encountering diverse populations,' (skills) and the statement 'Patients prefer healthcare providers who are genuinely concerned with their cultural preferences' (empathy). Students in the simulation (p = 0.008) and lecture (p = 0.037) groups showed greater improvement than those in the case-scenario group for the former. Scores for the four new standards increased post-, including "Working with the local government" (+.5%), "Participating long term (more than a few weeks)" (+7.3%), "Volunteering with a well-established organization" (+8.1%) and "Learning all about the community, including local customs and culture" (+17.5%). The studies include a broad array of literature with significant diversity ( Table 2 ). The majority of the included articles assessed nursing education (38; 48.1%) [21, 25, 26, 28, 29, 33, 35, 37, 39, 42, 44, 47, 51-54, 57, 58, 63, 66, 68-73, 75, 77, 80-87, 91, 98] , followed by pharmacy (26; 32.9%) [20-28, 31, 36, 38, 42, 43, 51, 59-62] and medicine (25; 31.6%) [25, 26, 30, 32, 34, 40-42, 46, 48-50, 55, 56, 65, 67, 76-79, 88, 90, 94, 98] . A total of 12 studies described assessment of more than one health profession [21, 25, 26, 28, 31, 34, 42, 51, 54, 68, 77, 98] . Cultural competency (56; 70.9%) [21-25, 28, 30, 32, 34, 36-39, 42-47, 50-52, 54-58, 61, 62, 65, 66, 68, 71-73, 75, 77-85, 87-91, 93-98] was the most common aspect of global health subject area, and most studies reported data resulting from standard live didactic course structures (58; 73.4%) [20, 22-26, 28-32, 36, 38-42, 44-49, 51, 52, 54-57, 59, 61-65, 67, 69-76, 80-89, 95-98] A variety of methodologies were utilized to measure outcomes, but the most common were survey questionnaires (68; 86.1%) [20-42, 44, 46, 47, 49-52, 55, 57, 59-69, 71-79, 81, 83, 85, 86, 88-98] which were administered before and after educational interventions (51; 64.6%) [20-29, 31, 32, 35-38, 40, 42, 44, 46, 49-52, 57, 60-69, 71, 74-78, 85, 86, 88, 91-97] primarily collecting quantitative data (68; 86.1%) [20-42, 44, 46, 47, 49-52, 55, 57, 59-69, 71-79, 81, 83, 85-98] . Each study measured some aspects of students' attitudes, perceptions, and beliefs regarding their educational outcomes. Fewer than half of the studies utilized objective knowledge assessments (34; 43.0%) [20, 22, 25, 28, 31, 32, 35-38, 40, 42-44, 46, 47, 49-51, 57, 61, 62, 65-67, 71, 74, 79, 89, 92, 94-97] . Finally, sample sizes were split relatively equally among small (26; 32.9%) [25, 27, 31-33, 37, 38, 40, 43, 48, 49, 52, 53, 56-58, 60, 64, 70, 72, 74, 82, 83, 87, 91, 95] , medium (30; 38.0%) [20, 21, 23, 28, 34, 36, 44, 45, 50, 59, 61, 62, 66-68, 71, 73, 76, 77, 80, 81, 84-86, 88, 90, 92, 94, 96, 97] and large studies (23; 29.1%) [22, 24, 26, 29, 30, 35, 39, 41, 42, 46, 47, 51, 54, 55, 63, 65, 69, 75, 78, 79, 89, 93, 98] . A breakdown and crosstabulation of individual assessment methods within included articles is summarized in Table 3 . Details regarding the constructs of validated tools are provided in Table 4 . For cultural competence, the most commonly used validated tool was the Inventory for Assessing the Process of Cultural Competence (IAPCC), with different versions developed by Campinha-Bacote et al. [99, 100] , was used in eight studies [28, 37, 38, 42, 44, 57, 61, 73, 81] The following validated tools were used at least once: the Transcultural Self Efficacy Tool (TSET) [101] , the Clinical Cultural Competency Questionnaire (CCCQ) [52, 85, 102] the Cultural Competence Assessment (CCA) [75, 91, 103] , the Multicultural Assessment Questionnaire (MAQ) [32, 104] the Caffrey Cultural Competence in Healthcare Scale (CCCHS) [21, 77, 105] , the Cultural Assessment Survey (CAS) [71, 106] the Health Beliefs Attitude Survey (HBAS) [30, 107, 108] , the Attitudes Toward Lesbians and Gay Men (ATLG) [66, 109] the Faculty Observer Rating Scale (FORS) [78, 110] , the Intercultural Development Inventory (IDI) [83, 111] , the Posttraumatic Growth Inventory (PTGI) [72, 112] , the Sexual Orientation Provider Competence Scale (SOPCS) [94, 113] , the UCSF cultural competence and cross-cultural communication tool created and validated by Assemi and colleagues [23, 24 ] , and the Interprofessional Education Series Survey (IESS) [34] . Several tools in related domains were utilized in the subject areas of global health and health disparities. In health disparities, four validated tools were identified. Each tool was used by at least one study: the Attitude Toward Poverty (ATP) scale [69, 114] , the Ethnic Sensitive Inventory (ESI) [87, 115] a transphobia scale by Braun and colleagues [25, 116] , the Implicit Association Test (IAT) [41, 117, 118] , the Gay Affirmative Practice (GAP) scale [86, 119] , and the Centers for Healthy Communities Survey [26, 35, 56, 83] . Two validated tools were used in the area of global health, the International Education Survey (IES) [33, 120] and the Michigan Longitudinal Study Scales [63] . Although two articles used the California Critical Thinking Disposition Inventory (CCTDI) [37, 57] and two articles used the Readiness for Interprofessional Learning Scale (RIPLS) [77, 121] , these tools were not included because they did not specifically measure a construct related to global health. • ATLG [66] • CAS [71] • CCA [75, 91] • CCCQ [51, 65] • CCCHS [21, 77] • HBAS [30] • IAPCC [28, 37, 38, 42, 44, 57, 61, 73] • IDI [83] • IESS [34] • MAQ [32] • PTGI [72] • RIPLS [77] • SOPCS [94] • TSET [52, 81, 85] • UCSF Cultural Competence Tool [24] Not validated: [22, 25, 28 • ATP [69] • Centers for Survey [26, 35, 56] • ESI [87] • GAP [86] • IAT [41] • Transphobia Scale [25] Not validated: [26, 27, 29 • IES [33] • MLSS [63] Not validated: [20, 60, 64, 76, 90] • Chang et al. [90] (journal entries, grounded theory) • Curtin et al. [33] (reflective essays, critical reflection inquiry & content analysis) • Main et al. [53] (reflective journals, content analysis) • CCCQ [51, 65] • IAPCC [28, 37, 38, 42, 44, 57, 61, 73] • MAQ [32] • SOPCS [94] Not validated: [22, 25, 36, 46, 50, 51, 62, 66, 79, 89, [95] [96] [97] Grading: [47] Heffernan et al. [43] (focus groups, thematic analysis) Validated: • Centers for Survey [26, 35, 56] Not validated: [25, 31, 40, 46, 49, 67, 79, 92, 96] Grading: [47] Not validated: [20, 74] Grading: [20, 60] Skills Validated: • CCCQ [51, 65] • FORS [78] • IAPCC [28, 37, 38, 42, 44, 57, 61, 73] • MAQ [32] • SOPCS 94] Not validated: [62, 78, 79] Not validated: [31, 79] ASSESSMENT TOOL NAME SUBJECT AREA Non-validated quantitative tools Several articles used investigator-designed quantitative assessment tools. These tools were most commonly used in the subject area of cultural competence (25) [22, 25, 28, 36, 39, 46, 47, 50-52, 55, 62, 66, 68, 78, 79, 88-91, 93, 95-98] , followed by health disparities (17) [25-27, 29, 31, 40, 41, 46, 47, 49, 59, 67, 69, 79, 90, 92, 96] , and global/international health (6) [20, 60, 64, 74, 76, 90] . Some instruments were based on previously published but non-validated tools [22, 28, 36, 39, 46, 47, 62, 66] , while others described a process of ensuring face validity [25, 36, 62, 88, 91] Several studies also reported results of graded assignments as an assessment tool [19, 46, 59] . Several studies used qualitative methodologies to evaluate student learning, particularly focusing on attitudes, perceptions, and beliefs. Eleven studies used qualitative evaluations alone [43, 45, 48, 53, 54, 56, 58, 70, 80, 82, 84] while twelve studies used a combination of quantitative and qualitative methodologies to assess coursework [37, 47, 59, 68, 69, 71, 73, 74, 76, 77, 90, 92] . Fourteen studies evaluated a course focusing on cultural competence used qualitative assessments. Researchers used a diverse group of data sources for their qualitative evaluations including reflective essays [37, 45, 47, 54, 68, 80, 82] reflective journals [54, 90] , focus groups [43, 58, 73, 77, 82] semi-structured interviews [56] , student written assignments [48, 58, 84] , and recorded workshops/debriefs [37, 58 ], short answer reflections [47] , and instructor observations [82] . The most common analytic approach was thematic analysis; [37, 43, 54, 56, 58, 68, 77, 84] other studies employed the constant comparator method [82] , grounded theory [54, 90] , or content analysis [73] . One analysis used interpretive phenomenology as a strategy [37] , while another [45] used Linguistic Inquiry & Word Count (LIWC) and factor analysis to describe the content of student reflective essays. One study [47] applied the Transfer Barrier Framework [122] and Prochaska and DiClemente's Stages of Change Model [123] to written narratives prior to analysis, while a second study [80] used Krathwohl's Taxonomy [124] as a thematic framework for analysis of reflective essays. Seven of the studies that evaluated health disparities used qualitative methodologies. Data sources for health disparities evaluations included reflective essays and journals, [47, 48, 59, 90] short answer reflective responses, [47, 69, 92] student written assignments, and focus groups [47, 77] . Four studies [48, 59, 69, 77] conducted thematic analyses, one study used content analysis [92] , while another employed grounded theory [90] . Six qualitative global health evaluations included reflective essays [33, 74] , reflective journals [53, 90 ], short answer reflections [70, 76] , written assignments [33] , and semi-structured interviews [74] . Most of the studies that described their analysis strategy used content analysis [33, 53, 74] or grounded theory [76, 90] . This systematic review examined the diverse scope of assessment methods used in global health education for health professions students in the didactic setting. The results of this review expand the knowledge on global health in current literature. A recent scoping review by Costa Mendes et al. described the diversity, structure, models, emotional, cultural, and collaborative aspects of teaching global health in the Americas [125] . In this review, the authors recommended more consistency and standardization in educational approaches, echoing similar sentiments to a previous systematic review of global health graduate medical education by Bills and Ahn [88] . Despite these previous reviews providing excellent discussions on the educational strategy landscape, there have been limited publications specifically focused on assessment. The most relevant is a recent scoping review by Schleiff et al. [126] , which examined literature on competency-based training incorporation into curricula and evaluation strategies, with a subset focused on clinical and allied health professional training. This review identified three major forms of evaluation tools, including self-assessment surveys, assessment from multiple stakeholders' perspectives, and mixed-methods approaches. This current research corroborates these themes and provides an in-depth examination of specific assessment strategies. This study used a broad lens of global health while allowing for more refine selection of assessment tools based on into three distinct topic areas. The largest category of tools focused on cultural competence that measured it broadly or cross-cultural care specifically among health professions students. Almost all these tools utilized self-reported perceptions or behaviors using a Likert-type format. Although one of these tools, the IAPCC-SV, was developed for undergraduate students, it was utilized by several graduate programs, including pharmacy, medicine, nursing, and dentistry. The advantage of this tool is its relatively short format compared with others; however, its cost may be a challenge for a wide adoption. The related IAPCC-R requires an advanced reading level for comprehension and was developed specifically for a nursing audience. This tool also requires a fee for use with a process to obtain permission for use, with the online version costing more than the paper version. In addition, the TSET, CCCQ, CCCHS. and CCA were each used in multiple studies. The TSET is validated for use in nursing students to measure student transcultural selfefficacy perceptions related to the performing of general transcultural nursing skills in a diverse client population [101] ; the tool may be useful for pre/post learning evaluation and demonstrate changes over time. The CCCHS is designed to measure self-perceived knowledge, self-awareness, and comfort with skills of cultural competence [105] . This measure was used to assess nursing, pharmacy, and dental students with a strength being the ability to show student improvement over time [21, 52, 77, 85] . The CCA was designed as a pre/post learning tool and measures perceptions of experiences with diverse groups, awareness, and sensitivity [103] . The strength of the CCA is the potential use in variety of healthcare provider populations of different educational levels. Although CCCQ and MAQ were originally developed for practicing physicians, they have been used by other healthcare professionals to assess knowledge, skills, and attitudes. In all measures described, there must be consideration for the level of objectivity due to the self-report nature of the tools and the fact that evidence is lacking that attitudes translate to behavior. The updated search highlighted a trend toward a greater emphasis in global health education reflected in the high number of included studies. Approximately one-third of the studies in this review, those that included validated tools, were published recently (2017-2020) [71, 72, 75, 77, 78, 83, 86, 87, 91, 94] . While the updated search included more studies, the tools were primarily designed to assess cultural competence, there were a few that assessed health disparities parameters such the ESI and the GAP scales [86, 87] . While diverse assessment tools were used to measure global health outcomes broadly, global health comprise more than cultural competency. Only eight studies included in this review specifically assessed global health-related outcomes, with only two using a validated tool. This work highlights the need for global health educators to develop and validate innovative strategies in assessment, particularly in the area of didactic global health education. Similar to these findings, Kiles et al. [127] further highlighted that there were gaps in the literature regarding global health education. While their review focused on teaching strategies rather than assessing educational outcomes, it also recognized the need for further research on teaching strategies and assessments that may be used to assess the complex skills needed in the global health setting including understanding organizational factors, global healthcare system, and SDOH. In addition to validated survey tools, qualitative assessment methods may be used to assess cultural competency, health disparities and global health. Reflective essays, journal, focus groups, structured interviews and recorded debriefing sessions were used in this review, and most often evaluated student attitudes, perceptions, and beliefs. As with the quantitative assessments, cultural competency was the topic most frequently assessed. Although qualitative tools are useful for assessment, there were fewer qualitative studies included due the lack of rigor in the research methodologies of many of the studies. The use of qualitative tools to assess global health skills is an area for further investigation. While the topic of cultural competency/sensitivity is important for enhancing the knowledge, skills, and attitudes of students, these are only one part of the whole patient and system of health care. New effective assessment strategies are needed for examining student knowledge of frameworks of holistic patient care, including the social ecological model [128] . Frameworks and theories that 41 Connor et al. Annals of Global Health DOI: 10.5334/aogh.3389 emphasize structural competency, including those described by Metzl and Hensen [129] could be considered when developing global health assessment tools. Complex global health problems are better solved through teamwork. Experts note that interprofessional education may assist with preparing health care providers for the challenges of working in resource-limited settings [130] . This current review aimed to be inclusive of major health professions, in line with the understanding that students should be trained to solve complex problems in interprofessional teams with a focus on broader contextual factors that influence health [91] . However, a limited number of studies identified included multiple health professions in their assessments. Application of these assessment tools in interprofessional settings is needed in order to fully evaluate their usefulness. There are persistent and glaring inequities in health worldwide, despite decades of initiatives to promote social justice, disparities have become even more evident during the COVID-19 pandemic [92] . Highlighted are the structural problems that lead to disparities. Health professional education acknowledges the deficits in the current system [131] . Current assessment tools provide limited focus on the evaluation of the essential knowledge and skills needed by students to address the complex factors that affect the health of populations including the social determinants of health [127] . Moreover, because heath care professionals are confined by organizational, institutional, and governmental policies and regulations, an assessment of their cultural competency alone does not address the whole picture. The overall goal of global health education is rooted in health equity and social justice. It incorporates the multiple structural factors that impact individuals and populations. Structural competency is a framework that considers the knowledge, skills, and attitudes of the individual healthcare professionals while complementing awareness and action toward the structural changes needed in systems and policies [129] . However, it is noted that in studies that assess cultural competence alone, consensus was found to be complex [132] . An assessment of structural competency may only add to this complexity. Although acquiring skills is an essential element of global health competency, skills were measured least frequently and there is a lack of validated instruments to measure them. Thus, there is a critical need for a validated instrument designed to assess skills in global health among future healthcare professionals. Consequently, additional research is needed to address this gap. Although this study has many strengths, it is important to acknowledge the study limitations. First, this review may have excluded relevant literature due to lack of quality. For instance, some articles were excluded because their qualitative assessments lacked descriptions of methodology. Second, because the field of global health is constantly evolving, the lack of standardized definitions and terminology in the included studies was challenging. In an effort to be inclusive, the authors broadly considered the global health constructs, including health disparities and cultural competency. However, despite this inclusivity in the root understanding of the definition of global health, the review did place limits on other aspects of the research objective, including which health professions were included, and focused solely on didactic education rather than including experiential evaluations. While there are frameworks and competencies, validated assessment tools will be easier to develop with consensus on a definition. Third, this study was conducted by faculty from schools/colleges of pharmacy. Global health is by design interprofessional, the inclusion of viewpoints from other health professions would enhance the interpretation of the results. Finally, the approach was to design the literature search method to be as comprehensive as possible, which resulted in a large result set that required significant time to evaluate. Accordingly, this review does not include studies from outside of the United States. Despite these limitations, this study has several strengths. First, this research reviewed over two decades of literature on assessment methods in didactic education in global health. Second, this systematic review consisted of studies of learners from multiple healthcare professions increases the generalizability of the results. Third, this research categorized quantitative and qualitative data, assessments focusing on attitudes, perceptions, and beliefs as well as knowledge and skills, and validated and non-validated assessments. This comprehensive approach allows educators to consider the breadth and depth of available instruments to aid their own course assessment methods for what best fits their needs. Towards a common definition of global health How should schools respond to learners' demands for global health training? 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JRC has received previous funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists unrelated to this work. GlaxoSmithKline did not provide funding for this work and the contributions of RBV are solely her own and do not represent GlaxoSmithKline. The other authors have nothing to disclose. 143. Goode T. Promoting cultural competence and cultural diversity for personnel providing services and supports to children with special health care needs and their families. Available from: https://nccc. georgetown.edu/documents/ChecklistBehavioralHealth.pdf.