Global Health Experience and Interest: Results From the AAP Periodic Survey

We used data from the AAP PS from 1989 to 2017. The PS is a nationally representative survey of randomly selected, nonretired US members of the AAP (including residents). The 2017 survey was administered to 1628 respondents, and 758 eligible surveys were returned, resulting in a 46.7% response rate. We sent 7 mailed surveys and 2 e-mails (with a link to complete the survey electronically) to nonrespondents between June and December of 2017. The 2017 survey collected respondents’ demographic information, practice characteristics, and detailed responses regarding experience with and interest in GH. Questions in the 2017 survey were replicated from 1989, including participation in a GH program in the past 12 months, interest in working in a low- or middle-income country (LMIC) in the next 3 years, type of GH interests, and preferred length of time for participation in GH experiences. The 1989 survey was mailed to 1000 respondents, and 708 eligible surveys were returned for a 70.8% response rate.

For the purposes of this analysis, we excluded residents. Therefore, we omitted data from 70 to 90 residents in the 1989 and 2017 survey results, respectively. The analytic sample sizes for the 1989 and 2017 surveys were 638 and 668 respondents. In the 2017 survey, respondents and nonrespondents did not differ on sex or geographic region, but respondents (mean of 47.2 years) were slightly older on average than nonrespondents (mean of 43.8 years in 2017; P < .001); this information was not available for the 1989 survey. All surveys were approved by the AAP Institutional Review Board.

Our primary dependent variable was interest in future GH experiences in an LMIC. Respondents were asked “Would you be at all interested in serving in some capacity in a low- or middle-income country within the next 3 years?” Available answers included “yes,” “unsure,” or “no,” representing varying levels of interest in participating in a GH experience. For logistic regression analysis, we dichotomized this variable such that respondents indicating “yes” were equal to 1 and 0 otherwise. Other variables of interest included whether the respondent participated in an overseas GH program in the past 12 months, for how long they would be willing to participate in an overseas GH program (both with and without pay), and in what capacity they would prefer to participate in overseas GH activities. Respondent characteristics available across both surveys included sex, age, specialty status (with primary care pediatricians defined as those who self-reported spending ≥50% of their professional time in general pediatrics in 2017 and who self-reported spending “most of their time” in general pediatrics in 1989), and practice setting.

We first described the demographic and practice characteristics of the analytic samples. Next, using χ² tests, we examined bivariate relationships between pediatricians’ GH experience and interest and survey year. Finally, a multivariable logistic regression model estimated the independent effect of survey year on reporting interest in future GH participation, controlling for available demographic and practice characteristics. Data were analyzed by using the statistical software package R.⁷ 

In Table 1, we compare the 2 practicing pediatrician groups from 1989 and 2017. In 1989, only 29.6% of practicing pediatrician respondents were women, but this increased to 62.1% by 2017 (P < .001). The age profile of the samples also varied across surveys, with the 2017 sample having significantly more pediatricians ages ≥50 (31.5% compared to 46.5%; P < .001). The practice setting distribution also shifted, with 2017 respondents being more likely to work in group practices or medical school, hospital, or clinic settings and less likely to be in solo or 2-physician practices (P < .001). Subspecialists comprised 47.1% of the sample in 1989 compared to 37.1% in 2017 (P < .001).

Overall, a larger share of pediatricians reported a recent GH experience in 2017 compared to 1989. Table 2 reveals that 2.2% of practicing pediatrician respondents in 1989 had a GH experience in the past 12 months compared to 5.1% in 2017 (P = .005).

Increases in recent participation in GH experiences held across most of the available demographic characteristics. Table 2 reveals the change over time in the percent of pediatricians reporting recent GH experience by each of the characteristics included in the analysis. Notable increases were found for women (1.1% in 1989 to 4.5% in 2017; P = .008) and men (2.7% in 1989 to 6.1% in 2017; P = .048), respondents in medical school, hospital, or clinic settings (2.9% in 1989 to 7.6% in 2017; P = .019), and subspecialists (2.5% in 1989 to 9.0% in 2017; P < .001).

In particular, there were large increases in recent GH experiences in pediatricians aged ≥50 years. The largest increase in GH experience across all age groups was for respondents ≥60 years (1.6% in 1989 to 9.3% in 2017; P = .010), followed closely by those ages 50 to 59 years old (0.8% in 1989 to 5.4% in 2017; P = .017).

Interest in participating in future GH opportunities increased from 1989 to 2017. Table 3 reveals the percent of pediatricians indicating whether they were interested in serving in an LMIC within the next 3 years. The percent indicating yes increased from 25.2% to 31.7% across surveys, the percent indicating unsure increased from 11.1% to 23.4%, and the percent responding no decreased from 63.7% to 44.9% (P < .001).

Table 3 also reveals the change in interest among pediatricians over time by demographic characteristic. A similar trend in increased interest was also observed across a variety of demographic subgroups, with respondents being more likely to indicate yes to the question on future participation in GH opportunities in 2017 relative to 1989. This includes men (25.8% in 1989 to 34.7% in 2017; P = .017) and women (22.8% in 1989 to 30.3% in 2017; P = .052), generalists (20.0% in 1989 to 26.3% in 2017; P = .044) and subspecialists (30.5% in 1989 to 40.6% in 2017; P = .017), and those in medical school, hospital, or clinic settings (32.0% in 1989 to 42.2% in 2017; P = .023). Interest increased from 17.7% to 38.6% for respondents ≤39 years old (P < .001).

Across surveys, interest in participating in GH clinical care was the top preference for type of GH experiences, followed by teaching. Administration and research were the least likely to be selected in both surveys (Table 4). In 1989, 63.6% of respondents indicated clinical care was their first preference, and 28.4% reported teaching as their first preference; in 2017, 79.1% indicated clinical care as their first preference, whereas 16.5% reported teaching as their first preference (P = .001). This indicates a growing preference among practicing pediatricians to participate globally through clinical care relative to other kinds of activities.

In the 2017 data, the strong preference for clinical care reveals that generalists are more likely to prefer clinical care than subspecialists (88.6% vs 68.5%; P < .001). Similarly, solo or 2-physician practices (93.8%) prefer clinical care more than group practice pediatricians (83.7%) and medical school and/or hospital pediatricians (72.4%; P < .001) There were no differences on the basis of age (P = .212).

For GH opportunities, both with pay and without, the responses indicate that practicing pediatricians are shifting their preference from long-term GH experiences to short-term GH experiences between 1989 and 2017 (Table 5). For instance, 21.1% of respondents in 1989 indicated they would be willing to participate in a GH opportunity for a year or more with pay compared to 8.6% in 2017 (P < .001). For service without pay, 19.0% reported being willing to participate in a GH opportunity for up to 1 week in 1989 compared to 37.1% in 2017 (P < .001).

In Table 3, we showed that at a bivariate level, the percent of practicing pediatricians reporting interest in working in an LMIC in the next 3 years significantly increased from 25.2% to 31.7% from 1989 to 2017 (P < .001). To examine if this overall change in interest holds, even when taking the changing demographic profile of pediatricians into account, we conducted a multivariable logistic regression.

In the multivariable logistic regression model estimating the likelihood of reporting interest in participating in a future GH experience in an LMIC in the next 3 years while controlling for demographic and practice characteristics of respondents, respondents in 2017 were significantly more likely to report future interest relative to 1989 respondents (adjusted odds ratio [aOR] 1.52; 95% confidence interval [CI]: 1.13–2.04). Building on the bivariate results in Table 3, the regression results provide additional evidence of a statistically significant increase in pediatrician interest in future GH participation from 1989 to 2017, while also indicating that the observed increase in interest is not a result of changes in measured pediatrician demographics or practice characteristics across surveys.

We find no evidence for an independent effect of age or sex in the multivariable regression results. However, controlling for other factors, practicing physicians working in medical school, hospital, or clinic settings were more likely than those in group practice settings (aOR 1.69; 95% CI: 1.23–2.30) and subspecialists were more likely than generalists to report interest in future GH participation (aOR 1.43; 95% CI: 1.06–1.91) (Table 6).

Our study reveals that between the years of 1989 and 2017, there has been a 132% increase in practicing pediatrician participation in a GH experience over the past year and a 26% increase in practicing pediatricians’ interest in a GH opportunity within the next 3 years. These increases mirror the significant rise of trainee participation and interest in GH at both the medical school and residency levels.^1–3,5,6,8 

Interestingly, there is a significant increase in participation in GH experiences in pediatricians >50. Although this increase is not reflected in younger pediatrician age groups, more young pediatricians (≤39 years of age) are interested in participating in GH opportunities in the near future. Most age categories increased either their participation or intent to participate in GH with the exception of the 40- to 49-year-old age category, who did not change either component. This age group, who would be defined as midcareer professionals, may have other pressures (work, family, and financial) that may make it challenging for them to participate in GH.⁹ 

Increasingly, practicing pediatricians want shorter-term experiences, ideally <1 month in duration. If the GH experience were paid, the vast majority of pediatricians still only want a GH experience up to 1 month (54.4% vs 62.9% in 1989 and 2017, respectively). Similarly, short-term GH experiences with pay would also be preferred only up to 1 month (85.1% vs 88.4% in 1989 and 2017, respectively). Despite this difference, there are few guidelines that outline appropriate short-term experiences for practicing pediatricians.^9,10  Furthermore, many concerns have been raised about the potential negative impacts of short-term GH experiences and its impact on partners and colleagues overseas.^4,11–13  Possible explanations toward short-term GH experiences may include work and family obligations, increasing medical school and residency debt, and challenges in finding longer-term experiences.^14,15 

Over the past 28 years, there has been an increase in subspecialist participation (from 2.5% to 9.0%) and intent to participate (30.5% to 40.6%) in GH opportunities. This has been mirrored by evidence that residents that are interested in subspecialty training are very likely or likely to incorporate GH clinical work or research in an international setting.⁶  Furthermore, subspecialist participation is significantly higher than general pediatrician involvement in the past year (9.0% vs 2.9%), with an increased intent to participate in the next 3 years (40.6% vs 26.3%). These differences may reflect a change in practice and increasing demands in LMICs for more subspecialty care and teaching. As general pediatric residencies become more established globally, more subspecialty care is required to improve outcomes in LMICs. However, with these increased demands for GH in subspecialties, GH education should be focused not only on residencies but should be incorporated in subspecialty fellowships.

The vast majority of practicing pediatricians prefer providing clinical services (79.1%) and teaching (16.5%), and there is relatively little interest in research or administration (4.3%). This trend in clinical service has risen markedly from 63.6% to 79.1% between the 1989 and 2017 surveys, and there has been a concurrent decrease in the proportion of pediatricians interested in teaching from 28.4% to 16.5%. This is despite the rise of both research-focused GH organizations, such as the Bill & Melinda Gates Foundation, and successful GH teaching programs, such as Helping Babies Survive, as well as increasing emphasis on formal GH training at the pediatric postgraduate medical education level.^5,8  It is possible that the preference toward clinical services reflects the predominant career focus for the survey respondents, although individuals were not directly queried about the roles (eg, clinical, teaching, research, and/or administration) that they assumed at their home institutions.

Pediatricians who are affiliated with medical schools, hospitals, or clinic settings are more likely to have recently participated or want to participate in a GH experience than those with solo or 2-person practices or group practices or health maintenance organization (HMO) practice (see Tables 2 and 3). Possible explanations are that in solo or 2-person practices, there is a significant loss of income, and challenges around finding coverage to provide services at home while practicing pediatricians are overseas remain large barriers to GH experiences. Furthermore, those who work in medical schools, hospitals, and clinic settings may have established partnership support structures in place that allow GH experiences to run more smoothly.

Our multivariable regression model confirms 3 main factors are associated with the intent to participate in GH opportunities: (1) being a subspecialist, (2) working in a medical school, hospital, or clinic setting, and (3) 2017 survey participation as compared to 1989. These model results mirror the univariate results above.

Limitations to this study include a selection bias in the respondents to the Periodic Health Survey. In particular, those who are interested in GH may have preferentially responded to this survey. The study was also restricted by the nature of the questions that were included in the original 1989 survey for comparison. Finally, the cross-sectional nature of the study makes it difficult to make conclusions about the causality in the relationship between the variables of interest and the primary outcome: intention to participate in GH opportunities in the next 3 years. As well, we have used practice setting, but not the primary focus of the career (eg, clinical, teaching, administration, research), in our analysis, which may have biased our survey toward clinicians.

Despite these limitations, there appears to have been a significant increase in both participation and interest in participating in GH experiences among practicing pediatricians from 1989 to 2017, with a particular increased interest in participating in short-term clinical GH opportunities.

This is the first article, to our knowledge, used to describe a specialty’s long-term changes in participation and interest in GH experiences. Despite the global push toward creation of long-term, mutually beneficial, sustainable partnerships, there is an increasing pediatrician preference for short-term GH opportunities. Given the rising rates of participation and interest in GH experiences, paired with a preference for short-term clinical work, our pediatric community needs to be mindful of the potential negative impact of short-term work overseas and should strive for sustainable, ethically sound opportunities in partnership with global colleagues.

The American Board of Pediatrics Global Health Task Force and affiliates recently released multiple resources that offer guidance on GH-specific topics for pediatricians, including partnership best practices, preparation considerations, roles of pediatric departments in GH, opportunities for practicing pediatricians, and a comprehensive guide to GH education for residency and fellowship program directors.^10,16–19  The AAP Section on International Child Health also recently published a policy statement pertaining to the role of pediatricians in GH.²⁰  These resources, in addition to others, offer helpful guidance for providers seeking to engage globally.

There is still more to do. In this study, we look at how GH has changed for practicing pediatricians over the past 28 years. However, the picture remains incomplete. Research is required both qualitatively to look at the potential barriers and solutions keeping pediatricians from conducting GH work and quantitively to look at a more granular level to identify where pattern changes are occurring. Our community has to place more focus on providing GH training during subspecialty fellowship. We also need to promote previously published preparation standards for GH experiences, offer provider-level predeparture training, create communication networks, and develop ongoing mutually beneficial global partnerships to better support pediatricians seeking to engage in GH opportunities, with an ultimate goal of collaborating to improve child health worldwide.

AAP

American Academy of Pediatrics

aOR

adjusted odds ratio

CI

confidence interval

GH

global health

HMO

health maintenance organization

LMIC

low- or middle-income country

PS

Periodic Survey