A Tool for Educating Global Health Practitioners: the Curriculum Design Compass

In health professions education there is a call for global health practitioners while in higher education there is a complementary call for internationalisation of the curriculum. However, implementation has not matched aspiration partly because of a lack of practical tools and illustrative examples. This paper takes an interdisciplinary approach and presents the design and development of a practical tool: the curriculum design compass. The curriculum design compass covers four design spaces: What do students need to know about global health?; What do students need to be taught in order to develop cultural diversity awareness and intercultural competence?; How do we teach to facilitate and demonstrate intercultural learning?; and How do we bring students into contact with the wider world? The design compass was trialled with a Nutrition and Dietetics program and generalisability was confirmed with an unrelated profession. The programs studied were able to readily understand the tool and to use it to identify areas of existing good practice and areas for improvement. Therefore, it was both a review tool and a design tool enabling programs to manageably and holistically better prepare global health practitioners.


Introduction
The world and health professions have been calling for global health practitioners for reasons of social justice and personal professional fulfilment (McKimm & McLean, 2011). Working in developing countries is often attractive to those seeking humanitarian work as it benefits those with the poorest health and the greatest needs, plus promotes the sharing of best practice. Even within developed countries, health professions work with populations that are diverse and need culturally competent care (Law & Muir, 2006). However, the translation of theory and aspirations Schmidt L, Wray A, Miller J, Scott J, Pope K MedEdPublish https://doi.org/10.15694/mep.2017.000061 Page | 2 into practical developments in health professions education has been weak as illustrated by the analysis of uptake in Australian and German medical curricula (Stütz, Green, McAllister, & Eley, 2015). While the conversation in the medical education literature has mainly revolved around training for global health (Brewer, Saba, & Clair, 2009), a parallel conversation in the higher education literature has been around Internationalisation of the Curriculum (IoC) which focuses on situating the whole of the higher education experience in an international context. A way forward for educating for global health may lie in fusing the two. This paper presents a brief introduction to IoC and presents a tool and exemplars to help curriculum designers identify opportunities for IoC, and therefore the education of global health practitioners.

Current state of IoC
Many higher education institutions have adopted definitions of IoC (Knight, 2004) and the established one used by the authors' institution is, A curriculum with an international orientation in content and/or form, aimed at preparing students for performing (professionally/socially) in an international and multicultural context and designed for domestic and/or foreign students. Definition adapted from the Organisation for Economic Co-operation and Development, 1996 by Crowther et al. (Crowther et al., 2000;OECD/CERI, 1996) It covers the content that is delivered and assessed, includes the form (i.e. the 'how') by which the learning and teaching occurs, includes discipline-specific as well as generic skills (i.e. professional/social skills), and is inclusive of all the students in the class (domestic and international). However, while definitions articulate the goal and underpin theory, they do not by themselves provide a pathway for delivery and this lack of practicability may be an obstacle to uptake. Our solution to this problem was to translate the definition into a tool. We also tested the practicability of the tool using the criteria of clarity, parsimony, usability and generalisability (Prochaska, Wright, & Velicer, 2008). The tool consists of a framework (addressing clarity and parsimony) which also drives a process (which is useable and testable) that can be applied across disciplines (generalizable). We have called this tool the Curriculum Design Compass and in the next sections we will describe it and how we tested it.

IoC into action: The Curriculum Design Compass
Various examples of IoC have been published and these are useful sources of ideas (Association of Universities and Colleges of Canada, 2009). The typology developed by van der Wende (1996) also provides a useful set of starting points to inspire curriculum designers. However, the risk with exemplars and lists is that they can lead to tokenistic and fragmented approaches rather than a holistically internationalised curriculum. This section introduces the IoC Design Compass to meet this challenge.
Four key components can be extracted from the above definition of IoC. They are: content, form, international learning (the learning required to perform in an international context) and intercultural learning (the learning required to perform in a multicultural context). These can be used to construct axes (see Figure 1): North/South = content/form; West/East = international learning/intercultural learning.  The content is 'what' is taught and may encompass discipline-specific as well as generic skills and knowledge. The form is 'how' the content is taught. Note that the word 'form' has previously been used for the mode of delivery e.g. internal/distance delivery; delivery in another language; or delivery via another institution. For example, The form of the curriculum, the method through which it is taught and learnt…(IDP Education Australia for the Australian Department of Employment Education & Training, 1995, p. 22) However, the word 'form' can be used more expansively than this as it may also include classroom interactions and inclusive learning environments. To list all of the forms that teaching can take is beyond the scope of this paper but it is important to embrace this broad view of the word 'form' when internationalising the curriculum as it provides more opportunities and encourages innovation. Critically, 'form' is the counterpoint to 'content' i.e. how we teach is just as important as what we teach. This balance is especially important for academic staff acting as professional role models for students so that the students perceive that academic staff practice what they preach or, to use another idiom, both 'do as I say' and 'do as I do' are displayed in an internationalised curriculum.
International learning means learning about how systems differ between countries. For example: metric/imperial units; common law/codified legal systems; public/private health systems; safety and other regulations; electrical systems (e.g. voltage, power supply plug shapes). While some of these things may have had a cultural foundation, they are now impersonalised to some extent and are the 'stuff' one needs to know to function in a country. In comparison, intercultural learning focusses on developing students' abilities to constructively interact with people from diverse cultural backgrounds in a range of cultural settings. So the emphasis here, in contrast to international learning, is very much on human-human interaction. Note that the East-West axis of international learning/intercultural learning is more of a spectrum then a dichotomy as it can sometimes be difficult to differentiate between them, e.g. political systems.
Placing these four terms as compass points on axes (Figure 1) provides the basis for a curriculum design framework but the points need to be integrated in order to generate a holistically internationalised curriculum. This is achieved by focussing on the curriculum design spaces created in between the two axes (i.e. by looking at the North-West, North-East, South-East and South-West quadrants) as shown in Figure 1. This makes the curriculum design process both holistic and manageable by reducing it to four curriculum design areas. A key requirement for unit and program coordinators is to address all four quadrants and the following sections explain each quadrant in more detail.

NW: International Learning/Content, "What do the Students Need to Know about Global Health?"
This quadrant is about the necessary content in the curriculum that covers the essential regulatory and structural know-how that graduates will need to function in a global workforce and health-care setting. This can include practical topics such as familiarisation with both Imperial and Système Internationale (SI) units for clinical laboratory data, as well as broader issues such as a list of global health content areas for medical schools including: Human rights and global health; Global burden of disease; Healthcare delivery systems; Social determinants of health; Environment and health; Policy, trade, politics, policies and health; and Collaborative efforts and philanthropic organisations (for further detail, see Table 1 in McKimm & McLean, 2011).
There are many opportunities in this space to utilise international case studies and comparisons relevant to the discipline. For example, students at Bristol can undertake e-Learning case studies that place them in different roles to explore a health scenario in a low-resource country (Ellis et al., 2012). However, the challenge with international comparisons and case studies is that some academic staff may be reluctant to add more content into already contentheavy programs and this can become a point of resistance to IoC. Instead, this quadrant can provide an opportunity to cover existing content in a different way that develops higher order thinking. For example, consider the scenario of a Canadian medical student being (a) asked to describe the Canadian health system or (b) being asked to compare and contrast the Canadian and USA health systems. The second method pushes them into deeper, more critical thinking (Krathwohl, 2002).

NE: Intercultural Learning/Content, "What do Students Need to be Taught in Order to Develop Cultural Diversity Awareness and Intercultural Competence?"
This quadrant is about explicitly teaching students the skills required to work in multicultural teams and in various cultural settings. This does not happen by accident and there is a …need for taking deliberate and strategic action to assist all students, domestic and international, to move outside of their cultural comfort zone. (Leask & Carroll, 2011)  Locating student work in an international scenario can be an opportune way to address this issue. For example, Jha et al (2015) have provided a set of scenarios for discussion with medical students about medical professionalism in different cultural contexts while Parisi et al (2012) have used simulations to build cultural competence. Another approach could be through explicitly teaching intercultural competence and there are multiple frameworks for doing this such as Deardoff's Process Model of Intercultural Competence (Deardorff, 2006) and the Intercultural Development Continuum by Hammer (2011).

SE: Intercultural Learning/Form, "How do we Teach to Facilitate and Demonstrate Intercultural Learning?"
This quadrant is very much about practicing what we preach and includes encouraging and supporting interaction between students from diverse backgrounds (Arkoudis et al., 2010), providing a culturally safe classroom environment, and inclusive curriculum design. It is also about harnessing the diversity in the classroom to improve the learning for all and viewing that diversity as a learning asset. If this quadrant is well developed, then students will have a setting in which to practice and refine the skills they have learnt in the NE quadrant.
For example, a team of nursing educators has used structured exercises and questions to ensure that international and local students were given the opportunity to collaborate with the lecturer and one another in generating a studentcentred learning environment (Wallace & Hellmundt, 2003). An example of an assignment that addresses this quadrant is from a counselling course at Virginia Tech (Bodenhorn, Jackson, & Farrell, 2005) in which the academic staff leveraged the existing on-campus meetings of groups of international students. Pairs of counselling students joined the international student group and led discussions about U.S. culture. This provided an opportunity for domestic and international students to interact and to examine their own culture while learning about other cultures. The students rated this one of the most valuable assignments they did. Another example is from an Australian Biotechnology program where domestic students were recruited as facilitators for Peer-Assisted Study Sessions for new international students studying scientific communications skills. The interactive program impacted on the Australian facilitators who reported an increased empathy for international students (Schmidt & Miller, 2009).
The previous examples assume that the teacher has access to a culturally diverse campus but this may not be the case. In homogeneous classes, the academic staff will need to model culturally aware behaviour and construct opportunities to develop intercultural learning. For example, Geography students at Oxford Brookes University in the UK doing "The Speaking Stones" exercise are asked to explore their local environment from the perspective of a non-Western cultural tradition and report on how they would improve their habitat (Haigh, 2011). Alternatively, internet-based learning platforms are readily accessible and these provide opportunities to generate class diversity as discussed in the next quadrant.

SW: International Learning/Form, "How do we Bring Students into Contact with the Wider World?"
This quadrant looks at what we can do to expose students to other nations. The classic example of this is student mobility programs whereby a student spends time (short or long) studying, working or volunteering in another country although the transformative potential of this depends on complementing the field experiences with reflection exercises (Hanson, 2010). Cost can be an inhibiting factor though which is why it is reassuring that 'internationalisation at home' strategies such as those outlined in this paper may be as, or more, effective for the development of global, international, and intercultural competencies than mobility programs (Soria & Troisi, 2014 Other strategies can also include cross-institutional online discussion exercises which can bring students from different countries together without the costs of physical transport. While these will not capture the feel of visiting another country, they can bring students directly into contact with other cultures and contexts. One of many examples is the Global Understanding program at East Carolina University which brings …students from 18 different countries, 2 at a time, to the ECU classroom in real time to learn about each other's culture… After taking this course, all students stated their comfort level in working with, and their desire to interact with, culturally different others grew stronger and their xenophobia and isolationist attitudes decreased. (Chia, Poe, & Wuensch, 2009) Another possible activity in this quadrant is guest faculty from other countries teaching into local programs. There is also scope for joint/double degrees between institutions in different countries within this quadrant.
This quadrant also encompasses learning another language. Learning a language includes many elements such as knowledge about the countries where the language is spoken and the social and cultural associations with the language. Therefore facets of language learning sit within all four quadrants.
This quadrant could also include institutions offering their programs in the medium of another language. This is usually done as English-medium offerings in non-English speaking countries (Chalapati, 2007;Doiz, Lasagabaster, & Sierra, 2012) but there are some examples of English speaking countries offering programs in other languages, for example, students studying the trilingual business and management degree at HEC Montréal take one-third of their courses in French, one-third in English and one third in Spanish (Association of Universities and Colleges of Canada, 2009).

Summary: The Internationalising the Curriculum Design Compass
It is important to note that the scope of IoC design is the whole program of study leading to a degree and the design is done by a team of unit coordinators. Attempting to address internationalisation in just one unit could overload the unit and overwhelm that unit coordinator. The design compass is a tool that curriculum design teams can use to clarify their objectives and identify which elements of internationalisation will be covered at what points in the curriculum. The curriculum design compass reduces IoC to an achievable four-point plan but by encouraging design teams to adopt at least one thing in each quadrant, it develops a more holistic, internally consistent and selfreinforcing IoC.

Case Studies of the Application of the Curriculum Design Compass
To test the Curriculum Design Compass, this section provides case studies of how the IoC design compass was used by two Australian university programs to audit the internationalisation of their curriculum. The hypothesis was that the Curriculum Design Compass is an effective tool if program leaders are able to identify current IoC practices in their curricula, identify gaps, and propose new activities to fill those gaps. The primary program chosen for analysis was Nutrition and Dietetics. To test the generalizability of this approach to other programs, a common core unit in Computer Science, Engineering & Mathematics (CSEM) was also analysed. If the tool transferred effectively across professions (dietetics to engineering), then it should also transfer across health professions. The teaching teams in Nutrition & Dietetics and CSEM met with one of the authors who explained the Curriculum Design Compass to them. They then used it to independently review their programs and their reports, written by the respective teams,

Report written by the teaching team in Nutrition and Dietetics
Nutrition and Dietetics (N&D) teaches accredited vocational training courses for the dietetics profession which are recognised internationally. International students comprise approximately 25% of student enrolments, most of whom return home to practice. While international students must meet Australian professional competencies to work in the Australian health care system, they also need to be aware of equivalent policies, systems and practices relevant to their own country. We therefore have a strong commitment to internationalising the curriculum.
In 2010, we finalised a curriculum review and restructure as part of a university wide project with an aim to better prepare graduates for professional employment by incorporating internationalisation in the curriculum. Our premise was that for internationalisation to be fully integrated into a curriculum rather than tokenistic, it needs to be embedded within the learning outcomes of the topic and assessed. The IoC Design Compass provided a useful framework for reviewing our curriculum. International content and activities were matched to each quadrant of the compass and opportunities to introduce or expand internationalisation were identified.
The NW quadrant focuses on international content or what students need to know to function internationally as a dietitian/nutritionist. We introduced a comparative approach to topic content to investigate all aspects of food ranging from practical recipe modification classes to comparisons of food legislation, food systems and the global food supply. Public health policy and programs, such as National Dietary Guidelines have been taught with a focus on international comparison. New learning outcomes were created e.g. 'Students will demonstrate a thorough knowledge of the Australian food system and the global and local factors affecting our food supply.' The assessment was modified to incorporate the updated international content. One example is for students to consider the passage of a food (both imported and local) through the food supply from primary producer to retail outlet considering factors such as origin, food miles, trade agreements, processing and food legislation. Additionally we elected to adopt the globally recognised 'Nutrition Care Process Terminology (NCPT)' (Lacey & Pritchett, 2003; Writing Group of the Nutrition Care Process/Standardized Language Committee, 2008). Many contemporary nutrition issues such as obesity, malnutrition and food security are global and these issues can be readily examined using international comparisons. These have been identified as opportunities for future development.
The NE quadrant refers to acquiring multi-cultural skills. Cultural competence, culturally appropriate communication and cultural influences on health and food choice, are essential dietetic National Competency Standards and was already included in the curriculum to achieve course accreditation (Dietitians Association of Australia, 2009). A socio-ecological perspectives topic has as its premise to understand how our own values and culture shape our food choices and then to apply this awareness to other situations. As an example, this topic includes the following learning outcome: 'Students are able to discuss how social determinants such as socioeconomic status, gender, culture and Aboriginality affect food choice'. Assessment for this topic includes an essay discussing a topical nutrition issue by analysing its underlying socio-ecological determinants and student-led seminars on a variety of topics including 'International food issues and action for change.
The SE quadrant is how we teach intercultural learning. We achieve diversity in tutorial groups by designating a mix of domestic and international students. This encourages interaction and provides a different perspective on the topics studied. For example, the student-led seminar on 'International food issues and action for change' has greater depth from a mixed student group. Communication skills are universal for all professions and yet the etiquette of Schmidt L, Wray A, Miller J, Scott J, Pope K MedEdPublish https://doi.org/10.15694/mep.2017.000061 Page | 8 communication varies between cultures. Aspects of communication such as eye-contact, proximity, and formalities of addressing the client, can differ significantly between cultures. International students readily share this information which then often springboards into a robust discussion. The Communication and Counselling topic uses experiential learning methods and tutorials are designed to create a culturally safe and trusting environment in which students feel comfortable to experiment and take risks. Students learn to be aware of, and sensitive to, an individual's traits, cultural and religious beliefs.
The SW quadrant is how students are exposed to the wider world. Our program offers opportunities for an overseas placement in various places such as the Philippines where students contribute to a community feeding program for malnourished children.
Overall, the Curriculum Design Compass proved to be a user-friendly tool and provided us with a framework for thinking about the international content of our course. In general, topic content was easily separated into NW and NE quadrants. It was more difficult to categorise the 'how we teach' into SW and SE quadrants as activities often tended to span both quadrants and it was more useful to think of this as a spectrum. Topics in the final years of the course tended to be more difficult to categorise into quadrants. This is in keeping with the higher levels of learning appropriate for capstone topics, as defined by Bloom's taxonomy (Bloom, 1956), where students are applying knowledge, synthesising, analysing and evaluating. Many of these activities, such as work integrated learning, incorporated every quadrant i.e. they orbited the compass.

Report written by the teaching team in Computer Science, Engineering and Mathematics
The School of Computer Science, Engineering and Mathematics (CSEM) is responsible for a range of professional degree programs across engineering and computer sciences which are accredited by the appropriate professional body, several of whom are parties to international agreements that result in our awards being internationally recognised. A core part of all of these programs is the first year topic [1] called Professional Skills. The purpose of this topic is to introduce students to a range of skills used in their profession: communication skills, critical thinking, problem-solving skills, team work etc. The topic is built around a group project, the EWB Challenge, run by Engineers Without Borders, Australia. The Challenge is a sustainable development project set in a community with significant needs, either outside Australia or (as in 2010) in an Australian aboriginal community, in conjunction with a local partner organisation. Students are allocated into culturally diverse groups of four to six students and design a sustainable development project addressing the needs of the community.
The NW quadrant addresses what a professional needs to know to operate in an international context. One way the topic provides this is through the background material on the country and community that is the subject of the Challenge. In addition, the individual research undertaken by the students for their group project encourages selfidentification of the required knowledge. Demonstration of this knowledge is an explicit component of several assessment items attached to the Challenge.
Moving on the continuum towards the NE quadrant, the topic explicitly teaches the concepts of sustainable development and cultural appropriateness. This is assessed via a tutorial addressing cultural appropriateness .This is followed by the Challenge groups reflecting on the cultural differences between their culture (Australian or otherwise) and the culture that is the subject of the Challenge.
Currently there is little explicitly in the SE quadrant. Implicitly, however, diversity (international or otherwise) is given the opportunity to be seen through the process of undertaking the EWB Challenge. The consideration of what Schmidt L, Wray A, Miller J, Scott J, Pope K MedEdPublish https://doi.org/10.15694/mep.2017.000061 Page | 9 project to choose and how to design and implement it requires group discussion where diverse views across cultures can be presented.
In the SW quadrant, transnational classes are not currently a possibility, though running the topic as a distance education topic with online meetings etc is under consideration. Should this be adopted, it will be possible to have offshore enrolments.
Some opportunities to further strengthen the internationalisation of the curriculum have been identified. A more explicit presentation of the benefits of having cultural diversity in the Challenge groups may result in international or migrant students tending to conform less to Australian cultural norms and instead presenting and modelling international approaches. This is leveraging cultural diversity in the classroom (a contribution to the SE quadrant), perhaps a small step towards transnational classes (SW quadrant), and may also result in learning about other cultures (NW quadrant), Reviewing the learning outcomes of the topic, it is clear that the extent of internationalisation of the curriculum within the topic is not appropriately reflected and could be revised to explicitly acknowledge this aspect of the topic design. There are references to "environmental and social issues" and "sustainable development", but not to the international aspect of these concepts.
The use of the Curriculum Design Compass as a review tool has been useful and effective in acknowledging the extent of internationalisation currently in the topic, and suggesting steps to further internationalise the topic. It has provided a clearer view of the topic, which can be provided to degree accrediting bodies to assist in showing the merits of our degree programs in the international workplace.
The strongest feature of the internationalisation of the curriculum in this topic is that it is all centred on the Challenge, which acts as a unifying theme across the whole topic. Thus the different components of the topic that contribute to internationalisation are not fragmented but form a holistic, internationalised curriculum.
[1] 'Topic' here means one semester-long unit of study within the degree program.

Discussion and Conclusions
The test for the practicability of the Curriculum Design Compass was that program leaders would be able to identify current IoC practices in their curricula, identify gaps, and propose new activities to fill those gaps (illustrating utility, clarity and parsimony). Generalizability of the compass was tested by applying it in two different disciplines. The case studies above illustrate how two teaching teams successfully used the Curriculum Design Compass to reflect on their curriculum, to identify which elements contributed to IoC, and to identify areas for further improvement, thereby demonstrating its utility. The ability of both teams to rapidly (within a couple of hours) understand and apply the compass is evidence that it also meets the criteria of clarity and parsimony. The effectiveness of the compass across two very different disciplines -N&D and CSEM -is evidence that it meets the criterion of generalisability.
The N&D case focussed on the whole degree program whereas CSEM looked at one unit of study. It was predictable that N&D would find IoC across a four year degree, especially since they had consciously designed their curriculum Schmidt L, Wray A, Miller J, Scott J, Pope K MedEdPublish https://doi.org/10.15694/mep.2017.000061 Page | 10 to be internationalised. It was surprising though that CSEM were able to identify as many examples and opportunities as they did within a one semester unit of study that is one eighth of a study load for the year. A key reason for this may be the deliberately internationally located, project-based nature of the activity and the use of groups, especially since they have a culturally diverse cohort. Another insight from CSEM was the realisation through the use of the compass that they have internationalised their curriculum more than they thought they had, they simply had not attached the IoC label to what they were doing. N&D and CSEM are very different disciplines and yet they both reported that the design compass was a useful review and design tool and this suggests that it will also be useful for other health professions. Both teams reported that international accreditation requirements are a driving factor in internationalising their programs but may mean that alternative motivations are required for discipline areas that are not internationally professionally accredited.
Encouragingly, CSEM were able to identify areas where they could increase their IoC and provided concrete examples of what they would do, e.g. in the SE quadrant they would leverage the diversity in the classroom more. This shows that the compass can be a useful 'imagining' tool in the curriculum design process.
One of the issues raised was that the quadrants are not distinct entities and it may be better to think of the axes as spectra. This could be encouraged as the quadrants are actually overlapping and interacting spaces and, as discussed by N&D, activities such as work-integrated learning may cover all areas. What the compass did for these teams was provide four spaces to think about but it did not constrain their thinking.
In conclusion, the Curriculum Design Compass is a tool that can be used by different programs to review their curriculum, validate what they are currently doing as IoC, and provide focus areas for further improvement. The experiences of these teaching teams illustrate a path for education for global health. While educating global health practitioners may be positioned as being about content areas to be covered and exposure to particular global contexts; IoC positions global health education as holistically integrated within the curriculum as something that permeates what we do and how we do it.

Take Home Messages
Internationalisation of the curriculum (IoC) is a possible approach to producing global health practitioners Practical tools are needed to help teachers internationalise the curriculum IoC is about how we teach as well as what we teach What we teach includes global knowledge and cultural competence The Curriculum Design Compass is a tool for holistically reviewing and designing internationalised curricula