Exploring Trainee Priorities: A Qualitative Needs Assessment to Inform Global Health Education

Study design, setting, and conceptual framework

We used a qualitative study design employing FGDs to explore the topic in depth and harness group dynamics related to socially constructed knowledge [16, 17]. We used adult learning principles, specifically Knowles’s andragogy [18], as a sensitizing concept [19]. Knowles’s six assumptions—adult self‑concept, prior experience, readiness to learn, problem‑centered focus, internal motivation, and need to know [18]—are well suited to explore motivations, learning preferences, and the role of prior experiences for residents and fellows engaged in complex, practice‑based training.

Focus groups took place at a free‑standing children’s hospital, an academic pediatric institution in South Florida. The hospital offers a categorical pediatric residency and 14 pediatric subspecialty fellowships. At the time of data collection, there were 84 pediatric residents, 2 chief residents, and 38 subspecialty fellows. The program typically accepts approximately 55% to 65% IMGs. This study was deemed exempt from the hospital’s Institutional Review Board.

Focus group discussion guide

To develop the FGD guide, we conducted a literature search and incorporated principles from the American Board of Pediatrics’ Implementation Guide on Global Health in Pediatric Education [12], as well as questions from published survey needs assessments of trainee interests and attitudes toward GH [20, 21]. Open‑ended questions facilitated discussion. The guide was piloted with two volunteer trainees to refine questions and facilitation. During the pilot FGD, trainee participants had difficulty describing their GH experiences, and asked facilitators to clarify “what counts as global health?” This prompted the addition of the first question eliciting participants’ understanding of the term. After participants responded, the facilitator shared a broad definition of GH [22] to encourage further discussion beyond activities commonly described as GH, such as short‑term medical trips. The definition is as follows:

Following iterative changes, the final FGD guide contained 13 questions (see Supplemental Digital Appendix 1).

Participants

Using maximum variation purposeful sampling [23], post‑learners of different years in training and subspecialties were invited to participate. Participants were recruited via institutional email lists, class group messages, and daily noon conferences. Inclusion criteria included current pediatric residents, chiefs, and subspecialty fellows at the hospital. Those interested in participating completed an online sign‑up form, ranking their time availability, and answering “yes” or “no” to having had any previous GH experience. Participation was voluntary; all participants provided verbal consent. Participants received food and a $25 gift card upon completion of the FGD. Participants were assigned to different FGDs based on their self‑reported experience in GH. This was done to facilitate group homogeneity, as medical training level does not always reflect GH experience or knowledge. Rather, by grouping based on experience, the participants may better relate to each other [17]. FGDs were scheduled concurrently with recruitment and data analysis. By the fourth FGD, no new code categories or themes were observed, and the team determined that thematic sufficiency was achieved and thus recruitment ended after the fifth FGD [24].

Data collection

Prior to beginning the FGD, participants completed a brief anonymous paper survey to collect basic demographic data, including gender, level of training, type of training program, and whether they completed any medical training outside of the United States (see Supplemental Digital Appendix 2). All focus groups were one hour long, conducted in person, audio‑recorded and transcribed via Zoom Workplace (with video turned off). FGDs were facilitated by M.D. and F.M., who reviewed and edited the transcriptions alongside audio recordings to ensure accuracy, and removed participant names to maintain anonymity.

Data analysis

We conducted inductive thematic analysis of FGDs through a constructivist worldview. The learning theory of constructivism proposes that meaning is constructed from new experiences through pre‑existing knowledge [18, 25]. Using this worldview, we explored trainees’ understanding and meaning of GH experiences [26], as they relate to prior and desired engagement. Knowles’ assumptions [18] were used as a sensitizing concept to guide interpretation [19]. Two independent coders (M.D. and F.M.) coded the transcripts using ATLAS.ti software (version 9.24.3). We reviewed interview transcripts line‑by‑line, utilizing in‑vivo, process, descriptive, and interpretive codes [27]. Coders met regularly to reconcile differences. We then mapped categories to overarching themes based on logical associations and overall fit with analytical memos [28, 29]. Themes, subthemes, and visual thematic mapping were reviewed with the entire investigator team (M.D., F.M., R.G., C.S., J.K., M.H., and S.M.) throughout analysis steps for iterative feedback.

Research team and reflexivity

The research team had expertise in qualitative research, social sciences, medical education, and GH, acknowledging the influence of researcher identity on interpretation [30]. M.D. was a pediatric fellow, and R.G. held a leadership role in graduate medical education at the study institution; both had prior GH training and experience and sought to develop a GH program at their institution. F.M. was a PhD candidate in social work, with M.H. and S.M. having extensive experience in conducting community‑based research and were invited as qualitative research experts. F.M., M.H., S.M., C.S., and J.K. all have qualitative research experience in both interview and FGD facilitation and inductive thematic analysis. C.S. and J.K. both hold leadership positions in global child health education and research at a different institution, particularly working within the pediatric GH track with experience in GH program education and leadership. Team demographics supported analytic depth across social science and medical education perspectives. M.D. and F.M. engaged in ongoing reflexive discussion during analysis to consider how their experiences shaped interpretation.

Domain 1: drivers of engagement

Participants described internal motivators for engaging in GH (see Table 2).

Theme 1: Finding meaning: Participants described GH experience as a way to reconnect with medicine, often as a reminder of “why I went to medical school” (FGD 4, P5) or even “why I exist” (FGD 4, P7). This motivation appeared related to negative experiences during training, including “insurance and red tape” (FGD 4, P5) and perceived lack of trust from their patients.

Theme 2: Previous exposure: Participants traced their interest in GH to prior exposure to underserved populations through family, upbringing, or volunteer work.

Subtheme 2.1: Early experiences among AMGs: AMGs described early volunteer experiences, often with family or prior to choosing medicine, as formative. One participant visited children experiencing homelessness with their parents, saying “just something I grew up with” (FGD 1, P5), while another visited orphanages with their family while growing up. Others described volunteering prior to choosing medicine and wanting to continue after finding it gratifying. “My first experience, I wasn’t entirely sure that was I interested in medicine. Being able to work with patients that didn’t have the means […] was really gratifying.” (FGD 2, P1).

Subtheme 2.2: Sense of duty among IMGs: Among IMGs, a prominent theme was a sense of duty to give back, rooted in witnessing disparities in their home countries. They described training in the United States as a privilege that drives them to give back to their communities.

Theme 3: Professional development: Trainees described GH experiences as opportunities to build skills as well‑rounded clinicians beyond US medical training. These opportunities included exposure to unfamiliar pathology, “infectious diseases that we don’t have here (FGD 3, P3),” and development of basic procedural skills, “like placing an IV” (FGD 3, P1). Others valued clinical reasoning without over‑relying on diagnostic or therapeutic tools, by “doing more with less” (FGD 2, P5) while differentiating disease processes (see Table 2), and “think(ing) outside the box” (FGD 4, P6).

Domain 2: desired GH experiences/education

Across FGDs, trainees described various interconnected characteristics as essential to meaningful GH training. Figure 1 synthesizes these themes into a conceptual model illustrating how adaptability, interdisciplinarity, multimodal learning, and contextualization with a focus on impactful outcomes contribute to meaningful trainee–partner experiences.

Theme 1: Adaptable to learner: Trainees described wanting experiences that adapt to their interests and strengths. Several participants described connections to specific regions or interests in GH work but being limited by lack of organizational partnerships. These connections were rooted in learner capabilities for effective engagement, such as local language proficiency, knowledge of the culture, or understanding of needs. One participant asked “Can we develop more partnerships? I am really interested in going back to India at some point … because I speak the language” (FGD 3, P4). Some IMGs also described having current medical licenses in their home country,

Participants described wanting programs that leverage trainees’ existing skills and experiences to shape where and how they engage in GH.

Theme 2: Interdisciplinary: Participants identified diverse clinical and non‑clinical topics, reflecting the need for multiple, intersecting competencies in GH work. For example, clinical topics included “tropical diseases… parasitic diseases, things we don’t necessarily see here” (FGD 1, P1), “knowing the basics about nutrition, psychology …” (FGD 1, P1). Participants requested education in other disciplines that strongly interplay with health, including “politics” (FGD 5, P2) and how it affects access to care, and “learning about the health care systems” (FGD 2, P1). Other participants discussed the importance of administrative skills, “I think we will have to learn a lot about it, how to manage clinics, how to manage people, how to manage supply chains,” (FGD 2, P4), highlighting training that prepares them for concrete roles and responsibilities to address real‑world GH problems.

Theme 3: Multimodal: Participants were asked which modality they prefer for learning GH, to which they frequently expressed preferences for hands‑on workshops and opportunities for discussion to “bounce ideas off of each other” (FGD 2, P1). One exchange illustrated trainees’ view of dialogue as central to learning:

Participants emphasized that learning occurs “when we talk,” underscoring the importance of structured time for discussion over passive information delivery. They described conversations—especially with peers who hold different perspectives—as a way to enhance understanding. Some vocalized distaste for online modules; “I think it’s more of a chore to have to do an online module and then everyone just wants to click through to the end,” (FGD 3, P4) and didactics “if you give me a lot of slides, like a lot of PowerPoints, I’m not gonna learn anything.” (FGD 5, P3). At the same time, participants acknowledged the realities of limited curricular time during training. They suggested didactics, self‑paced modules, or pre‑recorded sessions as ways to acquire foundational knowledge in advance, allowing scheduled in‑person time to be used for higher‑level discussion, reflection, and hands‑on skills. “It will be beneficial if we do like some modules before we do the hands‑on [part] to save some time.” (FGD 1, P4).

Theme 4: Contextualized: Trainees emphasized aligning educational content with the realities of practice in partner sites and their own patient populations.

Trainees emphasized the importance of training grounded in local context, including cultural factors and social determinants of health that shape health care delivery.

Theme 5: Impactful: Trainees sought partner‑driven initiatives with sustainable, measurable impact. They described wanting to contribute to work that is ethically grounded, partner‑driven, and designed to continue beyond their presence.

Although the themes describe ideal GH experiences and curriculum, participants noted several personal and institutional barriers hinder their ability to pursue these experiences and proposed solutions to mitigate these barriers. Table 3 outlines salient challenges and proposed strategies to combat them. We noted that IMGs suggested themselves as part of the solution.