Global health is defined as “collaborative trans-national research and action for promoting health for all” (Beaglehole & Bonita, 2010, p.1). The definition implies the importance and the need for collaboration among the healthcare providers within various health professions. Global health has become one of the main concerns of the world leaders because of the increasing rate of the burden of diseases in most countries brought about by increased human mobility, an expanded number of refugees, and increased rate of the chronic and communicable diseases worldwide to name a few (Gopfert et al, 2014).

The Philippines is not spared from these health phenomena. One of the WHO reports (2014) about the Philippines stated that “the health situation in the Philippines can be summarized in three words (a) stagnation (b) inequality and (c) opportunity”. The report said that Philippines suffers a “triple burden” of disease: (i) high incidences of all key communicable diseases and 13/17 of the WHO recognized neglected tropical disease remained endemic; (ii) increasing level of non-communicable diseases and high prevalence of all risk factors as well as (iii) the third highest disaster prone country in the world. Furthermore, the report presented a set of disappointing facts like, global disease burden growth has increased 4% annually in the past decade. 50% of the population still lives on less than $2/ day. 30% of children under 5 years of age are stunted; half of all children are iron-deficient, 30% iodine-deficient and with moderate and severe malnutrition. Moreover, medicine prices in the Philippines remain some of the highest in Asia. All of these health challenges require collaboration among all the healthcare providers and the government. This public health situation in the Philippines draws pensive reflection, considering the fact that the country has a large number of nurses as members of the health team.

Global health challenges require high-level of involvement from the nurses, particularly to address the United Nations' 2030 Sustainable Developmental Goals(Klopper & Hill, 2015; Ventura et al., 2014, Veras et al., 2013). On 17 June 2015, the International Council of Nurses (ICN) and the World Health Organization (WHO) held the first professional consultation on the Global Strategy on Human Resources for Health (HRH).The consultation stressed the key role of nurses in achieving the Sustainable Development Goals (ICN, 2015).

Comprising the highest number among the healthcare providers, nurses have the power to act, both as caregivers and role models in implementing the sustainable development agenda worldwide. Hence, nurses are highly encouraged to take a prominent role in the current global health challenges. Global health awareness among the nurses is a fundamental need to equip them with the needed competencies to pursue with their role in developing the global health. Therefore, it is imperative for all the nursing schools to assess, enhance and develop the global health competencies of their students.

Thompson and Hyrkas (2014) stated that nursing leadership can be a pivotal force in creating a healthier tomorrow for the patients, clients, and citizens for whom care is provided. The engagement of nursing education in addressing the global health activities and its challenges will help the future nurses to fulfill their role in helping the public achieve the optimum level of health and wellness. However, only a few number of studies showed global health competencies being included in the undergraduate curriculum. A dearth of literature about the evolving global health concepts and challenges in the nursing curricula was identified(Battat et al, 2010).

A study, “Integration of Global Health Concepts in Nursing Curricula: A national study”, conducted by Carlton et al. (2007) revealed that only eight of the 39 respondents indicated that the concept of global health was defined in their schools' curricula. The study included the Deans and Directors of all schools of nursing with baccalaureate and master's degree programs listed in the National League for Nursing Accrediting Commission Directory of Accredited programs in the United states of America. Carlton et al. (2007) stressed the need to come up with new ideas to integrate the evolving global health concepts and issues in the nursing curriculum. Such integration will intensify the level of awareness of the nursing students toward the global health importance.

Findings of another study conducted in Brazil, that assessed the Global Health Competencies in the Nursing Curriculum, showed that most of the core competencies assessed by faculty members were not included in the curriculum offered at the schools of nursing (Ventura, et al, 2014) . A multi–institution global health competency survey was conducted by Mirella Veras in 2014 to assess the global health competencies among the family medicine residents, nursing, physiotherapy and occupational therapy students. The study sample included 420 students within five universities in Canada. The study showed that all students lack the global health competency in general. It is not enough for the nurse leaders(Huston, 2008) to recognize the importance of having competent nurse practitioners who can work in collaboration with multi sectorial agencies, but they should push toward curriculum restructuring that must begin with a faithful belief of the need to beat the global health challenges(Veras, et al., 2014).

The poor public health situation in the Philippines as reported by the WHO is a multi-sectoral responsibility that needs to be addressed by key players like the government, nongovernmental organizations, and the education institutions. This study focused on the role of educational institutions in developing competencies of would –be nurses who represent the largest sector among the health team (Institute for Health Metrics and Evaluation University of Washington; Human Development Network the World Bank. 2013).

The Article 4 of the Philippine Commission on Higher Education memorandum order (CMO) No. 5 Series of 2008 entitled “Policies and standards for Bachelor of Science in Nursing (BSN) program”, includes the competency standards that should be integrated in the BS.N curriculum. The competencies comprise 11 areas: Safe and quality nursing care, management of resources and environment, health Education, legal responsibility, ethico-moral responsibility, personal and professional development, quality improvement, research, records management, communication, collaboration and teamwork. However, despite the importance of all of these areas, nothing was explicitly mentioned about the global health competencies (CHED, 2008).

Since global health competencies are not explicitly embedded in the BSN curriculum, the researcher deems that it is important to delve into the competencies of the nursing students. The purpose of this study was to assess the knowledge, skills, and learning needs related to global th health of the 4 year nursing students in a selected School of Nursing (SON) within Baguio City, Philippines. The study determined the level of global health competence th among the 4 year nursing students in terms of (1) Global Burden of Disease,(2) Health Implications of Travel and Displacement, (3) Social and Environmental Determinants of Health, (4) Globalization of Health and Healthcare, (5) Healthcare in Low Resource Settings, and (6) Healthcare as a Human Right and Development Resource. It also explored whether the global health competencies are integrated in to any of the courses in the BSN curriculum.

This study is a descriptive cross-sectional survey. A standard Self-rated assessment tool was used to assess the level of global health competencies.

The study was conducted in a selected school of nursing (SON) within Baguio City, Philippines. This School has maintained its status as a top performing school of nursing in the country, and it is accredited as one of the few Centers of Excellence in Nursing Education in the Philippines. Furthermore, it is known for their high standard of nursing education, stringent clinical training and rigorous student retention policies.

Considering 95% as a confidence level and 4 for the confidence interval, the representative computed sample size was132 out of 200 students using the Slovin's formula. There were 160 fourth year students who voluntarily participated.

In 2008, a Consortium of Universities for Global Health (CUGH) was launched to promote the involvement of American universities in confronting key aspects of global health. The CUGH held a meeting in Washington, D.C. on September 2009 with representatives from the Global Health Education Consortium (GHEC). The GHEC is leading an initiative aimed at developing global health competencies among medical students (Monograph, 2011). Researchers from the University of Alabama at Birmingham (UAB), the Autonomous University of Mexico (UNAM), Johns Hopkins University (JHU) and the University of São Paulo (USP) at Ribeirão Preto got permission from GHEC to adapt the instrument developed for medical students in nursing, with a view to identify the agreement among nurses about the global health competencies needed for their activity at an expanded level. The questionnaire was initially validated and used in a research focusing on Spanish-speaking nursing faculty from Latin America and North America, and later validated and applied in Brazil (Ventura et al., 2014). The competencies are divided into six subscales, and the respondents will rate each competency on a 4-point Likert scale, with high scores reflecting a high level of competence. The 30 competencies were divided into six categories as the following:

• Global Burden of Disease,
• Health Implications of Travel and Displacement
• Social and Environmental Determinants of Health
• Globalization of Health and Healthcare
• Healthcare in Low Resource Settings
• Healthcare as a Human Right and Development Resource

Administrative clearance was obtained from the Dean of the School of Nursing to conduct the survey. The study th objectives were explained to the 4 year students, and their informed consent was obtained. Several meetings were th arranged to meet most of the 4 year students based on their availability within the time frame set for data gathering. A total of 160 (80%) from the 200 fourth year students voluntarily accepted to participate in this study after they received a brief explanation about the study and its objectives. Data collection processes were completed within three weeks in October 2015. A 100% retrieval rate was achieved. Data were collated and analyzed statistically.

The study was approved by the appropriate human subject protection committee within the educational institution, all needed precautions were taken to protect the anonymity and confidentiality of the participants. Furthermore, participants were informed about their voluntary participation and they were free to withdraw at any time. No information identifying student was collected. There was no vulnerable group among the participants (Lorenzo et. al, 2007).

Four-point Likert scale was used in the questionnaire to determine the self assessed ability to perform the global health competencies among the fourth year nursing students in using the following values (1 = Not at all, 2 = Sometimes, 3 = Often, 4 = Always). MS Excel spreadsheet (version 2010) was used to yield a descriptive statistics. Mean, Standard Deviation (SD), and percentage were used to determine the level of competence. To facilitate the interpretation of the gathered data, Classes interval of the yielded values was constructed after determining the class width of 0.6 based on the difference between the highest value and lowest value, and minimum of five classes were established Triola, 2004). (Qualitative (Verbal) interpretations were assigned to the constructed classes interval as illustrated in Table 1.

Table 1. Mean Values Range and Qualitative Description

Figure 1 shows the mean distribution of the level of competencies on global health of the fourth year nursing students. It revealed that,

• The students are moderately competent in the Global Burden of Disease category with a weighted mean score of 2.6;
• Competent in four categories of GHCs specifically, Health Implications of Travel and Displacements, Globalization of Health and Healthcare; Healthcare in Low Resource and Healthcare as a human right and Development Resource with weighted mean scores of 2.88, 2.85, 3.04 and 3.28 respectively;
• Students are highly competent in Social and environmental determinants of health with weighted mean score of 3.46. The overall result for global health competencies implies that the students are competent in general with a weighted mean score of 3.02.

Figure 1. Mean Distribution of the Level of Competencies on Global Health of the Fourth year Nursing Students

Table 2 shows the percentage distribution of the affirmation  from the 4^th year BSN students on the inclusion of the global health competencies in the BSN curriculum of the School of Nursing. The result demonstrated that all of the competencies were included in the curriculum offered at the nursing school. The percentage of the students who stated that the GHCs were included in the curriculum extended from 82 to 98%, while the percentage of the ones who said the GHCs were not included extended from 2 to 18%.

Table 2. Percentage Distribution of affirmation from the 4^th year Nursing Students on the inclusion of the GHC in the BSN Curriculum of the School of Nursing

The mean and standard deviation of global health  competencies among the 4^th year students are between 2.60 (0.71) to 3.46 (.67) with total average of 3.02 (0.76),  demonstrate a competent level among the 4^th year students. The result implies that the fourth year students assessed themselves to be competent in collaborating with trans-national research and actions for promoting health for all. This finding is not consistent with results reported from a study conducted to assess the global health competencies among medical, physiotherapy, and nursing students in five universities across Ontario, Canada. Unlike these findings, the study showed that the self-reported knowledge and confidence in global health issues and global health skills were low for family medicine residents, nursing, physiotherapy and occupational therapy students(Veras et al., 2014). This is the only study found from search engines that included direct assessment of global health competencies among health science students at the time this study was done. The lack of the number of conducting studies assessing the global health competencies among the nursing students was one of the major challenges that made the findings of this study difficult to compare(Tejada et al, 2012).

Community Health Nursing at School of Nursing

Although the evaluation was self- assessed, the Dean of the School of Nursing strongly affirms the findings of this study that the fourth year students are competent to address global health issues. According to the Dean of the School of Nursing (Personal communication, 2015), the world health organizations (WHO) related activities and global issues are highly addressed by most of the faculty members in their given area of community-based clinical assignments and class discussion with their students in most of the offered courses. She added, that the positive finding of the study could also be attributed to the high level of engagement of the students to the School of Nursing Mobile Nursing Clinic (MNC) extension service, which was long established in 1979. The primary aim of this pioneer program was to alleviate the state of healthcare systems in depressed or neglected communities by developing and enhancing the skills of the community on how to manage their own health programs. MNC is considered as an institution per se being the first and longest-running college based extension program of the university in the face of rapid globalization. The MNC is considered as a model healthcare facility for providing primary healthcare services not only within the communities of the city, but is extended to the under-served and far-flung areas of nearby provinces. In addition, the SON has prioritized the promotion and advancement of community health development at the top of its agenda. The MNC now utilizes a collaborative approach to health development called the Community Organizing-Participatory Action Research (COPAR) to address the following objectives:

• To pursue relevant researches with the community as co-researchers,
• To mobilize a multi-sectorial linkages,
• To extend training to other schools and concerned agencies,
• To widen the program's scope, and
• To maximize community participation and involvement.

Moreover, the school maintains national and international linkages, which are vital to expanding skills and knowledge, enhancing the curriculum, bringing in resources, and promoting trans-cultural learning and appreciation among its faculty and students.

Community Health Nursing course was reviewed as part of this study to explore its relation to the current global health trends. The Course Learning Outcomes (CLO) included seven areas, namely:

• Define the nature and scope of public health / community health nursing,
• Summarize important dates, people and event that shaped community health nursing in the Philippines,
• analyze the implication of the local, national and global health situation,
• evaluation of solutions to healthcare concerns and issue / health situation,
• discuss the qualities, qualification, competencies of community health nurses,
• propose a responsive health care system and
• justifies action with existing relevant programs, laws and regulation governing public health.

CLO 3 discussed various items covering health indices at national, regional and global level, health and social determinants under which there was focused on social, political, economic, factors, cultural and environmental factors. CLO 4 included also the part about the health situation in the Philippines and the healthcare delivery system, including health facilities, health service delivery, healthcare financing/economics of healthcare and health human resource. Millennium Development Goals were covered under CLO 4. Various laws related to family, child and maternal health were discussed in CLO 7. Furthermore, non-communicable diseases prevention and control program, environment occupation health, and communicable disease prevention and control were discussed in CLO 7.

The high engagement of nursing students in community health services through their extensive community related learning experience for the Primary Healthcare and Community Health Nursing courses, and the MNC program can be considered as major factors on the competency level of global health competencies they have(Foronda, 2010). The extensive Community Health Nursing activities of the School of Nursing undoubtedly exemplifies the recommendation of previously conducted studies which emphasized the importance of employing the global health competencies beyond the classroom activities and include it in a wide-ranging action plans Ventura et al., 2014) (. The BSN students experience first-hand socio-political, and health conditions affecting the communities, and are extensively engaged in activities addressing health burdens and empowering the community people to address their own health needs within their level of resources.

The School of Nursing BSN curriculum is considered as capable to equip and develop the future nurses to be competent in responding to global health issues. The global health competencies are integrated into their BSN curriculum in both theory and clinical although stated in different nomenclature.

Implications and Recommendations

The SON where this study was conducted is one of the centers of excellence for nursing education in the Philippines, with a community-based curriculum is expected to graduate students who are competent and excellent. It is gleaned from the study that the BSN curriculum is more or less the same as all other BSN curricula in the Colleges of Nursing in the Philippines, although may have not explicitly expressed inclusion of the global health competencies identified in this study but is able to develop among their students congruent competencies which may be expressed in another form. Therefore, it is recommended that a further study or reviews on the curriculum vis-à-vis the global health competencies with its six categories identified by the consortium of international universities.

In order to confirm further and objectively, it is recommended that similar studies assessing the level of global health competencies be conducted to more schools of nursing in the Philippines but with the use of a more objective tool to measure the competencies. By then, it can be safe to recommend that other schools of nursing may benchmark from the Philippine BSN curriculum in terms of developing global health competencies among the nursing students.

It can also be assumed that the BSN curriculum of the Philippines adequately prepares their students in terms of global health as evidenced by the large number of Filipino nurses being employed in almost all parts of the world since a long time ago. The long history of Filipino nurses being preferred by most host countries may imply the ability of the Filipino nurses to adapt and respond to global health issues anywhere else in the world.

The result of the study can be considered as an informal input into the database of the WHO and United Nations, Organizations, and other global health stakeholders as a springboard for further study that will lead to program development or further actions to improve global health competencies among the nurses and student nurses.

The researchers would like to thank Lynda Law Wilson, RN, PhD, FAAN for the permission to use the global health competencies self-assessment tool. The researchers also would like to thank the Dean Mary Grace C. Lacanaria RN, MAN, PhD for facilitating the conduct of the study in the School of Nursing, Saint Louis University, Baguio City, Philippines.