Introduction

Settele et al¹ explain ‘A single species is responsible for the COVID-19 pandemic – us. This is the human hand in pandemic emergence’. (p. 1). Current approaches to address pandemics such as SARS-CoV-2, are to provide a band aid once they occur, relying on vaccine deployment and therapeutics towards mitigating pandemic spread. What is required to prevent disease occurrence, is a focussed transdisciplinary approach to understand and address the underlying social, behavioural, economic and environmental factors driving zoonoses emergence.² The conceptual framework of OH, representing the interconnection between animal health, environmental health and human health, provides such a strategy for enabling a collaborative public health response for tackling global health emergencies. On September 5^th, 2021, the G20 Health Ministers recognised the urgency to operationalise a OH approach at all levels of governance, towards preventing and controlling the occurrence of future pandemics of zoonotic origin.³

Osterhaus et al² advocates that, as the source of all key global health issues have their origins at the human-animal-environmental interface, the ‘best solution’ (p. 2) would be for health professionals and policy-makers to adopt a transdisciplinary OH approach in attending to these threats in an interprofessional manner. For example, policies to restrict the global wildlife trade can intercept the spill-over of agents such as SARS-CoV into humans, with implications for preventing the occurrence of pandemics such as COVID-19. Additionally, food and water security can be maintained using OH approaches as trends in agricultural and aquaculture practices are responsible for transmission of antimicrobial resistant organisms to humans.² Surveillance in animal species for the genomic similarities that occur in human cases of SARS-CoV is essential to identify the viral origin and to prevent the occurrence of similar diseases as well as to predict future occurrences.

Interprofessional collaboration that executes a OH approach is necessary to prevent and control emerging diseases of animal origin impacting human health such as COVID-19. It is crucial that medical, veterinary, environmental and public health practitioners appreciate their environmental and social responsibilities and the long-term impact of their actions on protecting the public health. It is the collaborative effort of these groups in driving policy changes that protect nature, that is necessary for preventing the occurrence of future pandemics.¹ IPE which promotes shared learning between health professionals⁴ is thus crucial for these groups to understand the key expertise and roles other medical professional groups have to play in drafting a suitable response to pandemic emergences of zoonotic origin.

Osterhaus et al² described the urgent need to dissolve the siloes long established between animal health and human health, as echoed by Hall.⁵ To promote interprofessional collaboration requires exposing medical and veterinary graduates to the principles of OH. The implementation of IPE, more specifically shared courses that familiarise MD and DVM students with the principles of One Health, is essential to prepare these groups to prevent and mitigate the effects of infectious diseases on the public health. The development of such structured IPE initiative between MD and DVM students, currently not a requirement by the accrediting agencies of either group, requires a comprehensive analysis of the need for curricula inclusion of OH and the factors required for informing its design. A Mixed Methods Research (MMR) approach was selected to achieve our research objective as it strengthens validity and reliability of research findings through the use of data triangulation. MMR approaches allow for the collection of both qualitative and quantitative data in a single study, enabling us to obtain a comprehensive perspectives on the need for curricula inclusion of OH within the MD and DVM curricula of one institution, drawing on insights both from students and faculty members.

The MMR approach thus coupled a quantitative evaluation of the students’ readiness for IPE and understanding about the importance of OH to practice, with the qualitative faculty perspectives on the need for IPE and OH portrayed using a joint display design. This approach allowed us to further close gaps in the existing literature as it pertains to the readiness of MD and DVM students for IPE, by simultaneously drawing on the faculty perspectives for informing the development of these initiatives. These gaps, found as the result of a rigorous literature review, are depicted in Table 1.^6,7

Table 1.

Originality of the research in closing existing gaps.

The aims of the study were as follows:

While quantitative methods enabled us to quantify student readiness for IPE, qualitative data provide us with in-depth insight on the rationale for student readiness for IPE and perceptions on the relevance of One Health. We share the opinion of Fetters⁸ who aptly describes a mixed methods approach as enabling different aspects of a phenomenon to be explored that allows an understanding of the ‘whole greater than the sum of the individual parts’ (p. 263). In this paper we show how combining data from both phases provided a nuanced understanding of the factors that influence the readiness scores of students across the programmes for IPE, and their perceptions about the relevance of One Health than could have been done by using one methodology alone. Importantly, Guetterman et al⁹ discussed the lack of innovative methods in the health sciences, specifically joint displays that enhance the value of data integration for analysis of the research findings. In this paper, we illustrate how the use of a joint display can be effectively used to portray the contributions of integrating data.

As Lavelle et al¹⁰ argued, conventional singular approaches to research teaching and learning issues in medical education have limited the ability to provide solutions or to extend the theoretical frameworks that guide teaching and learning. Lavelle et al¹⁰ stated that mixed methods designs allow a ‘layered’ (p. 273) approach to assessment of the different strata of factors (social, personal, delivery methods, institutional, autobiographical) that may impact student readiness for learning.

Theoretical Frameworks

We used 2 theories as frameworks to explain the findings of this study.¹¹ The structuralist lens of Role theory¹² was used to explain how the student’s perceptions of their future professional roles as physicians, veterinarians or public health practitioners, influenced by the culture of their discipline, may explain the differences in readiness for IPE and their perceived importance of the OH concept. The Theory Based Stakeholder Evaluation (TSE)¹³ model was used as an analytical framework for the focus group interviews with faculty. Gaps exist in the literature on the use of theoretical underpinnings to explain the stakeholder perspectives on the development of OH initiatives.

Intervention theories (programme theories) represent assumptions about how an intervention (programme) will alter (positively or negatively) the current institutional situation regarding the issue being addressed.¹³ The intervention theory used in the TSE,¹³ consists of 3 components: situation theory, causal theory and normative theory. Situation theory in this study describes the faculty and administrator participants’ assessment of the need for OH in the curriculum. Normative theory describes participants’ views of the opportunities presented with the development of OH. Finally, causal theory is used to describe the participants’ views of the challenges to developing the concept of OH in the curricula.

The purpose of this study was to provide insights, necessary for planning a successful introduction of OH into the MD and DVM curricula. Based on TSE, this then acted as a basis to generate information about (1) the institutional context and needs of the medical school pertaining to student readiness for IPE for familiarising them with the principles of OH (2) normative insights on the opportunities IPE and OH interventions could bring and (3) causes of problems of low readiness and how these can be eliminated through IPE interventions.

Methods

The research was conducted at a private University based offshore in the Caribbean that offers programmes such as the Doctor of Medicine (MD), Doctor of Veterinary Medicine (DVM), Master of Public Health (MPH) and an Arts and Sciences programme. The University caters mainly to North American students. The DVM programme is accredited by the American Veterinary Medical Association (AVMA) and the Royal College of Veterinary Surgeons (RCVS) and the MPH by the US Council on Education for Public Health (CEPH). The MD programme is accredited by many State level boards within the US and students must undertake the qualifying examination for medicine to obtain residencies at North American affiliate schools.

A sequential explanatory QUAN → qual Mixed Methods design was used which involved the collection and prioritisation of quantitative data followed by qualitative data. In the quantitative phase, a survey was conducted from October to November 2018, that included the Readiness for Interprofessional Learning Scale (RIPLS).¹⁴ The version of the RIPLS¹⁴ used for the purpose of this research consisted of 19 items that assess student readiness for IPE within 4 subscales: Teamwork, Negative Professional Identity, Positive Professional Identity and Roles and Responsibilities. Data were collected in Qualtrics over a 6 weeks’ period and analysed using SPSS version 24. The RIPLS was piloted with my EdD supervisor, a statistician, Chair of the Information Technology Department, an MD graduate, a DVM student, and a dual degree MD MPH and DVM MPH student.¹¹ No problems were reported as arising from this pilot as everyone interpreted the questions as relevant to their own programmes as health professionals. For example for item 17, ‘the function of nurses and therapists is mainly to provide support for doctors’, veterinary students assumed this was in reference to the working relationship between veterinarians and veterinary nurses. All piloted data were removed from the survey before conducting the final study. A detailed analysis of the survey results can be found in a previously published paper by Roopnarine and Boeren.¹⁵ The survey also included 2 open-ended questions to obtain students understanding about the OH concept and its relevance to clinical practice.¹⁶ Demographic information as well as prior public health experience was also collected from the participants.¹⁵

The qualitative phase of the study occurred in November 2018 and consisted of 2 focus group interviews with faculty across the MD, DVM and MPH programmes evaluating the student data to determine the institutional needs, opportunities and challenges for developing IPE that includes OH.¹⁷ Thematic analysis as described by Braun and Clarke¹⁸ was conducted to elicit the key themes emerging from the data. Details of the findings are described in the published article by Roopnarine and Regan.¹⁷

The implementation matrix¹⁹ details the data collection and analysis used in this study and is depicted in Table 2 below. Table 3 depicts the overall plan for the integration of the data.

Table 2.

Implementation matrix.

Table 3.

Plan for integration of the data.

A total of 864 students at the selected university who had completed courses in infectious diseases relevant to understanding the concept of OH were invited to participate. The latter consisted of: 598 MD, 99 DVM, 145 MD MPH and 22 DVM MPH students. The research participants representing those agreeing to participate consisted of 237 out of 598 (39.6%) MD students and 78 out of 99 (78.7%) DVM students. A total of 94 out of 145 (62.2%) dual degree MD MPH and 19 out of 22 (86.3%) DVM MPH students at the same university participated in the study, as they undertook a core course in OH and experience IPE throughout the MPH programme. All students who belonged to the research population defined by the researchers were invited for participation in a survey.

The primary inclusion criteria for the faculty focus group participants were involvement in teaching courses relevant to IPE and OH or being senior administrators of the School of Medicine (SOM) and School of Veterinary Medicine (SVM). Based on this, 13 faculty members were identified across all the programmes of which 2 opted out. The Institutional Research Board (IRB) for the participating institution was also concerned about how veterinary faculty would be selected without bias as many are colleagues in the department of the primary investigator conducting the focus groups interviews. To address the issue of selection bias, my Department Chair was required to select veterinary faculty for participation in this study. The Curriculum Chair of the MD programme identified appropriate faculty willing to participate in the study. Two focus groups consisting of eleven faculty in total, across the MD, DVM and MPH programmes participated in the study. Focus group 1 consisted of 6 participants, that included 2 DVM faculty members and 2 senior faculty in the Department of Public Health and Preventive Medicine (DPHPM) which offers the MPH programme. The fifth faculty member was stationed in the MD programme. The sixth and final participant is a key administrator. Many of these faculty members hold adjunct positions in the graduate school where they are involved in research as well as holding dual positions in one or other of the programmes discussed in this study. Focus group 2 consisted of 5 faculty. One participant is in the MD programme. Another participant is a graduate MD MPH and one of the faculty advisers for the American Medical Students Association (AMSA). Three other faculty members are in the DVM programme.

Charts that depicted the students’ agreement and disagreement to the survey responses¹⁵ and their definitions on OH¹⁶ were presented to the faculty focus groups. The primary researcher had prepared semi-structured focus group questions described in the earlier referenced manuscript¹⁷ that discusses the analysis and results of the faculty focus groups sessions. In order to address the clear biases that the faculty would have had regarding the need for OH education – as faculty recruited for the study were those involved in courses pertaining to IPE or OH – the primary investigator was aware that there would be potential biases in casting their perspectives on the institutional needs for OH. To address this, the primary researcher deliberately sought to create heterogeneous focus groups involving faculty across the MD, DVM and MPH programmes, to obtain the diverse perspectives of faculty across the disciplines in active discussion.²⁰

Onwuegbuzie and Johnson²¹ provided the framework for assuring the validity of the overall MMR design used in this study. The entire student population who met the inclusion criteria for the first phase of the study were invited to participate. Sample integration legitimation was addressed whereby a purposeful sample was used allowing the outcomes of the phase involving the student survey to be augmented through the insight of the faculty in the second phase. Peer review involved an assessment of my interpretation by the second author, my doctoral supervisor, to verify my interpretation of the faculty responses. This was done to balance my own views and that of my respondents. Conversion legitimation involved quantitization of data (counting themes; word count; prior public health responses made numeric) but with minimal transformation done because of risks associated with problems legitimising these conversions. Paradigmatic legitimation involved analysing each phase of the study and then both phases for integration and drawing of inferences.

Ethical Considerations

Approval for this research was given by the participating University’s Institutional Research Board (IRB). The Participant information and consent forms were emailed to both the students and the faculty invited to participate in the study, to familiarise them with the expectations of their participation in the study. The student consent form was embedded within the survey on the Qualtrics platform, which enabled the respondents to read the form and provide their informed consent indicating their agreement to participate in the survey by selecting yes or no. Written consent for the focus groups was obtained by the faculty that participated, prior to beginning the focus groups sessions, which were conducted in person.

Mixed Methods Integration and the Joint Display

Presentation of results in this study followed an integrative approach as described by Fetters and Molina-Azorin.²² Quantitative data provided insights into the differences in readiness for IPE between students in different programmes. The analysis of open-ended statements on the relevance of OH led to the themes that emerged across the MD, DVM and dual degree programmes.¹⁶ The qualitative focus group interviews allowed us to understand why these differences occurred as faculty explained that differences in accreditation mandates and curricula requirements influenced the differences across the programmes in IPE readiness as well as perceived relevance of OH to clinical practice.¹⁷

Results

Overall, 428 students responded to the survey question asking them to affirm or negate their familiarity with the term One Health. Of 428 students, 322 said they were familiar with the term and 106 said they were not. A total of 364 students across the MD, DVM and dual degree MPH programmes completed all of the RIPLS questions. Of these, 265 students completed the question requiring them to define the concept of OH, while 273 completed the question requiring them to define the relevance of the concept. The joint display depicted in Table 4 below shows how the results of the survey¹⁵ were integrated with those of the qualitative data.

Table 4.

Joint Display relating the findings of the RIPLS to the Focus groups data.

The results of the RIPLS scores demonstrated the greater readiness of the DVM MPH students to other groups for IPE which was consistent with their more comprehensive understanding of the concept of OH and its relevance.¹⁵ The DVM MPH students were able to appreciate the relevance of OH in policy development, zoonoses prevention and the role of environmental, specifically climatic factors on the public health and their role in mitigating these effects.¹⁶

Faculty analysis of the RIPLS scores and the focus group data supported these findings and provided an explanation as to why these differences occurred. The DVM programme promotes OH unlike the MD programme, and DVM students are aware of their role in protecting the public health from diseases of animal origin. Combining an MPH with the DVM provides the additional emphasis on OH and the role of the effect of environmental factors on public health. Faculty explained that MD students were the least ready for interprofessional learning as reflected by their lack of participation in the campus OH clinics and their negative attitude towards the one lecture given to them introducing them to the concept of OH. Faculty also explained the reasons for why MD students perceived OH was only about human health and were unaware of the roles of environmental and animal health to the concept. OH is not an accreditation requirement for the qualifying exams for the MD programme and thus students are not aware of the value of interprofessional collaboration with health professionals outside of the medical and allied health groups.

The dual degree students again had the highest scores for the RIPLS subscales ‘Positive Professional Identity’ and ‘Teamwork’ and perceived the importance of collaboration with other health professional groups as representing the embodiment and relevance of the OH concept.¹⁴ The greater emphasis placed on the importance of these subscales by the dual degree students, are explained through the qualitative data as being due to a lack of an accreditation mandate for IPE and OH in the singular MD and DVM curricula. The RIPLS items associated with Roles and Responsibilities revealed that MD students agreed with the statement that ‘the function of nurses and therapists is mainly to provide support for doctors’. Their support for this statement is consistent with their perception of OH as centred on human healthcare without any consideration of the need for interprofessional collaboration. The MD students also yielded the lowest score for Negative Professional Identity as is consistent with the group being the least ready to engage in IPE.

Discussion

In this study, the MMR approach provided a comprehensive assessment of the readiness for IPE by students. Insights from the student survey responses as well as their own expertise enabled faculty to provide in-depth insight into the rationale for the differences in student readiness for IPE across the programmes.

Theoretical Explanation for Integration

Through the process of integration, role theory was linked to the TSE. Faculty drew on the gaps in the student’s knowledge about OH and differences depicted by their RIPLS scores. The greater readiness of the dual degree students for IPE and OH was linked to role theory which suggests that the MPH programme exposes students to shared learning and OH in a way that promotes the benefits of interprofessional collaboration for public health practice. In contrast, the culture of medicine and the qualifying examinations for the discipline, are believed to contribute to MD students yielding the lowest readiness scores as students are not expected and required to engage in shared learning with veterinarians in their future professional roles. The MD students also reported the least accurate definitions in describing the concept and relevance of OH.

Using the TSE model, it was possible to identify the needs of the specific institution based on gaps in the student’s knowledge about OH, opportunities for developing IPE and OH based on its perceived value and importance for future practice. Also discussed were the challenges to developing the intervention that logically flows from the results of this study, in order to eliminate problems relating to low readiness for IPE.

The results of this study indicated that core OH competencies should ideally be incorporated within the MD curricula.¹⁶ Roopnarine et al¹⁶ compare and discuss the distribution of OH content across the curricula of each programme and suggest content that should be brought to the table of the MD and DVM programmes. The curriculum of both the MD and DVM programmes should include core of socio-cultural and environmental factors on the occurrence of zoonoses; the dangers of antimicrobial resistance for both animal and human health; the impacts of global warming including emergence of vector borne diseases, natural disasters, heatstroke and respiratory diseases on their patients. IPE and OH Faculty across the disciplines that already teach courses relevant to OH champions, can be involved in developing Communities of Practice (CoPs)²³ that involve students in IPE and OH activities that can assist the maturation of the student’s interprofessional identity, appreciation of the benefits of shared learning and the relevance of executing the principles of OH for practice.

Recommendations for Future Studies

This was the first known research study that used a MMR approach that allowed an integration of quantitative data on student readiness and a faculty evaluation of these data to inform the development of IPE that includes OH. This research approach could be further extended into practice where researchers could couple the data obtained from pandemics on death and case occurrence obtained through epidemic curves, with qualitative data obtained by researching the possible social, economic and behavioural reasons that impact the occurrence of diseases like SARS CoV-2. The latter is critical for influencing and driving policy development in favour of OH.

We would recommend that other medical and veterinary educators embark upon the use of MMR studies that would enable a comparison to be made to our own findings and whether these findings are similar to those at other contexts. Specifically, educators could obtain survey data before and after applying an IPE/OH intervention and obtain qualitative interviews data from students describing any changes in their readiness for IPE and perceived relevance of OH. These studies could be expanded to include students in their clinical years and earlier stages of the programme, to observe differences in readiness scores at different stages of their programme using the RIPLS and obtaining student focus group data across the programme to provide an explanation for their scores and responses about OH and its relevance. The use of faculty evaluators to assess these responses could contribute information about what factors promote interest in IPE /OH and its perceived benefits, as well as providing information on the best place to implement the intervention in the curricula.

Limitations

This study was only conducted at a single institution. This deters a generalisation of these findings to other institutions elsewhere. Also, in surveying the students using Qualtrics, the study may have been limited in its quantitative approach, as it did not allow for students to provide their own rationale for their responses about OH or feelings about interprofessional learning in a follow-up interview.

Conclusion

This study enabled us to compile an assessment of the needs, opportunities and challenges for informing the development of an IPE/OH intervention in an offshore medical school. Integration of the student data with the faculty assessment of the institutional needs through the use of an MMR approach, provided a nuanced perspective that enabled us to provide recommendations for enhancing the curricula of the MD and DVM programmes. Specifically, accreditation mandates for MD and DVM programmes should incorporate OH so students perceive the concept as relevant to their roles as future practitioners.

Importantly, these findings have implications for tailoring such interventions to prepare graduates to understand their roles and those of other health professionals in eliminating, preventing and controlling the occurrence of emerging diseases such as COVID-19.