Health Care Voluntourism: Addressing Ethical Concerns of Undergraduate Student Participation in Global Health Volunteer Work

Integrating multi-national teams: over a decade of lessons learned in Chiapas with Partners in Health-Mexico

In a globalized world where pathology and risk can flow freely across borders, the discipline of global health equity has proposed to meet this challenge with an equal exchange of solutions, and people working toward those solutions. Considering the history of colonialism, ongoing economic exploitation, and gaping inequities across and within countries, these efforts must be taken with care. The Partners In Health program in Chiapas, Mexico was founded in 2011 by a team of leaders from both the United States and Mexico to strengthen the public health and care delivery systems serving impoverished rural populations. Key to the strategy has been to marshal funding, knowledge, and expertise from elite institutions in both the United States and Mexico for the benefit of an area that previously had rarely seen such inputs, but always in close partnership with local leaders and community processes. With now over a decade of experience, several key lessons have emerged in both what was done well and what continues to present ongoing challenges. Top successes include: effective recruitment and retention strategies for attracting talented Mexican clinicians to perform their social service year in previously unappealing rural placements; using effective fund-raising strategies from multinational sources to ensure the health care delivered can be exemplary; and effectively integrating volunteer clinicians from high-income contexts in a way that benefits the local staff, the foreign visitors, and their home institutions. A few chief ongoing challenges remain: how to work with local communities to receive foreign visitors; how to hire, develop, and appropriately pay a diverse workforce that comes with differing expectations for their professional development; and how to embed research in non-extractive ways. Our community case study suggests that multinational global health teams can be successful if they share the goal of achieving mutual benefit through an equity lens, and are able to apply creativity and humility to form deep partnerships.

Reexamining dental outreach programs: A model for local empowerment and sustainable development

BACKGROUND

To address the inadequacy of oral health care in developing nations, outreach programs have facilitated the provision of dental services by foreign volunteers to areas of need. However, the effectiveness of the current aid model on the long-term well-being of the recipient population and sustainability of efforts remains uncertain. The authors examine the strengths and areas of improvement of outreach initiatives to inform a reorientation of the aid model.

METHODS

The authors conducted a PubMed search and reviewed included articles to assess the current limitations and recommended strategies for outreach programs. The identified limitations and strategies were sorted into 4 key areas of change and organized using the Theory of Change framework to inform an improved aid model.

RESULTS

The current aid models were found to have limitations in scope and coverage, interventions that were not applicable or integrated into local systems, and an inadequate evidence base. To address these limitations, efforts should be directed at the capacity building of local workers through individual training and evidence-based interventions, improved understanding of local contexts, and integration and alignment with local systems.

CONCLUSIONS

The empowerment of local communities is critical in ensuring an effective and sustainable aid model in developing nations.

PRACTICAL IMPLICATIONS

By adopting an improved aid model, outreach programs can enhance the long-term access and availability of quality oral health care that is delivered by local providers and communities.

Are you ready? A systematic review of pre-departure resources for global health electives

BACKGROUND

There has been an exponential increase in the offering of short-term international field experiences in recent years in response to student demands for global health opportunities. Pre-departure preparation is an essential component to equip trainees with the adequate safety, wellness, and cultural competence needed to engage in a meaningful and mutually beneficial elective. This review seeks to quantify the plethora of pre-departure preparation training available to public health, clinical, and undergraduate trainees across the continuum of education for short-term experiences in low-and middle-income countries (LMICs).

METHODS

We performed a systematic review of Pubmed, Embase, Web of Science, Scopus, and Ovid Global Health in February, 2018. A three-concept search was employed and included "global or international health"; "education or preparation of personnel/students"; and "field programs or travel." The study teamed used PRISMA reporting guidelines to conduct title and full-text reviews and conduct data extraction and analysis.

RESULTS

The search returned 2506 unique articles. Of these, 55 met inclusion criteria and were included in the final review. Ninety one percent (91%) of articles focused on pre-departure trainings for medical students and residents. Nine thematic domains for short-term international field experiences emerged; culture, safety, and project-specific knowledge were the most frequently covered domains while mentorship, professionalism, and emotional wellness and culture shock were least common. Approximately half (53.3%) of studies specifically evaluated the pre-departure component of the international experience using a survey or evaluation form. Recommendations emerged from these evaluations including early engagement with international partners, inclusion of self-reflection exercises and site-specific content, and utilization of interactive approaches in learning. Some institutions face barriers to conducting pre-departure preparation such as lack of dedicated faculty, finances, and institutional support.

CONCLUSIONS

Interest in pre-departure training for international experiences is growing but few programs conduct and publish evaluations of these trainings. Pre-departure trainings should be developed in partnership with receiving institutions and faculty and incorporate critical self- reflection throughout the experience. In addition to the experience itself, institutions need to evaluate these curricula to better understand how they influence trainees' capacity to effectively engage in LMIC settings.

A mixed-method study of chiropractic student clinical immersion placements in nonmetropolitan Western Australia: Influence on student experience, professional attributes, and practice destination

OBJECTIVE:

To explore the influence of nonmetropolitan clinical immersion placements (CIPs) on undergraduate chiropractic student experience, professional attributes, and practice destination.

METHODS:

Students enrolled in an Australian undergraduate chiropractic program were invited to complete a service experience questionnaire and an open-ended reflective feedback form following a nonmetropolitan CIP (Part A). Online searches were performed to gather data on graduate practice location (Part B).

RESULTS:

Sixty-four students participated in Part A. All agreed that the placement was educational and should be retained in the program. Students agreed that the placement enhanced respect for individuals and awareness of others in need, highlighted the importance of respect for all people, improved empathy for the disadvantaged, and provided an opportunity to improve communication skills. Most indicated that they were more likely to practice in a country setting as a result of their placement, with those participating in a country placement more likely to practice in nonmetropolitan regions after graduation.

CONCLUSION:

Many chiropractic programs around the world are adopting CIPs. This study is the 1st to investigate the possible influence of nonmetropolitan CIPs on the development of desirable attributes in Australian chiropractic students. It also discusses the potential influence of nonmetropolitan CIPs on future practice location decisions. These results support the utility of CIPs to help meet the educational objectives of chiropractic programs and possibly address the maldistribution of the chiropractic workforce in Australia.

Working in global health: A planning and implementation framework for international electives

Purpose: Propose a framework for planning and undertaking an international elective. Methods: On returning from conducting maternal health and well-being research in several remote communities in India, two undergraduate medical students have reflected on and documented their experiences with the view to assisting other students (and their supervisors) considering undertaking an international elective. Results: A framework for undertaking clinical or research electives in remote or rural communities is presented. The framework comprises three distinct phases: Pre-departure planning and briefing, in-country experiences and returning from the elective and considers a range of factors to ensure that, as a minimum, visiting students "do no harm" and are themselves not harmed. Conclusions: Students' home institutions have a duty of care for preparing them for their international electives by providing pre-departure training, support during the elective and comprehensive de-briefing on their return. These electives should be evaluated (including by host communities) to ensure that exchanges are socially accountable, with no harm to the often-vulnerable communities in which students gain considerable experience. Also important is that future students build on the positive experiences of their predecessors to ensure sustainability of any interventions in host communities.

Global service learning and health systems strengthening: An integrative literature review

Introduction

The sustainability of many global interventions, in the absence of adequate local financial and human resources to sustain them in the long term, is questioned. In response, there has been a shift in focus among global health actors towards the strengthening of local health systems via global service learning to effectively, efficiently and sustainably deliver healthcare and build capacity. There has been considerable research examining the benefits of global service learning experiences for students, but limited research has been conducted to determine the impact that health sciences global service learning experiences are having on the host country health systems.

Main text

An integrative review of the literature was conducted to examine the linkages between global service-learning and health systems strengthening. A comprehensive search of international literature from 2005 to 2017 in PubMed, CINAHL, Embase, ERIC, Scopus and Web of Science databases was conducted. The search was limited to peer-reviewed articles published in English language. Thematic analysis revealed three key themes: a dominant service-LEARNING typology, a unidirectional pattern from high-income to low and middle-income countries, and the preeminence of the nursing discipline in global service learning. There was limited evidence on sustainability and health systems strengthening.

Conclusions

The healthcare workforce of the future is willing to meet the challenges facing health systems across the globe. Global service-learning has yet to be examined in the context of health systems strengthening and particularly within a context of reciprocity. The onus is on higher education institutions in high-income countries to develop and deliver evidence-based global service-learning that is beneficial and engaging for students while most effectively meeting the need of the global community.

More harm than good? The questionable ethics of medical volunteering and international student placements

It has been argued that much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteers’ grasp of the damage caused. The literature on ethical concerns in medical volunteering has grown tremendously over the last years highlighting the need for appropriate guidelines. These same concerns, however, and an appreciation of the reasons why current aid paradigms are flawed, can serve as indicators on how to change existing practices to ensure a better outcome for those who are in need of help. Such paradigm change envisages medical assistance in the spirit of solidarity, social justice, equality, and collegial collaboration.

Short-term volunteer health trips: aligning host community preferences and organizer practices

BACKGROUND

Short-term medical missions (STMMs) are quite common and largely understood to be a response to health needs in low-income countries. Yet most information about STMM practices is anecdotal. Even less is known about the preferences of in-country host communities regarding STMMs.

OBJECTIVE

We aimed to gather enough quantitative and qualitative information from both STMM organizers and host community staff to compare dominant practices of organizers as well as preferences of host community staff. We use these data to discover differences between practices and preferences and suggest ways in which STMMs can be more responsive to the communities they serve.

METHODS

Researchers gathered online survey responses from 334 STMM organizers and conducted interviews to determine existing practices. Similar methods were used to collect 49 online survey responses from, and conduct 75 interviews with, host community staff.

RESULTS

Organizer practices and host community staff preferences are different in several areas. Organizers admit to minimal screening and preparation of volunteers whereas host staff have clear ideas of topics that should be covered in preparation, including culture and basic language skills. Organizers prioritize provision of clinical care during trips whereas host staff prioritize capacity building. Practices and preferences also differ in relation to the length of STMMs, the nature of the partnership itself, and the type of assessment and evaluation that is needed.

CONCLUSIONS

The large amount of data gathered for this study allows us to confidently say that organizer practices are often not aligned with host community staff preferences. Several concrete changes can be made to STMMs to bring practices more in line with the desires of the communities they serve.

The Voluntariat: A Frieirean framework to understand the nature of undergraduate international (medical) experiences

Despite literature documenting limited and asymmetrical benefits along with ethical issues, short-term international volunteering is increasingly popular among North American university students as a perceived advantage when applying to professional healthcare schools or the job market. Academic institutions are also encouraging students to pursue international experiences in order to cultivate values as global citizens. These experiences are most typically limited to economically privileged students. Furthermore, international activities in developing countries often lack a pedagogy of social justice and may confirm a simplistic understanding of development. Brazilian educator Paulo Freire's "liberation pedagogy" provides a framework for understanding the limitations of international volunteering, whereby the presence of privileged volunteers implementing Western models of development may hinder aspects of local movements. Regardless, university students face intense competition in accessing opportunities, such as medical school, and pay large sums to participate in volunteering to strengthen their academic credentials. We propose that these students form "the voluntariat." They simultaneously play two roles by, first, contributing to the conditions that oppress the very communities in which they volunteer and, second, by playing a role as objects of oppression by the liberal institutions of learning and employment to which they are attempting to gain access.

The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions

Global health education has been expanding rapidly and several universities have created an undergraduate major degree (bachelor's degree) in global heath or global health studies. Because there are currently no national guidelines for undergraduate degrees in global health, each of these programs was developed along individual lines. To guide the development of future global health majors, we conducted a systematic review of undergraduate majors in global health. We identified eight programs and invited program directors or representatives to a symposium at the Consortium of Universities for Global Health 2016 conference to review their existing undergraduate major in global health and to discuss lessons learned and recommendations for other colleges and universities seeking to develop undergraduate degrees in global health. We noted significant diversity among the existing programs in terms of required courses, international field experiences, and thesis research projects. In this review, we describe these global health programs, their student characteristics, as well as the key educational competencies, program requirements, and core global health courses. Based on program reviews and discussions, we identify seven recommendations for the development and expansion of an undergraduate major in global health and discuss issues that have arisen in the curricular development of these programs that warrant further exploration. As the field of global health education continues to expand, following these students after graduation will be essential to ensure that the degree programs in global health both meet student needs and launch students on viable career pathways.

Community-Informed Health Promotion to Improve Health Behaviors in Honduras

BACKGROUND

Honduras is the second poorest country in Central America. The already high burden of disease is disproportionately worse among individuals with less education and limited access to health care. Community engagement is needed to bridge the gap in health care resources with the need for health promotion and education. Culturally relevant health promotion activities can foster transcultural partnerships.

PURPOSE

The purpose of this study was to partner nursing students with village leaders to assess a community's health needs and implement health promotion activities in Honduras.

DESIGN

Participatory action research was used in the study.

METHOD

U.S. nursing students ( n = 4) partnered with a nonprofit organization and community partners in Villa Soleada to interview mothers in Villa Soleada, a Honduran village of 44 families, and implement health promotion activities targeted to the health priorities of their families.

RESULTS

Structured interviews with 24 mothers identified gastrointestinal issues, health care access and quality, and malaria as the top three priorities. Ninety-two percent of respondents were interested in nurse-led health promotion. Activities engaged new community partners.

DISCUSSION

This partnership and learning model was well received and sustainable. The U.S. nurses involved in the partnership gained exposure to Honduran health issues and led locally tailored health promotions in Villa Soleada. The community's response to health promotion were positive and future activities were planned.

IMPLICATIONS

Nursing student's immersion experiences to support population-based health activities in low-resource settings are a replicable model that can help build healthier communities with a sustainable local infrastructure. Transcultural nursing experiences enhance students' perspectives, increase personal and professional development, strengthen nursing students' critical thinking skills, and for some students, confirm their desire to practice in an international arena.

Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions

International health electives pose specific ethical challenges for students travelling from to low and middle income countries. We undertook a systematic review of the literature on interventions to prepare students to identify ethical issues addressed, educational approaches and to collate evidence on the effectiveness of different strategies. We searched nine electronic databases of peer-reviewed literature and identified grey literature through key word searches; supplemented through citation mapping and expert consultation. Articles that described ethical training conducted by universities or professional bodies were included for review. We reviewed forty-four full text articles. Ten sources of published literature and seven sources of grey literature met our inclusion criteria. We identified thirteen ethical situations that students should be prepared to manage and eight generic skills to support this process. Most interventions were delivered before the elective, used case studies or guidelines. Some suggested ethical principles or a framework for analysis of ethical issues. Only two papers evaluated the intervention described. Our paper collates a small but growing body of work on education to prepare students to manage ethical issues. Ethical training should have elements that are delivered before, during and after the elective. Interventions should include case studies covering thirteen ethical issues identified here, linked to ethical principles and a process for responding to ethical issues. We suggest that evaluations of interventions are an important area for future research.

Perceptions of the Role of Short-Term Volunteerism in International Development: Views from Volunteers, Local Hosts, and Community Members

Background. Short-term international volunteer trips traditionally involve volunteers from high-income countries travelling to low- and middle-income countries to assist in service-related development activities. Their duration typically ranges from 7 to 90 days. The city of La Romana, Dominican Republic, receives hundreds of short-term international volunteers annually. They participate in activities aimed at improving conditions faced by a marginalized ethnic-Haitian community living in bateyes. Methods. This qualitative analysis examined perceptions of short-term international volunteerism, held by three key stakeholder groups in La Romana: local hosts, international volunteers, and community members. Responses from semistructured interviews were recorded and analysed by thematic analysis. Results. Themes from the 3 groups were broadly categorized into general perceptions of short-term volunteerism and proposed best practices. These were further subdivided into perceptions of value, harms, and motivations associated with volunteer teams for the former and best practices around volunteer composition and selection, partnership, and skill sets and predeparture training for the latter. Conclusion. Notable challenges were associated with short-term volunteering, including an overemphasis on the material benefits from volunteer groups expressed by community member respondents; misalignment of the desired and actual skill sets of volunteers; duplicate and uncoordinated volunteer efforts; and the perpetuation of stereotypes suggesting that international volunteers possess superior knowledge or skills. Addressing these challenges is critical to optimizing the conduct of short-term volunteerism.