International clinical volunteering in Tanzania: A postcolonial analysis of a Global Health business

Decolonizing study-abroad programs in nursing in low- and middle-income countries

Study abroad programs expose scholars, including nursing faculty and students, to different settings and cultures. However, the world of global health is rooted in colonial practices that have the potential to cause harm to communities. In this reflection, we provide lessons we have learned through study abroad that guide strategies for decolonizing our practice while working toward cultural safety and humility. We utilized a qualitative case study method. Authors discussed and reviewed study abroad programs through a series of virtual discussions. Discussions showed that study abroad programs present opportunities for students and faculty to grow and learn. However, unacknowledged privileges among visiting students and faculty, and lack of understanding of the impacts of colonialism, may lead to harm in communities and inequitable relationships with local providers. Understanding the privileges that we hold is important in advancing positive and equitable experiences in study abroad programs.

Examining Opportunities Offered Outside of Home Country in Physical Therapy Education: Considering the Colonial History of Global Health

BACKGROUND AND PURPOSE

Increasingly, PT programs in the United States are providing educational experiences outside of the home country (OHC) where faculty and students engage in global health initiatives. It is important to consider that the field of global health has its historical roots in colonialism, which has led to inequities and injustice. Those who are engaged in this work must assist in reversing this colonial legacy. The purpose of this position paper is to present the colonial history of global health, to provide context, and to spark critical reflection among PT educators about how OHC experiences are developed and configured.

POSITION AND RATIONALE

As a profession, we must educate ourselves about the history of global health and critically reflect on OHC engagements to ensure that we support equity and justice.

DISCUSSION AND CONCLUSION

We must start by grounding our OHC experiences in health equity and justice. This should be done by considering the colonial history of global health and the privileges we hold as members of academic institutions in the United States. Why we offer OHC experiences in PT education should be investigated and clear to both faculty and students. Excluding this colonial history and its impacts risks perpetuating the historical harms to the health and well-being of the populations we claim to be serving.

Health professionals' involvement in volunteering their professional skills: a scoping review

Background

Volunteering positively affects overall health of both volunteers and recipients through social interaction, support and physical activity. Health professionals' volunteering has considerable potential to improve health outcomes in communities.

Objectives

This study aimed to summarize published scientific literature regarding volunteering by health professionals.

Method

Medine, Embase, Scopus, PsycINFO and CINAHLdatabases were searched to identify eligible studies published between 2010 and 2023. Data on study methods and findings were extracted and synthesized.

Results

Of the 144 eligible studies, 80 (56%) used quantitative methods, 46 (32%) used qualitative, 18 (12%) used mixed methods and 8 (6%) were interventional. Doctors (74 studies, 51%) and nurses (n = 40, 28%) were the professions with most reports of volunteering. Half the studies were from USA (n = 77, 53%), followed by UK (n = 19, 13%), Canada (n = 12, 8%), and Australia/New Zealand (n = 11, 8%). International volunteering in low-to-middle-income countries was reported in 64 studies (44%). Providing service and training were the dominant types of activities (n = 90, 62.5%), with health promotion reported in only 4 studies (3%). Studies reported positive impact from volunteering, both professionally and personally. Time and family commitments were the main barriers. Enablers, barriers and impact were summarized in a socio-ecological map.

Conclusion

Health professionals volunteer in diverse activities and report multifaceted benefits. Studies of volunteering interventions could enable new, sustainable approaches to health promotion.

Relational Harm: On the Divisive Effects of Global Health Volunteering at a Hospital in Rural Zambia

Drawing on ethnographic research at a hospital in rural Zambia, I show how the presence of white Christian medical volunteers from the United States damaged relations between local health workers and patients. Working from a position of economic and racial privilege, medical volunteers received praise from many patients and residents. However, these positive attitudes incited resentment among many Zambian health workers who felt that their own efforts and expertise were being undervalued or ignored. Focusing on these disrupted relationships, I argue that it is crucial to understand how global health volunteering can produce enduring forms of "relational harm".

Admitting privileges: A construction ecology perspective on the unintended consequences of medical school admissions

Medical-school applicants learn from many sources that they must stand out to fit in. Many construct self-presentations intended to appeal to medical-school admissions committees from the raw materials of work and volunteer experiences, in order to demonstrate that they will succeed in a demanding profession to which access is tightly controlled. Borrowing from the field of architecture the lens of construction ecology, which considers buildings in relation to the global effects of the resources required for their construction, we reframe medical-school admissions as a social phenomenon that has far-reaching harmful unintended consequences, not just for medicine but for the broader world. Illustrating with discussion of three common pathways to experiences that applicants widely believe will help them gain admission, we describe how the construction ecology of medical school admissions can recast privilege as merit, reinforce colonizing narratives, and lead to exploitation of people who are already disadvantaged.

An Exploratory Study of Physical Therapists From High-Income Countries Practising Outside of Their Scope in Low and Middle-Income Countries

PURPOSE

To quantify how often physical therapists from high-income countries (HIC) travelling to low- and middle-income countries (LMIC) practise outside their scope of practice, in what circumstances, and their likelihood of doing the same in the future.

METHODS

An exploratory descriptive study using a survey.

RESULTS

One hundred and twenty-six licensed physical therapists from around the world participated. Physical therapists typically spent less than a month (73.8 per cent) in LMIC; 67.5 per cent believed that physical therapists practise outside of their scope, and 31.7 per cent reported doing so. Reasons were believing that something is better than nothing (47.5 per cent ), a mismatch between the physical therapist's and host's expectations (40.0 per cent ), and preserving their relationship with the host (25.0 per cent ). It was deemed appropriate by 64.5 per cent to practise outside of their scope in some situations and 53.8% considered repeating the activity in the future. Half of the respondent's first experience in LMIC occurred as a student or in their first decade of practice.

CONCLUSIONS

Working in LMIC requires a keen understanding of the risks and challenges associated with such experiences. To ensure best practice, a skill set that consists of critical self-reflection, systems thinking, and structural competency combined with clinical competency and accountability is imperative.

International medical electives in Sub-Saharan Africa: experiences from a 19-year NGO-driven initiative

BACKGROUND

Mainstream medical education remains largely focused on national health issues. Therefore, in order to expose medical students to international health issues, it is beneficial to facilitate international medical electives.

METHODS

This article describes the Junior Project Officer (JPO) program, a medical experience based on clinical electives in Sub-Saharan Africa, supported by a Non-Governmental Organisation (NGO). Residents spend 6 months as part of a multidisciplinary medical team in Africa. A post-elective online survey was administered to all who participated in the program in the period 2002-2020. The questionnaire comprised three domains: (i) general and pre-departure information; (ii) the experience; (iii) the post-experience.

RESULTS

Questionnaires were received from 157/241 subjects, a response rate of 65%. The most common specialties were pediatrics, public health, and internal medicine. Of all, 87% carried out clinical activities; 45% also worked in the management of health services, and 60% carried out research activities. About 64% reported difficulties linked to a lack of equipment, different ways of working (57%), and exposure to situations for which they did not feel technically prepared (56%). In 25% of cases, residents reported that their school's attitude to their doing the elective was not positive: upon their return, over 50% felt that their experience was not sufficiently valued by their institution. Respondents considered the experience important for professional and personal growth (93% and 80% respectively ). Forty-two participants (27%) reported that the experience had a significant impact on their future career choices.

CONCLUSION

Despite the difficulties encountered, a well-structured experience in international health can have a positive impact on residents, professionally and personally. Key factors behind the positive outcomes are the substantial length (6 months) of the experience, and the long term working relationships between the sending and receiving institutions. The schools in Italy that provide the students for the electives need to see more evidence that international electives are worth the investment.

Learning from women who trade sex in Kenya about the antiblackness of Global Health

Sex work and violence have become co-constituted, routinized, and even sanitized in Global Health journals dispassionately advocating for intervention. This paper situates ethnographically shared experiences of Kenyan sex working women within the global condition of antiblackness. By grounding our conceptual analytic in Black Feminist scholarship, we illustrate how antiblackness subtends the conditions of possibility for women's entry into sex work, their subsequent experiences with interpersonal and institutional forms of predatory violence, and lack of recourse for their material needs and suffering. This analysis requires a meditation on the relationships between the types of violence conditioning Kenyan women's lives and the limitations of Global Health's conceptual logics and disciplinary practice. Our discussion reflects on the ways Global Health practice can neglect conceptual foundations in antiblackness, thus complicit in upholding violence against the very groups it purports to assist. In charging Global Health "as usual" as methodologically violent and sustaining global antiblackness, we call for disciplinary transformations beginning from a shared consciousness regarding the ways global antiblackness structures health inequities. Beyond critique, our meditation is an invitation for all committed to dignified Global Health to contribute creative, non-hierarchically collaborative work engaged with those in material, structural, and immaterial need.

Global health wars: a rhetorical review of global health critique

The critique of global health is a longstanding tradition in the global health humanities (GHH). Typically, this critique takes an expected tack: critics take a slice of global health, identify its rhetoric, expose its power, and elucidate its unanticipated consequences. Here, I subject global health critique to its own approach-conducting a 'rhetorical review' of global health critique in order to ascertain whether it has rhetoric, power and unanticipated consequences of its own. Following this review, I find that global health critique has a rhetoric, and that this rhetoric can be organised into three types: (1) 'global health as mere rhetoric', (2) 'splitting global health', and (3) 'figuring global health war.' Ultimately, I argue that the rhetoric of GHH critique, like the rhetoric of global health, is a rhetoric of consequence-and a rhetoric worth revisiting.

Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health

Short- term experiences in global health (STEGH), also known as short-term medical missions continue to be a popular mode of engagement in global health activities for students, healthcare providers, and religious groups, driven primarily by organizations from high-income countries. While STEGH have the potential to be beneficial, a large proportion of these do not sustainably benefit the communities they intend to serve, may undermine local health systems, operate without appropriate licenses, go beyond their intended purposes, and may cause harm to patients. With heightened calls to “decolonize” global health, and to achieve ethical, sustainable, and practical engagements, there is a need to establish strong guiding principles for global health engagements. The Advocacy for Global Health Partnerships (AGHP), a multi-sectoral coalition, was established to reflect on and address the concerns relating to STEGH. Towards this end, AGHP created the Brocher Declaration to lay out six main principles that should guide ethical and appropriate STEGH practices. A variety of organizations have accepted the Declaration and are using it to provide guidance for effective implementation of appropriate global health efforts. The Declaration joins broader efforts to promote equity in global health and a critical reevaluation of volunteer-centric, charity-based missions. The current state of the world’s health demands a new model of collaboration – one that sparks deep discussions of shared innovation and builds ethical partnerships to address pressing issues in global health.

Ethical Considerations for Short-Term Global Health Projects

Various types of health professional volunteers from high-income nations are increasingly engaged in short-term global health projects in low- and middle-income countries. The goal of global health projects is to improve health for all people and address health inequities. Short-term projects lasting days to months can create challenges for volunteers and hosts. Despite attempting to do good, volunteer efforts may unwittingly cause harm to host organizations by planning projects without consideration for the local infrastructure, the community, and the health care staff. Although well-intentioned and often beneficial, volunteer efforts can fail to provide adequate follow-up or may disrupt or override local health efforts. In some low-resource settings, dire health needs and lack of supervision may result in volunteers practicing beyond their professional scope. Recently published guidelines, competencies, and position statements have addressed ethical behaviors for short-term global health experiences. Partnerships that are founded on principles of justice and autonomy provide an avenue for mutual collaboration. Short-term global health projects that focus on host needs are likely to strengthen local capacity to improve health outcomes. This article reviews guidelines for short-term global health experiences and addresses the ethical principles for planning effective projects.

Using a Health Equity Lens to Evaluate Short-Term Experiences in Global Health (STEGH)

Background:

The growing popularity of short-term experiences in global health (STEGH) has given rise to increasing criticism around their purported benefits and outcomes. With the global health and development community’s growing focus on improving population health and equity worldwide as outlined in the United Nation’s Sustainable Development Goals, there is a growing opportunity to examine and optimize the conduct of STEGH using an outcomes and equity focused lens.

Objectives:

This viewpoint aims to develop a framework that can be used to plan and evaluate STEGH on outcomes underpinned by a health equity focus.

Methods:

Drawing on logic model theory, the analysis first identifies extant issues and their drivers around the planning, implementation, and evaluation of tradition STEGH (focused on clinical service provision.) The analysis then explores various definitions of health equity, settling on a broad definition around context that promotes health for all as opposed to equity of access to healthcare services. With that definition as the ultimate benchmark of success, the analysis then proposes questions that can be used to determine how and when a STEGH might best be deployed to meet that goal.

Findings:

Traditional reliance on process outputs from service-based approaches have historically limited an understanding of if and how STEGH might advance health equity. Using an outcomes-focused approach identifies critical questions around the value of such experiences, when weighed against a broad definition of equity and other key global health themes such as sustainability, cultural humility, and impact. Measuring STEGH against the goal of improving population health status and equity worldwide allows careful consideration of the appropriateness and effectiveness of such efforts on their own and in concert with other interventions.

Conclusions:

The extent to which health equity is advanced should be the ultimate metric used to evaluate not only STEGH, but any global health endeavours.

Die Erfahrungen von Physiotherapeuten in der internationalen Freiwilligenarbeit im Ausland – Eine Analyse aus postkolonialer Perspektive

Hintergrund Physiotherapeutische Projekte in der internationalen Freiwilligenarbeit erfreuen sich in Deutschland immer größerer Beliebtheit. Es existiert jedoch kaum Wissen über die Erfahrungen von Physiotherapeuten in solchen Freiwilligenprojekten.

Ziel Unter Berücksichtigung der postkolonialen Theorien wurde ermittelt, wie deutsche Physiotherapeuten retrospektiv über ihr Erleben der Projektarbeit und deren Nachwirkungen auf ihr (Berufs-)Leben berichten und inwieweit die (Re-)Produktion kolonialer Machtstrukturen darin deutlich wird.

Methode Drei Physiotherapeutinnen – ehemalige Freiwillige (Ghana, Nepal, Vietnam, Ruanda) – wurden mittels episodischer Interviews befragt. Der Feldzugang erfolgte über Freiwilligenorganisationen, Hochschulen und soziale Medien. Die Datenauswertung erfolgte mittels Situationsanalyse nach Clarke und der Grounded Theory.

Ergebnisse Die Freiwilligen erlebten sich in einem Spannungsfeld zwischen der Selbsteinschätzung ihrer fachlichen Kompetenzen, den Erwartungshaltungen von Projektmitarbeitern und Patienten sowie der erfahrenen Projektrealität. Dieses Spannungsfeld ist u. a. auf das Vorhandensein sowie die (Re-)Produktion kolonialer Machtstrukturen zurückzuführen, die in unterschiedlichem Maße von den Freiwilligen wahrgenommen und reflektiert wurden. Die Einsätze wurden dennoch als bedeutsam für die persönliche und berufliche Weiterentwicklung von den Freiwilligen wahrgenommen.

Schlussfolgerung Es zeigt sich, dass koloniale Machtstrukturen zu widersprüchlichen Erwartungen sowohl bei den befragten Physiotherapeuten als auch bei den lokalen Partnern führen. Künftig wäre es sinnvoll, ein Bewusstsein für koloniale Machtstrukturen zu schaffen, eine bessere fachliche Vorbereitung der Freiwilligen zu gewährleisten und Austauschmodelle generell zu überarbeiten.

Global health electives: Ethical engagement in building global health capacity

Purpose: Little is known about the impact medical trainees undertaking global health electives (GHEs) have on host institutions and their communities in low-and middle-income countries. The goal of this study was to explore the relationship dynamics associated with GHEs as perceived by host stakeholders at three sites in sub-Saharan Africa.Method: This case-based interpretive phenomenological study examined stakeholder perspectives in Mwanza, Tanzania, and Mbarara and Rugazi, Uganda, where the University of Calgary, Alberta, Canada has long-standing institutional collaborations. Between September and November 2017, 33 host stakeholders participated in semi-structured interviews and 28 host stakeholders participated in focus group discussions. Participant experiences were analyzed using interpretive phenomenological techniques.Results: The findings revealed that, although GHEs are well-established and a common experience for host stakeholders, their perceptions about who visiting medical trainees (VMTs) are remains indistinct. Participants acknowledged that there are a variety of benefits to GHEs, but overall VMTs appear to benefit the most from this unique learning opportunity. Host stakeholders described significant challenges and burdens of GHEs and recommended ways in which GHEs could be improved.Conclusions: GHEs need to be designed to better embrace ethical engagement and reciprocity with host stakeholders to ensure equity in benefits and responsibilities.

Rethinking Goals: Transforming Short-Term Global Health Experiences Into Engagements

The authors challenge the conventional wisdom guiding what participants in short-term experiences in global health (STEGHs) should be learning. Medical students and residents from the United States have been told to focus on standardized competencies and ethical principles, in addition to the biomedical knowledge, skills, and attitudes highlighted by working internationally. The authors suggest that although these training goals are important, they may divert learners from developing their professional identities in ways that contribute to the health of all persons, especially those who are economically poor and socially marginalized. The authors postulate that such a professional transformation will occur only if STEGH participants attend to 5 key learning goals: develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies. Further, the authors argue that only by attending to these goals will any genuine change in the root causes of inequities in health outcomes occur. The authors review these goals and encourage their use for professional and pedagogical purposes over the duration of any STEGH-before departure, while in host communities, and upon return home.

Healthy, safe and effective international medical student electives: a systematic review and recommendations for program coordinators

Background

Thousands of medical students undertake international medical electives each year. These students face potentially substantial health and safety risks as well as educational and ethical challenges and therefore should undertake their electives within well-structured and coordinated programs.

Methods

We conducted a qualitative systematic review based on a pre-determined protocol. Relevant publications and guidelines relating to international medical electives were identified through a review of the literature using on-line search engines, principally PubMed. We then conducted a systematic qualitative synthesis to extract relevant publications. Finally, the literature was organized according to themes, with the aim of developing a structured set of Recommendations for Implementation for program coordinators.

Results

A wide range of important issues were identified which were categorized into seven themes upon which recommendations were made principally for the benefit of program coordinators: Responsibilities; General policies; Travel advisories; Occupational risk assessment; Funding & finances, Pre-departure training programs; and Post-return debriefing and screening.

Conclusions

Recommendations for program coordinators on the health and safety of medical students while on international medical electives have been sourced from existing guidelines and relevant publications. There was considerable consensus from the literature and as such these synthesised recommendations could form the basis for internationally accepted standards for elective placement program coordinators.

Electronic supplementary material

The online version of this article (10.1186/s40794-019-0081-0) contains supplementary material, which is available to authorized users.

Guidelines for responsible short-term global health activities: developing common principles

BACKGROUND

Growing concerns about the value and effectiveness of short-term volunteer trips intending to improve health in underserved Global South communities has driven the development of guidelines by multiple organizations and individuals. These are intended to mitigate potential harms and maximize benefits associated with such efforts.

METHOD

This paper analyzes 27 guidelines derived from a scoping review of the literature available in early 2017, describing their authorship, intended audiences, the aspects of short term medical missions (STMMs) they address, and their attention to guideline implementation. It further considers how these guidelines relate to the desires of host communities, as seen in studies of host country staff who work with volunteers.

RESULTS

Existing guidelines are almost entirely written by and addressed to educators and practitioners in the Global North. There is broad consensus on key principles for responsible, effective, and ethical programs--need for host partners, proper preparation and supervision of visitors, needs assessment and evaluation, sustainability, and adherence to pertinent legal and ethical standards. Host country staff studies suggest agreement with the main elements of this guideline consensus, but they add the importance of mutual learning and respect for hosts.

CONCLUSIONS

Guidelines must be informed by research and policy directives from host countries that is now mostly absent. Also, a comprehensive strategy to support adherence to best practice guidelines is needed, given limited regulation and enforcement capacity in host country contexts and strong incentives for involved stakeholders to undertake or host STMMs that do not respect key principles.

Made in Denmark: Scientific mobilities and the place of pedagogy in global health

Transnational Global Health programmes planned and financed in the North and executed in the Global South usually involve some transfer of capacity between sites or capacity building in place. Capacity investment in the form of skills, knowledge, experience and equipment is often assumed to 'flow' between countries, laboratories and institutions, following the trajectories of mobile subjects in the knowledge economy. Drawing on in-depth interviews with Danish and East African scientists, this paper considers the mobilities that underpin scientific capacity building, drawing attention to the paradoxical in ways in which these programmes produce stasis and fixity, as well as mobility and exchange.

A Comprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.