New trends of short-term humanitarian medical volunteerism: professional and ethical considerations

Humanitarian health education and training state-of-the-art: a scoping review

Introduction

In the past decade, humanitarian emergencies have been increasing, leading to an higher demand for humanitarian health professionalization. Education and training are critical for preparing these workers to provide effective care during crises. Understanding the current state-of-the-art in humanitarian health education is essential to inform research and development of future educational programs. This review surveys the peer-reviewed literature to provide insights into the current thinking in the field.

Methods

A review was conducted in March 2023 and updated in May 2024 using PubMed, Web of Science, Scopus, and Education Resources Information Center databases for English-language peer-reviewed articles published since January 2013. The review followed the Joanna Briggs Institute methodology for scoping reviews and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data were analyzed using qualitative content analysis and presented as a narrative descriptive summary.

Results

After screening, 32 articles met the inclusion criteria. The themes of the selected articles focus on education and training frameworks, mapping, and programs. Despite the growing opportunities, most education and training programs are based in the Global North. The gaps identified include a lack of standardized curriculum or competency frameworks and evaluation frameworks to guide the development and evaluation of further standardized training programs. Interdisciplinary and collaborative partnerships, iterative design, and mixed teaching methods and modalities, including e-learning, facilitated successful training. However, logistical and technical constraints and the lack of standardized training frameworks were barriers to developing, implementing, and evaluating such training programs.

Conclusion

This review provides an overview of the humanitarian health education trends over the last decade and identifies key areas for future educational development and research. The findings emphasize the importance of adapting interdisciplinary and collaborative partnerships and prioritizing the training of local staff through regional centers, local leadership, and accessible e-learning, including e-simulation. The review also highlights the need for continued research and evaluation of humanitarian health education and training programs with standardized metrics to evaluate training programs and identify areas for improvement. These steps will help ensure that humanitarian health professionals receive adequate training to provide effective healthcare in crisis situations.

Global Health Challenges: Why the Four S's Are Not Enough

A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.

The challenges of health volunteers management in COVID19 pandemic in Iran

PURPOSE

The use of volunteers is one of the approaches to capacity building, preparedness and the response of the health system in disasters. Appropriate management of volunteers during disasters and emergencies is essential. This study aimed to explain the challenges of volunteer management in the Pandemic COVID-19 in Iran.

DESIGN/METHODOLOGY/APPROACH

Qualitative research was conducted using the content analysis based on the Graneheim method. The participants' selection was done based on purposeful sampling and theoretical sampling until data saturation. Direct field observation and 26 interviews were applied to collect data.

FINDINGS

Four categories and 15 sub-categories emerged to describe the challenges of volunteer management during the COVID-19 crisis including policymaking barriers (including legal barriers, insurance and support coverage and risk governance), managerial barriers (including planning, coordinating and organizing, training and awareness, command and leadership and information management and documentation), socio-cultural barriers (personal safety attitude and culture, attitudes and expectations of the community and perspectives on volunteers) and executive-operational barriers (monitoring and evaluation, cost and needs assessment).

ORIGINALITY/VALUE

It is essential to increase managers', officials' and volunteers' perceptions of COVID19 risk through education and information. Preparing a database for volunteers' information, including non-governmental organization and governmental organization volunteers, planning for needs assessment, establishing a mechanism for recruiting volunteers and using their capacities and appropriate organizing, tracking and monitoring of volunteers can be among effective strategies.

Ethical global health in nursing education: An integrative review

AIM

The purpose of this integrative review is to provide a comprehensive review of ethical considerations for host communities and nursing programs in planning, implementing and evaluating global health experiences for nursing students.

BACKGROUND

Global health experiences for nursing students are proliferating rapidly across university settings while at the same time decreasing the average time spent in the host country engaged with local communities. Global health experiences are an area where students can experience ethics as it is applied across varied contexts including resource limited international settings. As nursing education expands its global programming, exploring the ethical implications of designing, implementing and evaluating GHEs becomes pivotal to build respectful, sustainable relationships with global partners and best prepare nursing students for ethical professional practice in an interconnected world.

DESIGN

We conducted an integrative review to examine ethical considerations in development of ethical global health experiences that benefit, rather than harm, host communities and participating nursing student guests.

METHODS

The search included articles published in English language, peer-reviewed journals between 1998 and 2021 that discussed ethics in the context of nursing students traveling internationally for global health experiences. Eighteen articles met criteria for review.

RESULTS

Overall, findings demonstrate relatively little research specific to ethical engagement in global health experiences. The articles in this integrative review discussed a range of ethical attributes including reciprocity or collaboration, respect, sustainability or commitment, justice and openness. Recommendations based on research and non-research articles are provided.

CONCLUSIONS

Ethical comportment in global health experiences requires careful planning, implementation and evaluation to assure an equitable and sustainable partnership between host community, faculty and nursing student guests.

Quō vādis? Short-term medical missions in a globalized world and the role of pharmacy

Short-term medical missions (STMMs) have evolved in the past few decades to provide non-emergent care including routine and follow-up primary care for acute and chronic conditions, along with treatment of neglected tropical diseases. Many STMMs operate outside the local health care infrastructure and may have limited local partnerships. STMM outcomes in improving local population health are often inferred but not well documented. Concerns such as ethical conduct, provider bias, and lack of adequate training and preparation continue to be raised. When disruptions occur (e.g. the COVID-19 pandemic), STMMs need to develop and prepare for challenges such as the inability to travel and provide care. Pharmacists as health professionals play a unique role when volunteering in STMMs. However, pharmacists' roles in STMMs need further development along with a framework to guide STMM work. Often driven by a few dynamic individuals, STMMs need to be aware of local geo-socio-political issues and develop local partnerships toward a meaningful legacy of building sustaining, long-lasting systems that will continue to serve others beyond the life of the STMMs and their founders.

'We had to take a hammer to get some roots out' - experiences, motivations and challenges among volunteer dentists: a qualitative study

Objectives To address a gap in the literature by examining the experiences, motivations and challenges among volunteer dentists engaged in short-term missions to low- and middle-income countries.Methods In-depth interviews among volunteer dentists (n = 20) who had provided voluntary dental care in low- or middle-income countries within the preceding five years. Interviews lasted on average 55 minutes and were recorded, transcribed and analysed using NVivo. Routine debriefings complemented analysis. COREQ principles guided this research.Results Motivations to volunteer included: exposure to new dental challenges (enhancing competence); discovering a new setting (tourism); and enhancing the lives of clients (humanitarianism). Volunteers enjoyed undertaking new tasks and developing new skills, but were burdened by a high patient load, challenging clinical conditions, peri- and post-operative complications, and a concern that their work was not addressing root causes of inadequate access to basic dental care. Respondents recommended that more information regarding the vision, equipment status, armamentarium and dental supplies be made available pre-departure, and that more dental schools include training on global oral health. Such measures could facilitate volunteers' abilities to provide care while also enhancing their personal and professional development. Creating an appropriate, sizable and competent capacity-building programme for local dentists was described as essential.

Conceptualizing Ethical Issues of Humanitarian Work: Results From a Critical Literature Review

This article presents results of a critical review of the literature discussing the ethical issues arising in humanitarian work, following the method proposed by McCullough, Coverdale and Chervenak. Our aim was primarily to focus on how the ethical issues arising in humanitarian work are conceptualized within the literature we reviewed. We think that properly conceptualizing the ethical issues which humanitarian workers may face can provide avenues to better respond to them. We analysed 61 documents, as part of a literature review, which revealed that there truly is a need, amongst the authors and in humanitarian work, to discuss ethics. Indeed, even if only a small number of authors define explicitly the words they use to discuss ethics, the great quantity that we have uncovered in the documents seem to suggest vast and rich grounds upon which to address ethical issues. We believe it to be important that the ethical issues of humanitarian work are increasingly addressed in the literature and argue that it would be helpful for the vocabulary used by authors to be employed and developed even more rigorously, so that their discussions show more precision, coherence, relevance, exhaustiveness, and sufficiency. The review of the literature, as well as the resulting analysis in this article, is part of a broader project to suggest a way to conceptualize the ethical issues of humanitarian work based on the strengths and innovations of this and other studies.

A Last Resort When There is No Blood: Experiences and Perceptions of Intraoperative Autotransfusion Among Medical Doctors Deployed to Resource-Limited Settings

BACKGROUND

Four and a half million people die globally every year due to traumatic injuries. One major cause of preventable death is bleeding. Blood for transfusion is often unavailable in resource-limited settings, where a majority of trauma deaths occur. Intraoperative autotransfusion (IAT) has been proposed as a safe and feasible lifesaving alternative to allogeneic blood transfusion. However, there is limited knowledge regarding its use among doctors working for international non-governmental organisations (INGOs) in resource-limited settings. The aim of this study was to explore the experiences and perceptions of IAT among INGO-affiliated medical doctors with clinical experience in resource-limited settings.

METHODS

We conducted semi-structured interviews via telephone or Skype with 12 purposefully sampled surgeons and anaesthesiologists. The interviews were recorded, transcribed verbatim, and analysed using content analysis.

RESULTS

We identified three main themes relating to IAT and bottlenecks preventing the scale-up of its use: variation in techniques and systems, contextual factors, and individual medical doctor factors. The participants gave detailed reports of missed opportunities for usage of IAT in resource-limited settings. Bottlenecks included the lack of simple and cost-effective products, limited availability of protocols in the field, and insufficient knowledge and experience of IAT.

CONCLUSIONS

The participants found that simple IAT is under-utilised in resource-limited settings. Missed opportunities to use IAT were mainly associated with armed conflict settings and obstetrical emergencies. In order to meet the need for IAT in resource-limited settings, we suggest further consideration of the identified bottlenecks.

Evaluation of the effectiveness of the Global Medical Student Partnership program in undergraduate medical education

BACKGROUND

The Global Medical Student Partnership (GMSP) is a medical student-led international initiative to promote accessible global health learning. This study aims to evaluate the effectiveness of the GMSP program in meeting its learning objectives.

METHODS

Canadian and international medical student pairs met online monthly (January-May 2018) to discuss global health-related medical cases. Students then reviewed cases with local GMSP peers and faculty experts. A mixed-methods study was performed to evaluate whether the objectives of the program had been achieved. 26 of 32 (81.3%) students completed a questionnaire, and 13 (40.6%) also participated in one-on-one semi-structured interviews. Descriptive statistics and thematic analysis were used to analyze students' perspectives on skill development through GMSP.

RESULTS

GMSP students agreed or strongly agreed that international collaboration and communication skills were more important to them following program participation (92.3%, 92.3% respectively). Many expressed that after GMSP, they knew more about their healthcare system, practices abroad and how to solve complex health issues (92.3%, 84.6%, 61.5% respectively). Qualitative data showed GMSP improved students' communication and presentation skills, provided a foundation for international relationships, fostered appraisal of diverse health systems, and furthered students' understanding of health advocacy.

CONCLUSIONS

Our findings demonstrate that GMSP met its original objectives by providing students with opportunities to engage in international collaborations and to further develop their skills in advocacy, communication, and health-systems research. This program may be an important addition to medical education as it makes use of technology and peer-to-peer exchange to enable global health learning.

Evaluating underpinning, complexity and implications of ethical situations in humanitarian operations: qualitative study through the lens of career humanitarian workers

INTRODUCTION

Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited.

METHODS

We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations.

RESULTS

61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks.

CONCLUSIONS

Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.

An Ethics-based Approach to Global Health Research Part 2: Strategies for Overcoming Logistic and Implementation Challenges

With the growth of global pharmacy partnerships and collaborative research, particularly between high-income countries and low- or middle-income countries, it is necessary to establish best practices for fair and ethical collaboration and research. There is a gap in the pharmacy literature in this regard. Through this commentary, authors will present a pathway for future global health researchers including generating ideas based on mutual needs of the partnership and the community; exploring the importance of regulations including the need to conduct research and partnership projects within the confines of each participant's professional scope of practice, expertise, and licensure; describing the need to develop agreements and the components that should be included in such an agreement; discussing ethical guidelines for research planning, obtaining ethical approval, and planning for adverse events; and illustrating ethical considerations for research implementation with considerations around consent, data collection, linking patients to care after the completion of the study, and dissemination. Global examples, with a pharmacy-specific approach where applicable, within each section highlight the importance of discussion and action around ethics and equity when pursuing collaborative research, recognizing that many of these situations involve difficult decisions.

Resident Rotations in Low- and Middle-Income Countries: Motivations, Impact, and Host Perspectives

Interest in clinical rotations in low- and middle-income countries (LMICs) has grown among high-income country (HIC) orthopaedic residents. This study addresses the following questions: (1) What motivates HIC surgical residents to rotate in LMICs? (2) What is the impact of rotations on HIC residents? (3) What are the LMIC partner perceptions of HIC collaboration?

MATERIALS AND METHODS

A search strategy of multiple databases returned 3,740 unique articles pertaining to HIC surgical resident motivations for participating in rotations in LMICs or the LMIC host perspective. Data extraction was dually performed using meta-ethnography, the qualitative equivalent of meta-analysis.

RESULTS

Twenty-one studies were included in the final analysis. HIC residents were primarily motivated to rotate in LMICs by altruistic intent, with greatest impact on professional development. LMIC partners mostly valued HIC sustained investment and educational opportunities for LMIC partners. From LMIC's perspective, potential harm from collaboration arose from system-level and individual-level discordance between HIC and LMIC expectations and priorities. HIC priorities included the following: (1) adequate operative time, (2) exposure to varied pathology, and (3) mentorship. LMIC priorities included the following: (1) avoiding competition with HIC residents for surgical cases, (2) that HIC groups not undermine LMIC internal authority, (3) that HIC initiatives address local LMIC needs, and (4) that LMIC partners be included as authors on HIC research initiatives. Both HIC and LMIC partners raised ethical concerns regarding collaboration and perceived HIC residents to be underprepared for their LMIC rotation.

DISCUSSION

This study synthesizes the available literature on HIC surgical resident motivations for and impact of rotating in LMICs and the LMIC host perception of collaboration. Three improvement categories emerged: that residents (1) receive site-specific preparation before departure, (2) remain in country long enough to develop site-specific skills, and (3) cultivate flexibility and cultural humility. Specific suggestions based on synthesized data are offered for each concept and can serve as a foundation for mutually beneficial international electives in LMICs for HIC orthopaedic trainees.

Expanding Medical Education for Local Health Promoters Among Remote Communities of the Peruvian Amazon: An Exploratory Study of an Innovative Program Model

PURPOSE

Community health workers (CHWs) play integral roles in primary health care provision in low- and middle-income countries (LMICs). This is particularly true in underdeveloped areas where there are acute shortages of health workers. In this study, we evaluated the development and community utilization of a CHW training program in the Loreto province of Peru. Additionally, a community-oriented training model was designed to augment access to basic health information in underserved and isolated areas of the Amazon.

METHODS

Health resource utilization was compared in each community by surveying community members before and after implementation of the CHW training program, which utilized a community participatory program development (CPPD) model.

RESULTS

All communities demonstrated significantly increased CHW utilization (p = 0.026) as their initial point of contact for immediate health concerns following CHW training implementation. This increase in CHW utilization was accompanied by trends toward decreased preferences for local shamans or traveling to the closest health post as the initial health resource.

CONCLUSION

The community-focused, technology-oriented model utilized in this study proved an effective way to promote the use of CHWs in the Amazon region of Loreto, and could prove valuable to CHW capacitation efforts within other Peruvian provinces and in other LMICs around the world.

Global Health Experience and Interest: Results From the AAP Periodic Survey

BACKGROUND

Interest and participation in global health (GH) experiences have increased over the past 30 years in both medical schools and residencies, but little is known at the level of practicing pediatricians.

METHODS

Data were compared from the American Academy of Pediatrics Periodic Surveys conducted in 1989 and 2017. The surveys had a response rate of 70.8% in 1989 and 46.7% in 2017. There were 638 and 668 postresidency pediatricians in the 1989 and 2017 surveys, respectively. Descriptive analyses were performed to look at changes in experience and interest in GH. A multivariable logistic regression was conducted specifically looking at characteristics associated with interest in participating in GH experiences in the next 3 years.

RESULTS

Pediatrician participation in GH experiences increased from 2.2% in 1989 to 5.1% in 2017, with statistically significant increases in pediatricians ≥50 years of age. Interest in participating in future GH experiences increased from 25.2% in 1989 to 31.7% in 2017, with a particular preference for short-term clinical opportunities. In the multivariable logistic regression model, the year 2017 was associated with an increased interest in future GH experience, especially in medical school, hospital or clinic practice settings, as well as among subspecialists.

CONCLUSIONS

Over the past 28 years, practicing pediatricians have increased their involvement in GH, and they are more interested in future GH experiences. The focus is on short-term opportunities. Our study reveals that practicing pediatricians mirror medical trainees in their growing interest and participation in GH.

Decentralized humanitarian aid deployment: reimagining the delivery of aid

Purpose

Current centralized humanitarian aid deployment practices may encourage urbanization thereby weakening short- and long-term resiliency of lower-income countries receiving aid. The purpose of this paper is first, to explore these shortcomings within the peer-reviewed literature and, second, propose a starting point for a solution with a decentralized humanitarian aid deployment (DHAD) framework.

Design/methodology/approach

The authors conducted a focused, qualitative review of available and relevant literature.

Findings

The literature reviewed demonstrates that current centralized humanitarian aid deployment models lack meaningful engagement of local assets while indicating a plausible connection between these same models and disaster urbanization. Next, the literature shows introducing a new decentralized model could represent a sustainable aid deployment standard for that country’s specific response, recovery, mitigation and planning opportunities and constraints.

Research limitations/implications

The next step is to develop a working DHAD model for a lower-income country using a multi-layered, GIS analysis that incorporates some or all of the socioeconomic and environmental variables suggested herein.

Practical implications

The practical potential of the DHAD framework includes establishing the impacted country in the lead role of their own recovery at the moment of deployment, no longer relying on foreign logistics models to sort it out once aid has arrived.

Originality/value

This paper discusses a topic that much of the literature agrees requires more research while suggesting a new conceptual framework for aid deployment best practices which is also largely absent from the literature.

Extent, nature and consequences of performing outside scope of training in global health

BACKGROUND

Globalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one's scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified.

METHODS

The authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years.

RESULTS

A total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time.

CONCLUSIONS

Given that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.

The Impact of an International Elective on Anesthesiology Residents as Assessed by a Longitudinal Study

INTRODUCTION

Participation of anesthesiology residents in international electives may lead to the acquisition of skills as described in the Accreditation Council for Graduate Medical Education (ACGME) competencies. There is great interest in participating in such electives, but it is not clear there are educational or professional benefits. The purpose of this study was to evaluate the educational benefits of participating in overseas electives among anesthesiology residents.

METHODS

A longitudinal study design was used between 2010 and 2015 to survey all anesthesiology residents selected to participate in the nationally competitive Society for Education in Anesthesia-Health Volunteers Overseas (SEA-HVO) Traveling Fellowship Program in which third-year residents receive scholarships and ABA credit for 1-month teaching electives in a low-resource country. Pre-elective and post-elective surveys were sent via de-identified e-mails during the third year of residency. We investigated residents' expectations, plans, and comfort level with teaching techniques prior to the elective and after and asked about perceived benefits.

RESULTS

The response rate was 68.8% of the 45 residents who received the survey. Participants were motivated by professional and humanitarian goals. Residents reported improved comfort with teaching techniques, especially lecturing and giving feedback. Participants acquired better skills in assessing the learning needs of students. There was a slight but nonsignificant increased comfort dealing with cultural and language barriers. The major self-perceived unique benefit of international electives was improvement in intercultural communication. The systems' changes reported by residents as the most important to improve were those that affected patient safety.

CONCLUSION

Global health electives have a small positive effect on teaching, cultural proficiency, and systems assessment skills. Residents improve in their ability to identify educational needs and to give feedback. Patient safety during anesthetic care is appreciated as the most important systems' need.

The ethical experiences of trainees on short-term international trips: a systematic qualitative synthesis

BACKGROUND

Medical student and resident participation in short-term international trips for trainees (STINTTs) has increased in the past few decades. However, there has been no systematic review of trainees' actual ethical experiences. The authors sought to identify what ethical issues medical trainees encounter during STINTTs, as elicited by and reported in peer-reviewed, quantitative and qualitative research papers.

METHODS

The authors systematically searched five academic databases finding 659 unique titles and abstracts. The authors applied inclusion and exclusion criteria to these titles and abstracts resulting in fourteen papers, which were analyzed using qualitative thematic synthesis.

RESULTS

The qualitative analysis of the papers generated four themes: (1) Trainees' Concerns Over Perpetuating Medical Tourism; (2) Struggling to Identify and Balance the Benefits and Harms of STINTTs; (3) The Complicated Trainee Mens (mind); and (4) Ethical Situations Encountered by Trainees. The fourth theme, which was the largest, was further divided into (a) Navigating social and cultural dynamics, (b) Trainees' experiences related to the learner role, and (c) Ethical situations not qualifying for other catagories. Some of these issues reported in the empirical research papers are well represented in the broader literature on STINTTs, while others were less so-such as mistreatment of trainees. All included papers were published after 2010, and comprised a total of less than 170 medical trainees.

CONCLUSIONS

Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The authors call educators' attention to specific challenges that trainees face. The relevant literature covering US and Canadian STINTTs is relatively young and largely qualitative. The authors briefly sketch a program for expanding the research on this increasingly common educational experience.

Global Health Education at Home: Canadian Medical Students' Perspectives After Learning Alongside Haitian Peers

PURPOSE

To explore how host medical students learn from visiting foreign students, by reporting on a global health program that has invited two or three Haitian medical students each year since 2013 to a Canadian medical school for a summer anatomy program.

METHOD

In 2017, the authors conducted a qualitative descriptive study that collected data through one-on-one, semistructured interviews with 10 Canadian students, who participated in the Université Quisqueya-McGill University collaborative, a bidirectional global health education initiative, 2013-2016. The authors' critical constructivist thematic analysis, while exploratory, was sensitized by their knowledge of contemporary frameworks of global health competencies, a postcolonial understanding of power relations, and three key concepts (agency, cultural humility, and reflexivity).

RESULTS

The authors found two phenomena related to bidirectional exchange: the nature of the relationship between Canadian and Haitian students, and elements of the learning experience that facilitated transformation and growth. There were three important components to the nature of the relationship between Canadian and Haitian students-reflection on practices and privilege, negotiation of power dynamics, and perception of Haitian students as agents-and three components of the learning experience that facilitated transformation and growth-working in groups, common learning objectives, and informal social gatherings.

CONCLUSIONS

Bidirectional programs may have implications for Canadian students' perception of the agency of international medical learners and may prompt self-reflection that manifests in a range of ways, including an experience of culture shock at home. These tensions seemed to create space to practice reflexivity and cultural humility.

Difficulties faced by Korean disaster relief workers while providing humanitarian aid: A descriptive study

The aim of the present study was to identify difficulties experienced by Korean disaster relief workers during humanitarian aid deployment. A convenience sample of disaster relief workers aged >18 years, who had been dispatched to an overseas disaster site, were recruited; 107 relief workers completed the Humanitarian Aid Difficulty Scale that consists of 23 items comprising five factors. The average difficulty rating was 2.64 on a five point scale. By item, participants gave the highest scores for bathroom use and the lowest scores for cooperation among team members. By factor, infrastructure was rated as the greatest difficulty, followed by health conditions, goods and equipment, culture and customs, and cooperation. Considering sociodemographic characteristics, there were significant age differences in the culture and customs factor, as well as significant occupation differences in the cooperation, culture and customs, and goods and equipment factors. These findings highlight the need to improve the welfare of workers. It is recommended that further research be conducted according to occupation and with repeated measurement prior to, in the middle of, and after deployment of relief workers.

A Collaborative Multidisciplinary and Without-Walls Research Curriculum in Global Health

Longitudinal and collaborative global health research curricula to train a well-versed global health corps through skills building in assessment and evaluation are lacking. A without-walls research curriculum was offered to medical and public health students between 2007 and 2015. Mentored cross-disciplinary research projects were developed and implemented in partnership with communities. A multilevel mixed methods design, including semi-structured interviews, post-curriculum surveys, presentations, publications, postgraduation metrics, and feedback from project sites, evaluated educational outcomes. Students (N = 25; aged 27 ± 1.9 years; 90.5% female) participated in the studies in 12 countries, resulting in 26 national-level presentations and 24 peer-reviewed publications, including per student average and range of Institutional Review Board submission (0.95; 0-3), poster presentation (0.85; 0-3), oral presentation (0.65; 0-2), and peer-reviewed submission (1.05; 0-4). On average, the studies (40% mixed methods) lasted 2 years. Analyses and manuscript writing were the most challenging; data collection and presentations were the most rewarding. Majority of the participants strongly agreed with achieving skills in community engagement, interviewing techniques, research design and implementation, research dissemination, and career development. Interview themes included expectations and learning goals, effective mentorship, impact on career goals, and ethical learning. Mentorship qualities were accessibility, real-time problem solving, research expertise, advocate, and balancing guidance with independence. Project sites' feedback was overwhelmingly positive regarding the projects' impact. Postgraduation participants hold positions in humanitarian organizations, research programs serving the underserved, and primary care residencies, fellowships, and faculty. This experience illustrates the feasibility and effectiveness of mentored global health research and underlines the crucial link between community collaboration and scholarship for effective global health practice.

Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement

Pediatric practitioners whose expertise is primarily focused on the care of children within health settings in the United States are increasingly engaged in global child health (GCH). The wide spectrum of this involvement may include incorporating short-term or longer-term GCH commitments in clinical care, teaching and training, mentoring, collaborative research, health policy, and advocacy into a pediatric career. We provide an overview of routes of engagement, identify resources, and describe important considerations for and challenges to better equipping US pediatric practitioners to participate in meaningful GCH experiences. This article is part of a series on GCH describing critical issues relevant to caring for children from an international perspective.

The Collaborative Role of North American Departments of Pediatrics in Global Child Health

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA-LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC-NA partnerships can contribute to reductions of child mortality and morbidity globally.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.

A Sustainable Model for Patient follow-up following an International Cleft Mission

Purpose:

Patient follow-up after cleft missions is imperative if we are to critically assess the quality of care provided in these settings. The adoption of mobile telephones among disadvantaged families abroad may enable such an undertaking in a cost-effective manner. This project aimed to assess the efficacy of cellular phone-based follow-up in a developing country following a cleft mission to Thailand.

Methods:

Changing Children's Lives Inc. performed a cleft surgical mission to Udon Thani, Thailand, in January 2013. Telephone numbers collected at that time were used to survey the patients or their parents 1.5 years postoperatively.

Results:

Of the 56 patients who underwent cleft lip and/or palate surgery during the mission, more than 50% ( n = 30, 54%) were reachable by telephone; all chose to participate in the study. The cost for families was U.S. $124.92 (56.15); 26 families (87%) believed their money was well spent. Follow-up care was received by 22 (73%) patients, and all but one family ( n = 29, 97%) felt that their child received all of the medical care and support required. All families ( N = 30) would recommend similar cleft care to a friend. Of the patients younger than 18 years of age ( n = 24, 80%), 20 (80%) families found their child more comfortable interacting with peers, more comfortable interacting with adults, and more confident postoperatively.

Conclusion:

In one month, a survey response rate of more than 50% was obtained by leveraging the increased adoption of mobile phones in rural settings. Nearly all patients/families treated during the cleft mission were satisfied with the care that they received.

Effective practices of international volunteering for health: perspectives from partner organizations

Background

The demand for international volunteer experiences to promote global health and nutrition is increasing and numerous studies have documented the experiences of the international volunteers who travel abroad; however, little is known about effective practices from the perspective of partner organizations. This study aims to understand how variables such as the skill-level of volunteers, the duration of service, cultural and language training, and other key variables affect partner organizations’ perceptions of volunteer effectiveness at promoting healthcare and nutrition.

Method

This study used a cross-sectional design to survey a convenience sample of 288 volunteer partner organizations located in 68 countries. Principle components analyses and manual coding of cases resulted in a categorization of five generalized types of international volunteering. Differences among these types were compared by the duration of service, skill-level of volunteers, and the volunteers’ perceived fit with organizational needs. In addition, a multivariate ordinary least square regression tested associations between nine different characteristics/activities and the volunteers’ perceived effectiveness at promoting healthcare and nutrition.

Results

Partner organizations viewed highly-skilled volunteers serving for a short-term abroad as the most effective at promoting healthcare and nutrition in their organizations, followed by slightly less-skilled long-term volunteers. The greatest amount of variance in perceived effectiveness was volunteers’ ability to speak the local language, followed by their skill level and the duration of service abroad. In addition, volunteer training in community development principles and practices was significantly related to perceived effectiveness.

Conclusion

The perceptions of effective healthcare promotion identified by partner organizations suggest that program and volunteer characteristics need to be carefully considered when deciding on methods of volunteer preparation and engagement. By better integrating evidence-based practices into their program models, international volunteer cooperation organizations can greatly strengthen their efforts to promote more effective and valuable healthcare and nutrition interventions in partner communities.

Pediatric Resident Academic Projects While on Global Health Electives: Ten Years of Experience at the University of Minnesota

PURPOSE

Many residency programs require residents to complete an academic project as part of a global health (GH) elective. However, there has been little description of the range of projects residents have pursued during GH electives or the extent to which these projects are consistent with proposed best practices.

METHOD

The authors conducted a document review of 67 written summaries or copies of presentations of academic projects (hereafter, summaries) completed by pediatric and medicine-pediatric residents at the University of Minnesota while on GH electives from 2005 to 2015. Two authors independently coded each summary for the type of project completed; when the project idea was generated; explicit mention of a mentor from the home institution, host institution, or both; whether a needs assessment was conducted; and whether there were plans for sustainability.

RESULTS

Most of the 67 projects were categorized into one of three project types: quality/process improvement (28 [42%]), education (18 [27%]), or clinical research (14 [21%]). Most summaries explicitly mentioned a mentor (45 [67%]), reported conducting a needs assessment (38 [57%]), and indicated sustainability plans (45 [67%]). Of the 42 summaries that indicated the timing of idea generation, 30 (71%) indicated the idea was developed after arriving at the host site.

CONCLUSIONS

Residents undertook a wide range of academic projects during GH electives, most commonly quality/process improvement and education projects. The projects were largely aligned with best practices, with most summaries indicating the resident worked with a mentor, conducted a needs assessment, and made plans for sustainability.

"Location is surprisingly a lot more important than you think": a critical thematic analysis of push and pull factor messaging used on Caribbean offshore medical school websites

BACKGROUND

Offshore medical schools are for-profit, private enterprises located in the Caribbean that provide undergraduate medical education to students who must leave the region for postgraduate training and also typically to practice. This growing industry attracts many medical students from the US and Canada who wish to return home to practice medicine. After graduation, international medical graduates can encounter challenges obtaining residency placements and can face other barriers related to practice.

METHODS

We conducted a qualitative thematic analysis to discern the dominant messages found on offshore medical school websites. Dominant messages included frequent references to push and pull factors intended to encourage potential applicants to consider attending an offshore medical school. We reviewed 38 English-language Caribbean offshore medical school websites in order to extract and record content pertaining to push and pull factors.

RESULTS

We found two push and four pull factors present across most offshore medical school websites. Push factors include the: shortages of physicians in the US and Canada that require new medical trainees; and low acceptance rates at medical schools in intended students' home countries. Pull factors include the: financial benefits of attending an offshore medical school; geographic location and environment of training in the Caribbean; training quality and effectiveness; and the potential to practice medicine in one's home country.

CONCLUSIONS

This analysis contributes to our understanding of some of the factors behind students' decisions to attend an offshore medical school. Importantly, push and pull factors do not address the barriers faced by offshore medical school graduates in finding postgraduate residency placements and ultimately practicing elsewhere. It is clear from push and pull factors that these medical schools heavily focus messaging and marketing towards students from the US and Canada, which raises questions about who benefits from this offshoring practice.

Surgical and Teaching Mission to Mongolia: Experience and Lessons

BACKGROUND

For decades, the disparity in medical care across the world along with the fundamental essence of medicine as service has laid the foundation for the global medical mission. Mongolia, a country often overlooked as an area in need of medical aid, harbors a fertile environment for long-term change. In the last 15-20 years, after the fall of the Union of Soviet Socialist Republics, Mongolia has turned to a free-market healthcare model and has been struggling with the transition from the formally state-run system. These changes have slowed the original progress noted among surgical specialties, namely neurosurgery, in Mongolia. A lack of resources, a desire for international interaction, and a need for technical mentorship remain a real struggle for local neurosurgeons.

METHODS

Under the auspices of the Virtue Foundation (www.virtuefoundation.org), we report on our 3-year experiences during our surgical and teaching mission to Mongolia and look towards long-term improvements in Mongolian neurosurgery.

RESULTS

A total of 15 operations were performed and more than 50 patients seen in clinic during the 3-year experience. Patients ranged from 1 to 77 years of age. No patients encountered any significant peri- or postoperative complications.

CONCLUSIONS

In our experience with the surgical and teaching mission to Mongolia, when directed appropriately, medical missions can serve as the perfect medium in fostering that environment, providing local healthcare professionals with the knowledge, skills, and motivation to create self-sustaining improvement in their own country, hence promoting intellectual and technological advancement and raising the standard of care.

International short-term medical missions: a systematic review of recommended practices

OBJECTIVES

To identify practices for conducting international short-term medical missions (STMMs) recommended in the literature and examine how these link STMMs to recipient countries' existing health systems.

METHODS

Systematic review of PubMed-indexed articles on STMMs and their bibliographies using preferred reporting items for systematic reviews and meta-analyses guidelines. Recommendations were organized using the World Health Organization Health Systems Framework.

RESULTS

In 92 publications, 67 % offered at least one recommendation that would link STMMs to the recipient country's health system. Among these recommendations, most focused on service delivery and few on health financing and governance. There is a lack of consensus around a proper standard of care, patient selection, and trip duration.

CONCLUSIONS

Comprehensive global standards are needed for STMM work to ensure that services are beneficial both to patients and to the broader healthcare systems of recipient countries. By providing an overview of the current recommendations and important gaps where practice recommendations are needed, this study can provide relevant input into the development of global standards for STMMs.

Looking good but doing harm? Perceptions of short-term medical missions in Nicaragua

In this paper, we present findings from a qualitative study that gathered Nicaraguans' perceptions of short-term foreign medical missions, towards deepening the understanding of what Nicaraguans value or find limited in the work of such foreign missions operating in their country. Fifty-two interviews were conducted with patients, relatives of patients, Nicaraguan physicians and nurses who partnered with or observed missions at work, 'beneficiary' community leaders, and individuals who were unable or unwilling to access mission-provided healthcare. Factors underlying participants' positive and more critical accounts of foreign primary and surgical missions are described and analysed. Empirical investigation on how, whether or not, or on what bases short-term medical missions (STMs) have been perceived as beneficial, harmful, or otherwise by those on the receiving end of these efforts is limited. This study aims to contribute to the evidence base for reflecting on the ethical performance of trans-national STMs.

The Ethics of Medical Volunteerism

Responding to disparities in health, thousands of health care providers volunteer annually for short-term medical service trips (MSTs) to serve communities in need as a result of environmental, geographic, historical, or sociopolitical factors. Although well intentioned, short-term MSTs have the potential to benefit and harm those involved, including participants and communities being served. The contexts, resource and time limitations, and language and cultural barriers present ethical challenges. There have been increasing requests for standardized global guidelines, transparency, and open review of MSTs and their outcomes. Principles of mission, partnership, preparation, reflection, support, sustainability, and evaluation inform and equip those engaging in medical volunteerism.

Developing pediatric surgery in low- and middle-income countries: An evaluation of contemporary education and care delivery models

There are several different models of education and care delivery models in low- and middle-income countries (LMICs), and many endeavors combine more than one of the described models. This article summarizes the burden of pediatric surgical disease and discusses the benefits and shortcomings of the following: faith-based missions; short-term surgical trips; partnerships, twinning, and academic collaborations; teaching workshops, "train the trainer," and pediatric surgery camps; specialty treatment centers; online conferences, telemedicine, and mobile health; specific programs for exchange and education; and training in high-income countries (HICs), fellowships, and observorships. It then addresses ethical concerns common to all humanitarian pediatric surgical efforts.

The Development of a Humanitarian Health Ethics Analysis Tool

Introduction Health care workers (HCWs) who participate in humanitarian aid work experience a range of ethical challenges in providing care and assistance to communities affected by war, disaster, or extreme poverty. Although there is increasing discussion of ethics in humanitarian health care practice and policy, there are very few resources available for humanitarian workers seeking ethical guidance in the field. To address this knowledge gap, a Humanitarian Health Ethics Analysis Tool (HHEAT) was developed and tested as an action-oriented resource to support humanitarian workers in ethical decision making. While ethical analysis tools increasingly have become prevalent in a variety of practice contexts over the past two decades, very few of these tools have undergone a process of empirical validation to assess their usefulness for practitioners.

METHODS

A qualitative study consisting of a series of six case-analysis sessions with 16 humanitarian HCWs was conducted to evaluate and refine the HHEAT.

RESULTS

Participant feedback inspired the creation of a simplified and shortened version of the tool and prompted the development of an accompanying handbook.

CONCLUSION

The study generated preliminary insight into the ethical deliberation processes of humanitarian health workers and highlighted different types of ethics support that humanitarian workers might find helpful in supporting the decision-making process.

Teaching corner: "first do no harm": teaching global health ethics to medical trainees through experiential learning

Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountered during outreach clinical work. While global health training guidelines emphasize the importance of developing ethical and cultural competencies before embarking on fieldwork, their practical implementation is often lacking and consists mainly of recommendations regarding professional behavior and discussions of case studies. Evidence suggests that one of the most effective ways to teach certain skills in global health, including ethical and cultural competencies, is through service learning. This approach combines community service with experiential learning. Unfortunately, this approach to global health ethics training is often unattainable due to a lack of supervision and resources available at host locations. This often means that trainees enter global health initiatives unprepared to deal with ethical dilemmas, which has the potential for adverse consequences for patients and host institutions, thus contributing to growing concerns about exploitation and "medical tourism." From an educational perspective, exposure alone to such ethical dilemmas does not contribute to learning, due to lack of proper guidance. We propose that the tension between the benefits of service learning on the one hand and the respect for patients' rights and well-being on the other could be resolved by the application of a simulation-based approach to global health ethics education.

Preparation of medical personnel for an early response humanitarian mission - lessons learned from the Israeli defense forces field hospital in the Philippines

Introduction

Humanitarian aid provision and early medical response missions to areas ravaged by natural disasters are as essential nowadays as in the past, and medical personnel play a pivotal role in these delegations.

Case description

In November 2013, tropical cyclone Haiyan (Yolanda) slammed the Philippines archipelago, leaving more than an estimated 6000 dead in its wake while demolishing vital infrastructure and affecting the life of an estimated 25 million locals. The Israeli Defense Forces (IDF) rapidly constructed and sent a humanitarian aid delegation which included a field hospital deployment with medical capabilities from diverse specialty fields.

Discussion and evaluation

The purpose of this article is to summarize our experience in the preparation process of medical personnel before and during deployment. We offer a simple, practical and structured checklist that will assist the medical specialist in preparation for his mission.

Conclusion

Preparation of medical personnel for humanitarian aid medical missions is a complex and vital task that might be better accomplished with thorough briefing and structured checklists which begin with addressing of personal safety and other daily needs of the staff.

Characteristics, determinants and perspectives of experienced medical humanitarians: a qualitative approach

OBJECTIVE

To explore the characteristics, motivations, ideologies, experience and perspectives of experienced medical humanitarian workers.

DESIGN

We applied a qualitative descriptive approach and conducted in-depth semistructured interviews, containing open-ended questions with directing probes, with 44 experienced international medical aid workers from a wide range of humanitarian organisations. Interviews were coded and analysed, and themes were developed.

SETTING

International non-governmental organisations (INGOs) and United Nations (UN).

RESULTS

61% of participants were female; mean age was 41.8 years with an average of 11.8 years of humanitarian work experience with diverse major INGOs. Significant core themes included: population's rights to assistance, altruism and solidarity as motives; self-identification with the mission and directives of INGOs; shared personal and professional morals fostering collegiality; accountability towards beneficiaries in areas of programme planning and funding; burnout and emotional burdens; uncertainties in job safety and security; and uneasiness over changing humanitarian principles with increasing professionalisation of aid and shrinking humanitarian access. While dissatisfied with overall aid operations, participants were generally satisfied with their work and believed that they were well-received by, and had strong relationships with, intended beneficiaries.

CONCLUSIONS

Despite regular use of language and ideology of rights, solidarity and concepts of accountability, tension exists between the philosophy and practical incorporation of accountability into operations. To maintain a humanitarian corps and improve aid worker retention, strategies are needed regarding management of psychosocial stresses, proactively addressing militarisation and neo-humanitarianism, and nurturing individuals' and organisations' growth with emphasis on humanitarian principles and ethical practices, and a culture of internal debate, reflection and reform.

A research agenda for humanitarian health ethics

This paper maps key research questions for humanitarian health ethics: the ethical dimensions of healthcare provision and public health activities during international responses to situations of humanitarian crisis. Development of this research agenda was initiated at the Humanitarian Health Ethics Forum (HHE Forum) convened in Hamilton, Canada in November 2012. The HHE Forum identified priority avenues for advancing policy and practice for ethics in humanitarian health action. The main topic areas examined were: experiences and perceptions of humanitarian health ethics; training and professional development initiatives for humanitarian health ethics; ethics support for humanitarian health workers; impact of policies and project structures on humanitarian health ethics; and theoretical frameworks and ethics lenses. Key research questions for each topic area are presented, as well as proposed strategies for advancing this research agenda. Pursuing the research agenda will help strengthen the ethical foundations of humanitarian health action.