Ethics of Short-Term Experiences in Global Health: Engaging Skeptics of Change

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.

Guidelines for short-term medical missions: perspectives from host countries

Background

In the past decade, there has been increasing guideline development for short-term medical missions (STMMs) traveling from high-income to low- and middle-income countries for the purpose of supporting health care services. The ethics of STMMs is criticized in the literature and there is frequently a lack of host country collaboration. This typically results in guidelines which are developed through the lens of the sending (high-income) countries’ staff and organizations. The aim of this paper is to evaluate an existing best practice guideline document from the perspective of host country participants with knowledge of STMMs from Honduras, Malawi, and the Philippines.

Methods

The guideline used for the evaluation consisted of nine best practice elements that were discerned based on literature and the experience of those working within the field. Semi-structured interviews were conducted in a cross-sectional study with participants (n = 118) from the host countries. Thematic analysis was conducted by two researchers and the results were assessed by working group members to confirm interpretations of the data.

Results

Overall, participants expressed a strong interest in having more structured guidance surrounding STMM practices. There was a positive response to and general acceptance of the proposed STMM guidelines, although participants found the 24-page document onerous to use; a companion checklist was developed. The key themes that emerged from the interviews included collaboration and coordination, care for hard-to-reach communities, capacity building, critical products and essential medical supplies, and opportunity and feasibility.

Conclusions

Host input suggests that the guidelines provide structured regulation and coordination of the medical mission process and have the potential to improve the way STMMs are carried out. The guidelines have also proven to be a useful tool for the actual implementation of STMMs and can be a tool to strengthen links and trust between mission teams and local health staff. However, local contexts vary considerably, and guidelines must be adapted for local use. It is recommended that STMM teams work in conjunction with host partners to ensure they meet local needs, increase capacity development of local health workers, and provide continuity of care for patients into the local system.

Ethical Considerations Regarding Global Surgery Experiences in Canadian General Surgery Residencies: A Preliminary Discussion

OBJECTIVE

Recently, there has been an explosion of interest in global surgery (GS) among students, residents and surgeons. However, little information exists regarding the ethical landscape of GS in general surgery residencies. Using an American College of Physicians position paper on the ethical obligations of global health experiences as a reference, this study provides a preliminary discussion of how GS experiences in Canadian residencies compare to the American College of Physicians-proposed ethical standards.

DESIGN

The Program Director (PD) at each Canadian general surgery residency program was invited to a complete an online survey.

RESULTS

All 17 PDs participated. Relative to the position paper, very few PDs included underserved settings in high income countries in their definitions of GS. Only 7 of 15 programs offer predeparture training for residents. Similarly, funding was available at less than half of all institutions. There is a need for the development of frameworks to assess the ethics of GS programs. Similarly, mechanisms on how to build relationships that are maximally beneficial for the stakeholders in resource-limited environments are not yet well established.

CONCLUSIONS

This is the first study to look at the ethical GS landscape in general surgery residencies across Canada. This study may assist other residencies in the development and tailoring of ethical GS programs. These results show the need for further characterization of the training, development and monitoring of GS programs.

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.