Managing the Unpredictable: Recommendations to Improve Trainee Safety During Global Health Away Electives

Background:

For institutions offering global health programs, the safety of trainees during clinical rotations at international sites is paramount. Current guidelines for global health electives recommend pre-departure training and safety-net resources, yet their advice on managing unanticipated problems is limited.

Objective:

This report illustrates critical safety considerations requiring additional guidance for programs and students and highlights approaches that may improve trainee safety while abroad.

Methods:

We present a series of five cases adapted from the experiences of students traveling to and from the Yale School of Medicine between the years of 2011–2021. These cases include instances of personal injury, mental health challenges following trauma, sexual harassment, political instability, and natural disaster. For each case, we recommend ways in which programs and their participants may approach the challenges and we highlight issues requiring additional analysis.

Findings:

We categorized the types of trainee safety issues into three groups: personal health emergencies, individual-level stressors, and large-scale crises.

Conclusion:

Ultimately, we recommend that rather than solely emphasizing a universal policy, programs and trainees should also be educated on the tools and resources available for addressing unexpected emergencies.

U.S. trainees' experiences of ethical challenges during research in low- and middle-income countries: A mixed methods study

High-income country (HIC) trainees are participating in research in low- and middle-income countries (LMIC) in increasing numbers, yet the ethical challenges they face have not been well described. We conducted a mixed methods study of U.S. graduate and undergraduate students who conducted research in LMIC, including an online survey and semi-structured interviews. Among 123 online survey respondents, 31% reported ethical challenges and nearly two-thirds of respondents did not feel well prepared to deal with ethical challenges. Qualitative analysis of the 17 semi-structure interviews and narrative survey responses revealed many themes of 'ethics in practice': challenges in setting research priorities, navigating relationships with host country partners, scope of research practice, and human subject protections. Respondents reported that pre-departure trainings were not reflective of ethical frameworks or research contexts in LMIC, and few described seeking host mentor help in addressing ethical challenges. These results suggest a need for improvements in training, oversight and mentorship of trainee researchers, and to further engage both HIC and LMIC institutions, educators and researchers in addressing ethical issues.

Pre-departure and Post-elective Requirements for Global Health Electives: Survey of Canadian Royal College Emergency Medicine Programs

Objectives: Global Health (GH) electives offer unique learning opportunities; however, risks to trainees and host populations should be minimized through pre-departure training and post-elective debriefing. In a 2016 study, only three Canadian residency programs mandated such training, although specific data on Emergency Medicine (EM) programs is lacking. This study aimed to identify GH elective requirements and perceived training gaps among EM programs.

Methods: We conducted two email surveys (one each for EM program directors [PDs] and residents) regarding training requirements and perceived gaps for GH electives. We also contacted university postgraduate medical education (PGME) and GH offices, via their online publicized emails, to assess university-wide requirements and resources.

Results: Nine PDs responded, with 78% reporting having residents participate in GH electives. Many PDs (67%) believed residents were moderately prepared for GH electives, while 33% felt they were unprepared to some degree. Forty seven out of an estimated 380 EM residents responded with 35% having completed a GH elective during residency. Of those, only one (6%) reported feeling very prepared, and 43% believed there was a need to improve trainings. Uncertainty around training requirements was reported, and residents identified challenges faced on electives, as well as priority topics for training. Responses from PGME and GH offices indicated that pre-departure training and post-elective debriefing were required or available at more universities than was indicated by the PD and resident respondents. However university requirements varied widely, with some exclusively requiring basic travel information and Health and Safety checklists or modules. The disparate responses indicate that residents and PDs may either be unaware of university requirements or not utilize available training resources for GH electives.

Conclusions: Although Canadian EM residents participate in GH electives, the majority of training programs do not require pre-departure training or post-elective debriefing. PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure training and post-elective debriefing and encourage EM residents to access available university-wide training.

The Health of Nepali Migrants in India: A Qualitative Study of Lifestyles and Risks

Background: Most health research on Nepali migrant workers in India is on sexual health, whilst work, lifestyle and health care access issues are under-researched. Methods: The qualitative study was carried out in two cities of Maharashtra State in 2017. Twelve focus group discussions (FGDs) and five in-depth interviews were conducted with Nepali male and female migrant workers. Similarly, eight interviews were conducted with stakeholders, mostly representatives of organisations working for Nepali migrants in India using social capital as a theoretical foundation. Results: Five main themes emerged from the analysis: (i) accommodation; (ii) lifestyle, networking and risk-taking behaviours; (iii) work environment; (iv) support from local organisations; and (v) health service utilisation. Lack of basic amenities in accommodation, work-related hazards such as lack of safety measures at work or safety training, reluctance of employers to organise treatment for work-related accidents, occupational health issues such as long working hours, high workload, no/limited free time, discrimination by co-workers were identified as key problems. Nepali migrants have limited access to health care facilities due to their inability to prove their identity. Health system of India also discriminates as some treatment is restricted to Indian nationals. The strength of this study is the depth it offers, its limitations includes a lack of generalizability, the latter is a generic issue in such qualitative research. Conclusion: This study suggests risks to Nepali migrant workers’ health in India range from accommodation to workplace and from their own precarious lifestyle habit to limited access to health care facilities. We must conduct a quantitative study on a larger population to establish the prevalence of the above mentioned issues and risks. Furthermore, the effectiveness of Nepali migrant support organisations in mitigating these risks needs to be researched.

Pre-Departure Training for Student Global Health Experiences: A Scoping Review

Purpose: The authors identify the recommended pre-departure training (PDT) practices for physiotherapy students participating in a global health experience (GHE): both the content to be covered and the preferred learning methods to be used. They also discuss the implications of these recommendations for the physiotherapy field. Method: A scoping review of scientific and grey literature was performed to identify the recommended PDT practices. A thematic analysis was then performed to identify emerging themes. Results: The recommended PDT content broke down into the following areas: global health knowledge; ethics, introspection, and critical thinking; cultural competency; cross-cultural communication; placement-specific knowledge; and personal health and safety. The recommended learning methods were a combination of didactic, reflective, and experiential components that would enhance knowledge, develop cross-cultural skills, and address attitudinal changes. Conclusion: The growing participation of Canadian physiotherapy students in GHEs requires universities to adequately prepare their students before they leave to mitigate moral hazards. Given that little empirical research has been published on the effectiveness of PDT, the authors encourage collaborative efforts to develop PDT and evaluate its effectiveness for students and its impact on host communities.