William Cherniak

Short term global health experiences and local partnership models: a framework.

AbstractContemporary interest in in short-term experiences in global health (STEGH) has led to important questions of ethics, responsibility, and potential harms to receiving communities. In addressing these issues, the role of local engagement through partnerships between external STEGH facilitating organization(s) and internal community organization(s) has been identified as crucial to mitigating potential pitfalls. This perspective piece offers a framework to categorize different models of local engagement in STEGH based on professional experiences and a review of the existing literature. This framework will encourage STEGH stakeholders to consider partnership models in the development and evaluation of new or existing programs.The proposed framework examines the community context in which STEGH may occur, and considers three broad categories: number of visiting external groups conducting STEGH (single/multiple), number of host entities that interact with the STEGH (none/single/multiple), and frequency of STEGH (continuous/intermittent). These factors culminate in a specific model that provides a description of opportunities and challenges presented by each model.Considering different models, single visiting partners, working without a local partner on an intermittent (or even one-time) basis provided the greatest flexibility to the STEGH participants, but represented the least integration locally and subsequently the greatest potential harm for the receiving community. Other models, such as multiple visiting teams continuously working with a single local partner, provided an opportunity for centralization of efforts and local input, but required investment in consensus-building and streamlining of processes across different groups.We conclude that involving host partners in the design, implementation, and evaluation of STEGH requires more effort on the part of visiting STEGH groups and facilitators, but has the greatest potential benefit for meaningful, locally-relevant improvements from STEGH for the receiving community. There are four key themes that underpin the application of the framework: 1.Meaningful impact to host communities requires some form of local engagement and measurement2.Single STEGH without local partner engagement is rarely ethically justified3.Models should be tailored to the health and resource context in which the STEGH occurs4.Sending institutions should employ a model that ultimately benefits local receiving communities first and STEGH participants second. Accounting for these themes in program planning for STEGH will lead to more equitable outcomes for both receiving communities and their sending partners.

Educational objectives for international medical electives: a literature review.

Purpose Although most medical schools and residency programs offer international medical electives (IMEs), little guidance on the educational objectives for these rotations exists; thus, the authors reviewed the literature to compile and categorize a comprehensive set of educational objectives for IMEs. Method In February and July 2012, the authors searched SciVerse Scopus online, which includes the Embase and MEDLINE databases, using specified terms. From the articles that met their inclusion criteria, they extracted the educational objectives of IMEs and sorted them into preelective, intraelective, and postelective objectives. Results The authors identified and reviewed 255 articles, 11 (4%) of which described 22 educational objectives. Among those 22 objectives, 5 (23%), 15 (68%), and 2 (9%) were, respectively, preelective, intraelective, and postelective objectives. Among preelective objectives, only cultural awareness appeared in more than 2 articles (3/11; 27%). Among intraelective objectives, the most commonly defined were enhancing clinical skills and understanding different health care systems (9/11; 82%). Learning to manage diseases rarely seen at home and increasing cultural awareness appeared in nearly half (5/11; 45%) of all articles. Among postelective objectives, reflecting on experiences through a written project was most common (9/11; 82%). Conclusions The authors identified 22 educational objectives for IMEs in the published literature, some of which were consistent across institutions. These consistencies, in conjunction with future research, can be used as a framework on which institutions can build their own IME curricula, ultimately helping to ensure that their medical trainees have a meaningful learning experience while abroad.

Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions

Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.

Career opportunities in global health: A snapshot of the current employment landscape.

Recent decades have witnessed a burgeoning interest in improving health and health systems in low and middle–income countries (LMIC). With the increase in program funding came parallel increases in the number of university programs in the US and Europe offering concentrations or degrees in a global health field [1–6]. The changes have been brisk and substantial [5–8], and beg the question: What do we know about the global health job market? While a few studies have provided limited insights into the employment landscape, the last comprehensive attempt to answer this question was by Baker 30 years ago [9]. Key questions (as yet largely unanswered) about the current global health job market include: How satisfactory is the numerical balance between job aspirants and job openings? Are the trend lines of aspirants and openings similar or divergent? Are we at risk of having too many job seekers or too few? How good is the qualitative match between employer needs and training program outputs? Which competencies are in short supply [10–12]? What are the contributions, and liabilities, of short–term trainee and volunteer participation in the workforce? How do their contributions fit into the larger picture of the global health workforce [5,10–12]? Answering these questions will take substantial effort through carefully structured investigations to provide reliable answers. In this article, we present a limited pilot study through a targeted web–based job posting review that does not attempt to answer all these questions but sheds some light on the current landscape of employment opportunities in program management, clinical, and public health–related aspects of global health in international settings. The investigative team consisted of five physicians, one with a doctorate in psychology, and another with a doctoral degree in Public Health. The team convened in March 2013. Review of online job postings occurred between November 2013 and January 2014. Websites with employment opportunities in global health were identified using the Google search engine. The terms, “Global Health Work,” “Global Health Jobs,” “Global Health Job Opportunities,” “Global Health Workforce,” “Global Health Hiring” were searched in August 2013. These searches returned a large number of results with potential sources of job information. From this sizeable response, for feasibility and efficiency’s sake, an initial cohort of 14 websites were selected, limited to English language websites primarily affiliated with organizations in North America, and (if the site permitted access) to a regularly available and rotating list of job postings. A similar consideration in prioritizing this initial pilot list was the Google “PageRank” of each site. Page Rank is an objective measure of a citation’s importance that corresponds with users subjective idea of importance [13]. Over the course of the entire survey, 12 further sites were selected to accrue additional postings by applying the same inclusion criteria. The need for additional sites addressed cyclical pauses in available job postings on several sites. Global health workforce employment opportunities were described as positions that focus on health–related efforts in low– and middle–income countries (LMIC). The investigative team developed a standardized selection and coding tool using a shared online document matrix. The tool allowed for easy categorization of a number of factors related to the job in question. 26 websites in total were selected for inclusion. Each investigator was assigned one high traffic website with frequent job postings and another with lower traffic and fewer postings. The six investigators then each reviewed a subset of the websites during two 6–week sampling periods. Each investigator retrieved a minimum of 10 job postings during each sampling period. The results were then tabulated and underwent basic statistical analysis. In this limited, but wide–reaching review of online job postings that included 178 employment opportunities from 26 websites, key findings included: 67% (119/178) of the positions were in non–governmental organizations (NGOs) in both developed countries and LMICs. When combined with multinational organizations such as the World Health Organization (WHO) and the World Bank, the two employer types accounted for 89% (158/178) of the total (Figure 1, plate A). Figure 1 Depiction of survey results of career opportunities in global health. A) Breakdown of types of global health employers. B) The primary disciplines sought by employers. C) Highest academic achievement required or desired by employers. D) A sub–categorization ... 14% (25/178) of the positions involved clinical disciplines primarily medicine. (Figure 1, plate B). 50% (89/178) of job posts included the request for applicants to have the kind of knowledge and skills normally acquired in schools of public health offering courses relevant to global health.(Figure 1, plate B) 51% (91/178) of the listed opportunities required at least a Master’s degree level of qualification or doctoral degree (23%, 41/178) (Figure 1, plate C). Photo: Courtesy of Trisha Pasricha, personal collection (from the documentary “A Doctor of My Own”, directed by T. Pasricha) 84% (149/178) of the positions were program–related. Program–related jobs included planning, program direction, finance, management and other supportive functions (not depicted but subcategorized in Figure 1, plate D). The majority of program–related jobs were identified to be at the senior program management and direction level (58% (87/149) (Figure 1, plate D). Second most common were supportive program functions (28% 41/149) followed by other support activities (9% 13/149) and program financing (5% 8/149) (Figure 1, plate D). Salary information, which could provide a basis for assessing the strength of demand and for calculating a rate of return on a global health job, was provided in only 18% (32/178) of the job offerings. Of those listed, most (56%, 18/32) were in the US

Images in clinical medicine: Syphilitic gumma.

61 000 – 90 000 range (Figure 2). Figure 2 Distribution of global health jobs based on salary range. The size, characteristics and trends of the global health workforce and jobs available are largely unknown. Our pilot study of internet–based job postings provides a initial snapshot of one view of global health employment opportunities in international settings. Aside from highlighting the many as yet unanswered questions regarding the global health workforce, the study itself has limitations with respect to its specific focus on the job market. These include: small sample size, use of only English language job postings accessible on the internet, the scant salary and benefit information available, and the generally limited scope of positions in LMICs. The salary ranges available may be on the lower end as higher salary jobs may conceivably not be publicized. We did not attempt detailed analysis of the many discrete skills sought by employers, nor did we make follow up phone calls to employers to learn whether they readily filled the advertised positions and with the requisite qualifications. Despite these limitations our findings have implications for the curricula of global health educational programs and to graduates seeking employment and career opportunities. For instance, our investigation draws attention to the importance of public health training and to program management skills. Global health programs should seek to include training in public health with an emphasis on leadership, planning, management, financial, communication, evaluation and related programmatic skills. Given that 74% of the jobs we surveyed required a Master’s degree or higher, the importance of advanced academic credentials is evident. This high level academic qualification has clear implications for students and trainees seeking a career in global health as they will be required to spend more time and tuition in academia before entering the job market. Given the ongoing increases in tuition costs for many undergraduate and advanced degrees, the average salaries offered may appear inadequate for those needing to repay student loans. Our study suggests the importance of probing more deeply into the dynamics of the global health workforce, including how this workforce is trained and educated as well as the employment opportunities available following the completion of training. Pending an updated investigation along the lines of the Baker 1982 study, several interim studies might be considered: (1) studies to gain a better understanding of the content and the characteristics of global health (and related) training programs; (2) studies to understand the match between employer needs and applicant qualifications; (3) analyses of the likely trends and stability of the global health job market; (4) surveys of the Global South host countries to determine if training among visitors from the Global North adequately meets their needs; (5) analyses of the intersections between domestic and international employment opportunities, training and career paths. We welcome exchanging views with others interested in learning more about the global health workforce.

Effectiveness of advertising availability of prenatal ultrasound on uptake of antenatal care in rural Uganda: A cluster randomized trial.

A 45-year-old woman presented to a clinic in rural Uganda with a 1-year history of a progressively enlarging ulcerated mass on the hard palate. The mass had initially been painless but recently had become painful and was causing difficulty in speaking and swallowing.

A Protocol to Develop Practice Guidelines for Primary Care Medical Service Trips

In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that “you will be able to see your baby by ultrasound” would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3–110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1–20.1) in control communities (rate ratio 5.9, 95% CI 2.6–13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4–31.2) compared to control (1.5, 95% CI 0.5–5.0, rate ratio 8.7, 95% CI 2.0–38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.

Assessing best practices on short-term medical service trips: an eDelphi-based theoretical model

BACKGROUND North American clinicians are increasingly participating in medical service trips (MSTs) that provide primary healthcare in Latin America and the Caribbean. Literature reviews have shown that the existence and use of evidence-based guidelines by these groups are limited, which presents potential for harm. OBJECTIVE This paper proposes a 5-step methodology to develop protocols for diagnosis and treatment of conditions encountered by MST clinicians. METHODS We reviewed the 2010 American College of Physicians guidance statement on guidelines development and developed our own adaptation. Ancestry search of the American College of Physicians statement identified specific publications that provided additional detail on key steps in the guideline development process, with additional focus given to evidence, equity, and local adaptation considerations. FINDINGS Our adaptation produced a 5-step process for developing locally optimized protocols for diagnosis and treatment of common conditions seen in MSTs. For specified conditions, this process includes: 1) a focused environmental scan of current practices based on grey literature protocols from MST sending organizations; 2) a review of relevant practice guidelines; 3) a literature review assessing the epidemiology, diagnosis, and treatment of the specified condition; 4) an eDelphi process with experts representing MST and Latin American and the Caribbean partner organizations assessing identified guidelines; and 5) external peer review and summary. CONCLUSIONS This protocol will enable the creation of practice guidelines that are based on best available evidence, local knowledge, and equitable considerations. The development of guidelines using this process could optimize the conduct of MSTs, while prioritizing input from local community partners.

Host perspectives on short-term experiences in global health: a survey

Abstract Background Short-term, primary-care medical service trips (MSTs) are a controversial modality for addressing the health of marginalised populations and responding to the burden of communicable and non-communicable diseases. As a health-care delivery model, MSTs are challenged by concerns over sustainability, fragmentation of care in host communities, and degree of preparedness among volunteers. Despite the increasing prevalence of such trips, no single framework is routinely used to evaluate their quality. We aimed to develop a literature-based tool for assessing the practices of volunteer MSTs and to validate this tool among stakeholders. Methods We reviewed recent literature to construct a preliminary list of commonly discussed MST best practices. A multidisciplinary panel of academic experts, medical professionals, MST programme coordinators, and non-medical MST volunteers participated in a three-round e-Delphi consensus-building exercise to revise the preliminary list. A 7-point Likert scale was used, with mean scores of 4–7 resulting in rejection of the element, scores less than 2 resulting in acceptance, and scores in between being redistributed for further discussion in rounds two and three. Findings The preliminary framework consisted of 30 elements sorted into six domains: preparedness, impact and safety, efficiency, cost-effectiveness, sustainability, and education. The 26 stakeholders on the eDelphi panel reached consensus on 18 desirable elements to include in the final framework for an effective MST. The elements of the final framework were directly adapted to create a rating scale for medical professionals and trainees to evaluate the practices of volunteer-sending organisations listed in a large online database ( http://www.medicalservicetrip.com ). Interpretation Evaluation of such practices will allow volunteers to select quality opportunities with effective, sustainable health-care delivery models. Future research should extend this study by initiating a dialogue on best practices between host communities, local clinicians, and MST-sending organisations. Funding None.

Grassroots Partnership to See and Treat Cervical Cancer in Rural Uganda

Abstract Background Competencies developed for global health education programmes that take place in low-income and middle-income countries have largely reflected the perspectives of educators and organisations in high-income countries. Consequently, there has been under-representation of voices and perspectives of host communities, where practical, experience-based global-health education occurs. In this study, we aimed to understand what global-health competencies are important in trainees who travel to work in other countries, seeking opinions from host community members and colleagues in low-income and middle-income countries. Methods We performed a literature review of current interprofessional global health competencies to inform our survey design. We used a web-based survey, available in English and Spanish, to collect data through Likert-scale and written questions. We piloted the survey in a diverse group of 14 respondents from high-income, middle-income, and low-income countries and subsequently refined the survey for greater clarity. We used convenience sampling to recruit participants from around the world and included a broad range of coauthors. A website was constructed in English and Spanish and the survey link added. This website and link were distributed as broadly as possible. It was mandatory for survey participants to list their country of birth and current work in order to confirm representation. Findings We received 274 responses: 227 in English and 47 in Spanish between Sept 1, 2015, and Dec 31, 2015. Respondents were from 38 countries across all economic regions. After data cleaning, we included 170 responses (132 in English and 38 in Spanish): 44 (26%) from high-income countries, 74 (44%) from upper-middle income countries, 31 (18%) from lower-middle income countries, and 21 (12%) from low-income countries. Respondents spoke 22 distinct primary languages. In terms of pre-departure competencies, 111 respondents rated cultural awareness and respectful conduct while on rotations as important. For intra-experience competencies, 88 of 112 respondents (79%) thought that it was equally as important for trainees to learn about the local culture as it was to learn about medical conditions. 65 of 109 (60%) respondents reported trainees gaining fluency in the local language as being not important. In terms of post-experience competencies, none of the respondents reported that trainees arrive as independent practitioners to fill health-care gaps. Interpretation Most hosts and partners across economic regions appreciate having trainees from other countries in their institutions and communities. There was a strong emphasis from respondents on the importance of a greater focus on cultural learning and building respect over medical knowledge and clinical practice. Additionally, respondents did not believe that trainees fill important human resource gaps, but are instead being provided with a beneficial learning experience. By gaining insight into host perceptions on desired competencies, global health education programmes in low-income and middle-income countries can be collaboratively and ethically designed and implemented to meet the priorities, needs, and expectations of host communities. Our findings could change how global health education programmes are structured, by encouraging North-South/East-West shared agenda setting, mutual respect, empowerment, and collaboration. Funding Child Family Health International.