Hyder, Adnan A. MD, MPH, PhD; Meddings, David MD, MHSc; Bachani, Abdulgafoor M. MHS
Injuries kill more than 5 million people each year and disable many more, resulting in a heavy disease burden for people in all age categories.1 Injury accounts for 12.1% of global disability-adjusted life year (DALY) losses (a summary measure of healthy life lost from mortality and morbidity) and is likely to account for 13.6% of all DALY losses by 2030.2 More than a million people, two thirds of them in low- and middle-income countries (LMIC), are estimated to die annually from road traffic injuries, and more than 2,600 children are estimated to die each day from unintentional injuries.1 National and regional estimates have also demonstrated the impact of intentional and unintentional injuries in developing countries.3–5 For example, some estimates show that road traffic injuries alone have drained developing economies of 1% to 2% of their gross domestic product (GDP) (about $100 billion) each year, more than the total development aid these countries receive.6
Addressing this global health burden requires a coherent and integrated strategy aimed toward injury prevention. Such a strategy must include capacity development in terms of both adequate human resources (knowledgeable and skilled personnel working on injury issues) and the establishment of sustainable systems within which these individuals can be effective. The inequities in financial viability, infrastructural readiness, and effective experience with injury prevention compared with other medical fields all underscore the great need for capacity development in injury prevention in LMIC.7–9
In addition, LMIC poorly fund public efforts in injury control.1,10 Even adjusting for the 20- to 30-fold difference in GDP per capita between developed nations and these poorer countries, this poor funding reflects the low priority given to safety in developing countries.11 Given this low level of investment, the generally neglected development of an adequately trained human resource base, and a relatively underdeveloped infrastructure to enable injury prevention, a rational approach for the development of capacity for injury prevention is not only timely but also possibly extremely beneficial to public health and welfare. In this article, we will discuss a new global mentoring program for injury and violence prevention known as MENTOR-VIP. We will cover the program’s rationale, modalities, objectives, and evaluation within the larger issue of developing human resource capacity to improve global public health.
Human Resources: A Rationale for Capacity Building
The importance of developing skilled human resources as a component of capacity building for health is well established. The area of health research offers some illustrative examples of the importance ascribed to building human resource capacity, some potential pitfalls of developing this capacity, and several established needs that require attention.12,13 Some past efforts to increase human resource capacity incorrectly assumed that research scientists from LMIC who train in high-income countries would return to their home countries. The associated brain drain and other issues (e.g., urban concentration of human resources, public- to private-sector drain) have contributed to recent concerns about the impact of such training programs on LMIC, particularly at the national level.14–16 In addition, low salaries and the lack of opportunities for professional advancement are also factors previously identified as significant contributors to the brain drain of health professionals from low-income settings.17
The exact percentage of health professionals who work in the injury prevention field is unclear; however, brain drain affects both the health and the allied health sectors (including injury prevention practitioners) of LMIC in general.17 MENTOR-VIP does not require a change in location or residence; it provides need-specific capacity building, and it is focused on the objectives defined by those joining the program.
Mentoring: Modalities for Developing Human Resources
Knowledge refers in a general sense to an awareness of information or facts and principles while skills refer to an ability to do something well and typically something requiring training and experience. Therefore, skills and their development usually imply both some prerequisite knowledge and additional expertise gained through experience. While people can gain knowledge to a large extent through formal training venues, skills flow from innate ability coupled with experience. Skills can also benefit, in particular, from mentoring.
Mentoring is a process of trusted counseling from one entity or person to another and can occur in different forms: individual-to-individual mentoring, group mentoring, peer mentoring, and institution-to-institution mentoring. While no universally accepted definition for mentoring exists, most definitions emphasize aspects related to skills development on the basis of transfer of experience between individuals. The operational definition adopted for the purpose of this article is “a deliberate pairing of a more skilled or experienced person (henceforth, the mentor) with a lesser skilled or experienced one, with the agreed-on goal of having the lesser skilled person (henceforth, the mentee) grow and develop specific competencies.”18
MENTOR-VIP: Mentoring for Injury Prevention
MENTOR-VIP derives its name as a complement to TEACH-VIP (itself an acronym for Training, Educating, Advancing Collaboration in Health on Violence and Injury Prevention). TEACH-VIP is a modular injury prevention and control curriculum developed by the World Health Organization (WHO) and a global network of injury experts to address the lack of injury-specific content in public health schools and medical schools, as well as within the broader injury prevention community.9 TEACH-VIP focuses on knowledge transfer and addresses an important gap in educating public health professionals; it is not designed to develop skills among the training or any audience.
Recognizing the need for a complementary modality that addresses skills development, WHO convened a global consultation in June 2006 to discuss the development of a global mentoring program for injury prevention. Participants included a range of injury experts from academia, training, research, ministries of health, and nongovernment organizations. The consultation established a number of founding principles (List 1) as the basis for the MENTOR-VIP program, the documentation for which participants drafted and peers reviewed by January 2007. The drafters felt these principles to be a strong foundation on which to build a program that would address the need for skills, incorporate sustainability, and prioritize mentee skills building.
The program is designed to set up a 12-month voluntary working relationship between junior injury prevention practitioners and more experienced individuals in the field of injury prevention. Its general objective is to improve global human resource capacity to effectively prevent and control injury and violence through the enhanced development of relevant skills. The specific objectives of the program in the first five years are (1) to match at least 100 mentor and mentee pairs and to ensure they complete their mentorships during the first five years of the program (2007-2011), (2) to maintain the proportion of mentoring pairs who do not conclude the mentoring arrangement at less than 5% during any given year, (3) to ensure that, during the first five years of the program, selected mentees come from all six of WHO’s regions and mentors come from at least four of these regions (Africa, South East Asia, Western Pacific, and Eastern Mediterranean), (4) to complete an initial evaluation of the pilot phase of the program within the first three years, and (5) to ascertain, on the basis of objective criteria, that at least 20 mentees have made substantive contributions to injury and violence prevention in their locations within the first five years of the program.
The program is currently in its pilot phase and is nearing the end of its second formal mentoring cycle, which began on September 1, 2008, and during which 15 mentor-mentee partnerships formed. By the end of the first cycle, 13 mentoring pairs are scheduled to have completed the accord. We received all of the applications for the second cycle by May 2008, and 19 pairs have signed their mentoring accord for 2008-2009. The pilot phase of MENTOR-VIP will last through two mentoring cycles, and we plan to carry out the first formal evaluation by the end of this year (2009). Currently, the mentors and mentees do not receive payment or financial assistance during this program.
Constituents and Skill Categories of MENTOR-VIP
As currently structured, four major constituent groups comprise MENTOR-VIP: (1) the Core Group, (2) WHO, (3) the mentors, and (4) the mentees (Figure 1).
The Core Group
The Core Group comprises nine individuals from diverse backgrounds relevant to injury prevention and includes one WHO staff member. WHO selects members of this group based on their experiences in global injury prevention; members remain part of the Core Group for an initial period of three years. The group provides overall guidance to the program, identifies appropriate individuals to become possible mentors, assesses applications and awards mentorships, and provides guidance for important activities related to the program such as evaluations.
WHO coordinates the program, financially supports the annual meeting of the Core Group, and ensures all secretariat functions for the program. WHO provides financial support for the coordination and evaluation of the program through staff support and ensures wide dissemination of the program within WHO’s global health networks. WHO also ensures that experiences from MENTOR-VIP are shared globally in order to benefit and potentially strengthen existing models that develop human resource capacity for global injury prevention and public health.
The Core Group selects mentees through a formal application process. Mentees submit their applications to the program by completing a candidate profile on the WHO Web site (www.who.int/en). While mentees do not need to meet any specific minimum qualifications, these individuals generally have an advanced degree and have demonstrated an interest in injury prevention in LMIC. The candidate profile elicits information about each mentee applicant’s education and experience, his or her linguistic and residential preferences, and his or her motivation for applying to the program. Mentee applicants must also indicate which area of skills they most want to develop. For this purpose, MENTOR-VIP defines eight different skill categories: (1) planning and conducting research, (2) evidence-based program design and planning, (3) program implementation and management, (4) program monitoring and evaluation, (5) policy analysis and development, (6) imparting knowledge and skills to others, (7) advocacy and communication, and (8) ensuring funding support.
WHO approaches mentors on behalf of the Core Group to determine whether they would agree to make the 12-month commitment to volunteer in the program. Selection of mentors is based on a number of factors: the breadth and depth of each potential mentor’s relevant skill sets, his or her established ability and interest in exchanging skills with less experienced individuals, and diversity in the skills, regions of origin, and language within the overall pool of mentors. By the beginning of the second cycle, the MENTOR-VIP database listed 19 mentors from all six regions of WHO and nearly all disciplines (e.g., public health, economics, engineering, transportation) important for injury and violence prevention.
The Core Group reviews candidate profiles during an annual meeting (July 2007, June 2008, June 2009) and matches the most appropriate mentee applicants with the most appropriate mentor from the pool of mentors available. Upon their acceptance of the award, we ask mentorship pairs to jointly develop a work plan for the 12-month mentorship, known as the mentoring accord. Both the mentor and the mentee sign this mentoring accord as well as a document laying out the program principles and commitments, and WHO receives a copy of the accord before the formal mentorship begins. At this time, MENTOR-VIP has established no formal course work or training to mentees in the program.
Evaluation of MENTOR-VIP
The success of this program, in great part, is a function of how well mentees can fulfill their own needs through MENTOR-VIP and sustain their interest and work in injury prevention after the 12-month contract. MENTOR-VIP will conduct evaluations at the end of the pilot phase (2009) and then at the end of the first five years (2011). The pilot phase evaluation will ask participants to assess the coherency of the overall framework of the program, how well specific processes worked, and whether assumptions (e.g., about financial implications) were valid. Over the medium term (five years), some of the outputs (e.g., papers, research proposals) and potential outcomes (e.g., trained professionals, policy change) will become more important. In both the pilot and five-year evaluations, systematic and structured feedback from mentors and mentees will be central and will allow the program to track the progress of mentors and mentees; this feedback will also enable the program to assess its contributions in terms of increased institutional or national capacity and in terms of greater promotion of practice and more research on injury. Specific indices will serve to inform continuous quality improvement of the program and serve to address how such efforts contribute to the larger goal of injury capacity development.
The Core Group, in consultation with external experts, will determine the framework to be used for monitoring and evaluating the program. In general, an approach that assesses four levels of the program—inputs, processes, outputs, and outcomes—over three time periods (prementoring, mentoring, and postmentoring) might be useful as it has been for evaluating other capacity development programs.19 Because the anticipated overall outcome of this initiative is to contribute toward a positive change in injury capacity globally, MENTOR-VIP will also require assessment of the overall impact of the program at three levels—individual, institutional, and global. During the pilot years of the training program, the Core Group and WHO will carefully discuss and further refine the focus of evaluation of the institutional and global impact.
Lessons learned thus far
During the development of MENTOR-VIP and its subsequent roll-out, we have learned that effective and regular communication, as well as managing expectations between the mentor and mentee, play a key role in the perceived success of the program. In addition, we have discovered that cultural and language differences, as well as time zones, require special attention, and all invariably play a significant role in the effectiveness and frequency of communication between mentoring pairs. We are already learning several important lessons through the midcycle feedback received from the first mentor-mentee pairs; this feedback suggests that, for the process to be effective, the mentor-mentee pair ought to (1) recognize barriers to progress and explicitly address them, (2) regularly review and revise the mentoring accord as the mentorship progresses, and (3) monitor that both parties are tracking progress.
We will incorporate and evaluate the sustainability of the program in multiple ways. First, the program itself reflects a shared vision of mentoring as a low-cost or cost-neutral form of collaboration. Secondly, we are devoting attention to the planning and execution of the program to allow mentees to incorporate injury work or research into their current professional positions. Third, we will develop structured opportunities for electronic interactions (a list serve, a newsletter) to discuss issues, allowing trainees across the years—and across the globe—to brainstorm and network. Fourth, the program will do what it can to foster the integration of mentees into existing injury networks, encouraging attendance at world injury conferences and participation in other relevant regional networks that can serve as resources for continuing collaboration, guidance, and professional development.
The high burden of injuries, the lack of human resources in LMIC, and the paucity of funds for structured training and degree programs in the developing world all make a clear case for investing in this field. MENTOR-VIP offers an innovative, sustainable, and flexible mechanism to match supply and demand for a tightly focused training experience that prioritizes development of key skills among more junior injury practitioners. Given the relative dearth of global public health investment in injury prevention and capacity building within this area, it represents a strategic response to make effective use of the resources and assets available within the global injury prevention community. MENTOR-VIP will be both an important contribution to building global capacity for violence and injury prevention and control, and a needed complement to TEACH-VIP (other projects are exploring opportunities to more tightly integrate these complementary programs). Targeting skills development is a compelling approach to strengthening human resource capacity in health; the MENTOR-VIP program is not only timely but also has the potential to further catalyze collective effort among the international injury prevention community.
The authors would like to acknowledge the Core Group, mentors and mentees currently within the MENTOR-VIP program, other individuals for their input through discussions organized by the World Health Organization in Durban, South Africa and Geneva, Switzerland, and colleagues who have informally influenced the writing of this paper. The views and opinions expressed in this paper do not represent the views of the World Health Organization or Johns Hopkins University.
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