In recent decades, thousands of healthcare professionals (HCPs) from high-income countries have volunteered their services in low-income countries (Centers for Disease Control and Prevention [CDC], 2011). Heeding the message from Christ, “I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, ... I needed clothes and you clothed me, I was sick and you looked after me” (Matthew 25:35-36, NIV), many Christians pursue international health missions. Serving as an HCP in short-term service of two weeks to six months in an international setting is an opportunity to serve, grow, and learn professionally and spiritually. Empowering countries to find rational and efficient solutions to their health problems is an important aspect of the work.
When an HCP volunteers internationally for a short period, the ability to work cooperatively to make decisions and deliver care with other members of the team, while performing with a high level of global health competence, is fundamental to being effective (Wilson et al., 2014). To best optimize international health collaboration, volunteers are encouraged to engage in a close examination of their global health competence.
Whether serving from a sense of altruism or seeking adventure, many volunteer HCPs do not prepare themselves or seek country-specific preparation before arriving in the country where they hope to serve (Wilson, Merry, & Franz, 2012). Volunteer HCPs may assume their current practice setting provides adequate experience to serve in resource-poor settings. Some reason that any healthcare is better than none, or the care they can offer is better than care existing in the host country. Therefore, they do not prepare adequately (Hawkins, 2013; Seager, 2012). They may lack knowledge of the country's culture or international directives for health improvement.
In fact, HCPs trained in developed countries can actually cause more damage than good when participating in short-term service in resource-poor settings (Hawkins, 2013; Seager, 2012). Having an attitude of superiority, based upon living in a country with material wealth and first-rate healthcare, can lead to paternalistic decision-making. Although some volunteer organizations provide an orientation for volunteers, the effectiveness is unknown or not measured. There is minimal research investigating the competence of volunteers who are the drivers and implementers of many global health projects. If volunteers are not properly prepared, effectiveness of the project could decrease, regardless of the evidence-base underlying interventions.
BUILDING GLOBAL HEALTH COMPETENCE
Significant health needs continue in many countries, and evidence exists of progressively worse health outcomes for those of lower social economic status within a country (Marmot, Allen, Bell, Bloomer, & Goldblatt, 2012; Marmot, Allen, Bell, & Goldblatt, 2012). More needs to be known regarding how to prepare volunteer HCPs to address global health inequities. The renowned Alma-Ata Declaration from the International Conference on Primary Health Care encouraged a more proficient and efficient use of the world's resources to protect and promote the health of all (World Health Organization [WHO], 1978). This includes a more effective use of human resources, which means individuals should be knowledgeable of, and competent in, global health. In addition, the United Nations advocates for world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women through the Millennium Development Goals (MDGs) (United Nations, 2000). At the 2011 World Conference on Social Determinants of Health, global leaders identified key action areas to address health inequities: improved governance and collaboration; greater participation in policy-making and implementation; focus on reducing health inequities; and accounting of progress (WHO, 2011). A curriculum based on understanding these core areas could improve the ability of HCPs to support health initiatives within social, cultural, economic, and environmental contexts where they go to serve.
A pilot study was designed to evaluate change in global health competence and team collaboration scores of HCP volunteers after completing an educational intervention focused on preparation for short-term service in resource-poor settings. Resource-poor is defined as having inadequate water, food, or healthcare, with an income level of approximately $1.25/day (The World Bank, 2013). When volunteers are serving in other nations, global competence is required to develop and implement solutions for the people being served. For the purposes of this study, global health competence refers to competencies that focus on issues pertaining to health and issues that affect health other than one's own, and is defined as the ability to “provide care in a clinically competent, safe, and culturally appropriate manner” (Wilson, Merry, & Franz, 2012, p. 213).
Engaging in evidence-based global health diplomacy can lead to more effective outcomes (Hunter et al., 2013). This relies on a fuller understanding of a country's goals, strategies, and resources. Sustainable health outcomes depend upon well-informed interdisciplinary HCP teams (Chan, Store, & Kouchner, 2008). The impetus for this study derived from the primary investigator's international experiences on a variety of levels: medical missions, instructor in global health nursing, international disaster volunteer and advisor to the development of an international health alliance. Although multiple anecdotal reports provide guidance on how best to prepare international volunteers, little evidence exists regarding evaluation of the preparation of volunteers.
TAKING IN THE PEOPLE'S VIEW
The emancipatory perspective provided the philosophical underpinning for this project. This perspective emphasizes the emic view of the situation, which is best described by a cultural native. This view provides an opportunity for local solutions or resolutions to be designed and implemented. Guided by this perspective, one uncovers the social, historical, and ideological forces inhibiting human growth; such oppressive forces lead to injustice (Airhihenbuwa, 1995; Chinn, 2011).
Paulo Freire speaks of “taking in the people's view of the world” (2005, p. 182). Dialogue between providers and receivers of care must occur with a sense of hope, and in the context of critical thinking based upon mutual trust, where all involved are equal (Chinn, 2011). For emancipatory nursing practice, one analyzes the social and political structures, recognizing that politics are values-based. Based on the emancipatory perspective, asset recognition and problem identification will unfold, as the group explores and discovers best ways of proceeding.
Although it is important to assure volunteers have a specific role in the host country (Withers, Browner, & Aghaloo, 2013), building social ties crossculturally is critical for global collaboration work. To avoid harm to the communities being served, one is cautioned against allowing untrained volunteers to perform healthcare, against focusing on the visiting team's medical interests, and not incorporating services and expertise of local providers (Seager, 2012; Wilson, Merry, & Franz, 2012). The Accra Agenda for Action on Aid Effectiveness (Organisation for Economic Co-operation and Development, 2008) lists five principles that acknowledge and guide the critical component of evaluating collaboration: (a) ownership by country, (b) alignment with country's goals, (c) harmonization of strategies between donors and country, (d) managing for development results, and (e) mutual accountability.
Challenges to implementation of health interventions include developing a better understanding of health priorities and assisting with their sustainability (Le Loup, Fleury, Camargo, & Larouzé, 2010; Mangham & Hanson, 2010). Historically, only measures of mortality, rather than other health-related quality measures, have been used to evaluate interventions. Oftentimes, interventions are not evaluated in resource-poor settings but only superficially adapted and implemented (Paltzer, Barker, & Witt, 2013).
This study used a pretest/posttest design with purposive sampling to evaluate a change in global health competence, and team collaboration scores of HCP volunteers after completion of an educational program for short-term service in resource-poor settings. Based on authoritative groups, it was thought that participation in an educational program, based upon global health competencies and international directives, would improve international HCP volunteers in both collaboration and global health competence. Two institutional review boards approved the study prior to participant recruitment. A consent statement for participation was provided to participants who indicated consent by proceeding with the pretests.
Participants initially were recruited from Lutheran church groups throughout the United States. A recruitment flyer was emailed to HCPs who had expressed interest in volunteering through the church. To increase participation, individuals from schools of nursing and hospitals in the primary investigator's home state were recruited. Participants also were asked to share the recruitment information with their colleagues.
Participants chose their preferred learning environment: online self-study modules or a two-day education program. A variety of teaching methods was combined to deliver content in a learner-friendly format. Online participants were emailed an electronic syllabus with URLs that provided access to the material. The education program was an abbreviated version of a three-credit college course required of all nursing students at a Lutheran college in the Midwest.
The education program content was based on international directives, including the WHO, MDGs, Institute of Medicine (IOM) reports, U.S. Centers for Disease Control and Prevention (CDC) recommendations, and the Alta-Ata Declaration, as well as authoritative literature published by international health practitioners. Faculty with expertise and experience in international health programs developed and provided the education program.
The program included an exploration of the issues of culture and regionalism, in the framework of modern international concerns, relating to health. A selection of world cultures was examined in the contexts of health, economics, social policy, and warfare (CDC, 2011; IOM, 2009; WHO, 2011). Participants evaluated the implementation of health programs across the globe.
The face-to-face program and online self-study utilized the same syllabus. The face-to-face program was a 12-hour course offered over two days. Various teaching methods were used, including PowerPoint presentations, discussions, writing, videos, short readings, web-based activities, and small group problem solving. Participants in the online self-study completed short reflection paragraphs upon completion of each topical section.
Participants viewed videos illustrating economic effects on health outcomes worldwide over the span of several decades. Two videos, Invisible Lives: Newborn Health in Nepal and Malawi (Balfour, 2010) and Mimba (Johansson, 2008), poignantly illustrate the daily struggles of women, children, and the people who try to help them attain health. The videos capture the challenges for healthcare providers and the emotional toll of working with too few resources.
Participants reviewed short, online articles describing maternal child health problems in resource-poor settings and the WHO global strategy for maternal child health. They also wrote a one-page reflection about the causes of maternal child health problems and what interventions might be helpful.
Participants searched online through the MDGs to determine benchmarks and progress. They used poverty calculators to compare various countries and relationships of income, life expectancy, and maternal mortality, then considered possible challenges to changing health outcomes.
Participants selected countries in which they might consider volunteering and were asked: What are the possible risks to health volunteers in particular settings? What personal health problems might preclude service in some settings? The CDC's recommendations for international health workers were reviewed, then participants discussed whether one country might be more appropriate for service than another, based on immunization requirements, availability of urgent medical care, or transportation system challenges.
The IOM (2009)Report on the United States Commitment to Global Health served as a discussion stimulator. This report emphasizes the coordination of public and private groups to align with MDGs, while supporting the host country's health workers. Participants in the online study completed a one-page reflection paper regarding the IOM report.
All aspects of the education program were viewed from a Christian perspective, acknowledging cultural differences and beliefs. Multiple philosophical views were shared, related to controversial topics. Participants reflected on personal beliefs and how these might affect serving different groups of people. For example, participants considered the HIV/AIDS epidemic in light of God's standards for one lifelong partner and sexual activity only within marriage. Discussions occurred in a nonthreatening, confidential environment. Learning objectives, the teaching outline, and teaching strategies with hyperlinks to content can be seen in Table 1.
Participants completed two measurement tools before and after the education program. Team collaboration was measured, using the Assessment of Interprofessional Team Collaboration Scale (AITCS) (Orchard, King, Khalili, & Bezzina, 2012). The AITCS uses a Likert-type rating scale with scores ranging from 37 to 185, with a higher score indicating higher collaboration. The AITCS consists of three subscales measuring partnership, cooperation, and coordination. Demographic information was collected with this tool, including age, gender, professional role, and educational background. This first tool took approximately 15 minutes to complete.
An instrument to measure global health competency in HCPs does not exist. Wilson, Harper, et al. (2012) adapted a list of global health competencies for medical students into a list of 30 competencies for nurses and surveyed 593 nurse educators in the Americas, asking if the competencies were essential for undergraduate nursing students. For the present study, a short-answer questionnaire of 26 global health competencies (GHCs), based on this work, was developed. Examples of the competencies are (Wilson, Harper, et al., 2012, pp. 216-217):
- Describe the major causes of morbidity and mortality around the world and how the risk of disease varies with regions.
- Describe major public health efforts to reduce disparities in global health (such as Millennium Development Goals, Global Fund to Fight AIDS, TB, malaria).
- Articulate barriers to health and healthcare in low-resource settings locally and internationally.
- Describe cultural and ethical issues in working with disadvantaged populations.
- Demonstrate a basic understanding of the relationship between health and human rights.
- Identify signs and symptoms for common major diseases that facilitate nursing assessment in the absence of advanced testing, often unavailable in low-resource settings (cardiovascular disease, cancer, diabetes).
One member of the study team evaluated and scored all of the short answers on the 26 items, with each item valued at one point. Correct answers to the items were points drawn from the teaching resources used for the training. A minimum of one specific, objective response was required to obtain a point for the item question, for a possible total score ranging from 0 to 26. For example, competency one states: “Describe the major causes of morbidity and mortality around the world and how the risk of disease varies with regions.” A correct answer would include one or more of the following: postpartum hemorrhage, malaria, respiratory infection, and diarrhea, and would describe how risk varies with regions. The GHC questionnaire took approximately 15 minutes for participants to complete.
RESULTS: IMPROVED COMPETENCE
Participants in this pilot study were a convenience sample of North American HCPs interested in short-term volunteering in resource-poor global settings. Eighteen participants (N = 18) completed the pretests; 11 completed the posttests. Figure 1 illustrates their discipline and the learning environment they used for the program. One online participant completed only the AITCS pretest, and one online participant completed only the GHC questionnaire pretest. Seven participants completed the two-day, face-to-face education program and all pre- and posttest surveys. Eleven participants enrolled in the online education program, with only four completing it. The primary reason noted for not completing the online program was lack of time to complete the 12 hours of self-study. Because of the small number of participants, the difference between learning environments (online vs. face-to-face) could not be assessed.
Two males and 16 females participated, ranging in age from 24 to 70 years, with an average age of 46. The following healthcare professions were represented: registered nurse (n = 14), medical assistant (n = 2), public HCP (n = 1), and physical therapy assistant (n = 1). Reported educational background was certificate (3), Bachelor of Science in Nursing (8), Master of Science (5), and Doctor of Philosophy in Nursing (1).
Paired sample t tests were performed on results from the AITCS, AITCS subscales, and GHC short-answer questionnaire (Table 2). A mean increase of 3.7 on the GHC questionnaire score after the education program was statistically significant. Results suggest a possible improvement in the AITCS subscale Cooperation post programs that approached statistical significance. Although not statistically significant, a decrease in the AITCS subscale Coordination occurred pre- to posttest. This decrease may have resulted from exposure to concepts and topics participants assumed to understand and know prior to the educational program. Subsequently, they may have recognized their inaccurate assumptions about the concepts included in collaboration, that is, partnership, cooperation, and coordination, and scored at a lower point on the scale posttest.
In this pilot study, the small sample size (N = 18) and lack of randomization and a nontreatment group limit the generalizability of study findings. Another limitation is the homogeneity of the sample—all participants were from two upper Midwest states and were primarily Lutheran in faith tradition. They did have various educational backgrounds and professional roles.
Further limitations came from the measures used in the study. The AITCS may be measuring aspects of collaboration not fully addressed by the education program content. The assessment of global health competence used a short-answer questionnaire that may have been more difficult for participants to complete than a Likert-scale type survey. The subjectivity of scoring the GHC questionnaire, using a single scorer, as well as no assessment of validity and reliability, are limitations. However, the items of the questionnaire have been previously assessed for content validity (Wilson, Harper, et al., 2012).
This pilot study provides insight that could guide decision-making for organizations using international health volunteers. Study findings support that a formal education program for international health volunteers can improve team cooperation and global health competence. Although altruism, passion, and commitment are commendable characteristics of the international HCP volunteer, an understanding of global health issues and concerns is fundamental to the work and to collaboration with organizations and providers in resource-poor countries. A willingness to engage in new ways of viewing issues provides opportunities that may otherwise have been missed (Panizales, 2013). Exposure to an educational program prior to serving can change volunteers' attitudes and behaviors, leading to collaborative relationships and better health outcomes (Reyes, Zuniga, Billings, & Blandon, 2013).
The task of engaging international health volunteers in the learning process needs refinement. The online self-study offered better accessibility and convenience to a wider audience; however, fewer participants completed the program online, reporting they could not find the time to complete the study. As an alternative and less convenient, the face-to-face two-day education program method allowed for group discussion and learning from one another's experiences. Rich conversations enhanced and contributed to the learning process.
Based on anecdotal feedback and results of this pilot study, this education program will be incorporated into an existing orientation program for short-term international health volunteers. Although informal feedback from the online study participants suggested the program seemed too lengthy, outcomes demonstrated an improvement in global health competency and possible improvement in team cooperation after completing the education program. Face-to-face participants had a 100% completion rate; therefore, a semi-annual in-person program is being considered. To offer the workshop to more participants, different geographic locations are being considered.
Excellent work has been done in delineating the global health competencies essential for medical and nursing education (Wilson, Harper, et al., 2012). However, research is needed to ascertain the utility of the competencies for assessing global health competence of HCPs. Program evaluation of the educational intervention through follow-up with participants and host country health workers after a short-term experience provide important feedback. The impact of different learning options (face-to-face or online) on outcomes needs to be assessed. The development of an instrument to measure global health competence would be beneficial to organizations facilitating volunteer healthcare opportunities.
Many are inspired by the words of the Old Testament prophet Micah, who wrote, “He has showed you, O man, what is good. And what does the LORD require of you? To act justly and to love mercy and to walk humbly with your God” (Micah 6:8). This biblical directive supports the Christian HCP who desires to serve. A heart for service, coupled with purposeful preparation, may optimize health outcomes and professional experiences when offering healthcare in an international setting.
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