TYPES OF OUTREACH ACTIVITY
Vertical (“parachute”) missions typically involve spending seven to 14 days in a host country to address a specific problem or provide a specific service. Trips may or may not involve much coordination from local providers, but it is critical to contact the local ministry of health to determine what regulations and credentialing apply. Although this type of mission can play a role in identifying local partners and providing basic services, if certain services such as dispensing hearing aids are completed during a short-term project, it can cause more harm than good. Dispensing hearing aids or seeing patients with chronic medical conditions requires a long-term commitment of human and monetary resources. Welling, et al., encapsulated these potential problems in their article, “The Seven Sins of Humanitarian Medicine” (Table1).1 Avoiding these “sins” will lead to a successful outcome.
Another way to get started is by providing hearing care through an existing umbrella organization that works in the region of interest. Umbrella organizations, particularly those with a permanent presence in a country, can provide insights into the local needs of the community, as well as connections with local physicians, clinics, hospital, schools, and universities. Existing program goals must be aligned with yours, and everyone involved must be committed to developing a plan to create or expand hearing services in the region. To start, carefully assess your strengths and talents, as well as those within the umbrella organization before moving forward with this type of mission trip.
Recurring outreach trips can serve as a step toward setting up your own vertical mission or becoming part of an established program. By returning to the same region or site, you can begin coordinating care with local partners and providers to support the needs of patients in between trips. Local partners should be interested in your activities and empowered to support your work. However, it is equally important for your work to support their efforts. This collaborative relationship will create a pathway for developing a long-term, sustainable project.
Integrated long-term community-based programs involve building infrastructure, with an emphasis on training/capacity building. Typically, such programs engage with other aspects of the health care system (e.g., rehabilitation or educational services) and have increased family/caretaker involvement. Such a program may provide more advanced services that require multidisciplinary or widespread activities such as telehealth, infant screening, or cochlear implantation. Training should involve primary care workers who can raise awareness and provide referrals. The World Health Organization (WHO) provides excellent materials for the training of primary care providers (see Table 2 online: bit.ly/Table2Saunders).2 A sustainable fund-raising strategy and/or a business model that includes local providers may be needed. If your host country does not have a national plan for ear and hearing care, the WHO provides helpful resources to develop one. It may also be helpful to approach other non-health agencies or institutions such as local universities to develop such a plan.
BUILDING A SUSTAINABLE AUDIOLOGY PROGRAM IN NICARAGUA
To illustrate this process, we will highlight an integrated, long-term, community-based program and how this non-profit and an American university work together to build capacity in Nicaragua. Mayflower Medical Outreach (MMO), Inc., began providing ear and hearing care services in the rural community of Jinotega, Nicaragua, in 1998. In 2005, the group recognized the need for deaf education, and by 2010, a permanent residential facility was built in Nicaragua. The group organizes biannual week-long mission trips with volunteer audiologists, otolaryngologists, speech pathologists, and deaf educators from across the United States. Today, the program has grown, with strong collaborations with local professionals and organizations, the Ministry of Health, and other like-minded individuals and groups from the United States. Equipment and supplies are obtained through donations, purchasing discounts, and grant funding.
Audiology Services. MMO provides diagnostic audiology services and hearing aids to patients across the lifespan following WHO Guidelines.2 Hearing aids are purchased at steep discounts through the International Humanitarian Hearing Aid Purchasing Program (IHHAPP) under the administration of MMO. Using digital behind-the-ear models that can be adjusted with trimpots, the need for sophisticated computer equipment, which are likely unavailable in low-resource settings, is eliminated. Earmolds are provided through an in-country lab or using preformed molds. Following fitting and counseling, patients receive a one-year supply of batteries (replenished annually), brochures on hearing aid care and use, and a Ziploc bag to use as a dry-aid kit by adding 20 kernels of rice. Recognizing the importance of providing year-round services and aspiring to pass the program on to the country's residents, MMO developed a formal audiometric technician training program with grant support from the Hear the World Foundation. Currently, a trained audiometric technician provides year-round services in the audiology clinic located at the public hospital, with support from U.S.-based audiologists when needed.
Program Expansion. MMO is now developing an early hearing loss detection program using OAE units acquired through a grant from the Oticon Hearing Foundation. Newborn hearing screenings will be conducted in the hospital and community health centers, coordinated with the infants’ immunization schedules. Seminars will be offered to community health care providers, and an educational component will be added for parents to understand the importance of early identification of hearing loss. This program also aims to procure a diagnostic ABR unit and develop listening and speaking therapy programs.
University Partnerships. Although MMO's efforts have been hugely successful in the rural area of northern Nicaragua, the majority of the Nicaraguans continue to have no access to hearing health care. The University of Nebraska at Lincoln (UNL), with its expertise in training audiology students and providing services to low-income individuals through statewide hearing aid banks, set out to reach beyond their borders and involve their students in every step of the process. In 2014, a needs assessment conducted in Leon in western Nicaragua confirmed that no audiology services were available in the area.
While preparing to embark on this project, the organizers realized that the biggest challenge would be building relationships within Nicaragua, particularly in interfacing with the Ministry of Health. To address this, UNL began conversations with MMO at an American Academy of Audiology's humanitarian working group. Meanwhile, careful deliberation of the goals of MMO and UNL revealed that these were well aligned and that combining their strengths could effectively advance capacity building in another Nicaraguan community. Knowledge of resources in both communities were shared, with UNL adopting many of the policies and procedures that MMO successfully established over the years instead of reinventing the wheel. New relationships and important partnerships formed, including one with the National Autonomous University of Nicaragua (UNAN) in Leon.
Today, a team of physicians and occupational health faculty members from UNAN work side-by-side with audiology faculty members and students from UNL. This partnership provides a rich, multidisciplinary clinical and academic environment. The long-term goal of this project is to collaboratively establish the first university-based audiology training program in Nicaragua. Such collaboration between a well-stablished non-profit and a robust university program has proven to be a very efficient and successful model.
These examples epitomize the concepts of a vertical mission that evolved into an integrated community-based program through recurring trips and teaming up with local health care providers and existing institutions. They demonstrate the value of a collaborative network with the shared goal of building capacity and sustainability.
Editor's note: This article is based on a workshop presented at the 9th Annual Conference of the Coalition for Global Hearing Health in Cape Town, South Africa.
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1. Welling DR, Ryan JM, Burris DG, Rich NM Seven sins of humanitarian medicine World J Surg. 2010 Mar; 34(3):466-70.