Mobile professional voluntarism and international development : killing me softly?

This book explores the impact that professional volunteers have on the low resource countries they choose to spend time in. Whilst individual volunteering may be of immediate benefit to individual patients, this intervention may have detrimental effects on local health systems; distorting labour markets, accentuating dependencies and creating opportunities for corruption. Improved volunteer deployment may avoid these risks and present opportunities for sustainable systems change. The empirical research presented in this book stems from a specific volunteering intervention funded by the Tropical Health Education Trust and focused on improving maternal and newborn health in Uganda. However, important opportunities exist for policy transfer to other contexts

The ethics of educational healthcare placements in low and middle income countries : first do no harm?

This book examines the current state of elective placements of medical undergraduate students in developing countries and their impact on health care education at home. Drawing from a recent case study of volunteer deployment in Uganda, the authors provide an in-depth evaluation of the impacts on the students themselves and the learning outcomes associated with placements in low resource settings, as well as the impacts that these forms of student mobility have on the host settings. In addition to reviewing the existing literature on elective placements, the authors outline a potential model for the future development of ethical elective placements. As the book concurs with an increasing international demand for elective placements, it will be of immediate interest to universities, intermediary organizations, students as consumers, and hosting organisations in low-resource settings

Optimising student learning on international placements in low income settings

This paper challenges the assumption that student visits to low resource settings inevitably promote the acquisition of cultural competence. Much of the literature and marketing rhetoric advocating the expansion of such ‘exposures’ lists numerous positive outcomes with an emphasis on ‘cultural learning’. With important exceptions, the concept of cultural learning remains uncontested, nestling in the fluffy haze of an inherently benevolent multi-culturalism. The emphasis in current research is on ‘learning’ or ‘competency’ at the expense of definitional clarity around the concept of culture itself. This results in a tendency to overemphasise (and essentialise) difference rather than commonality and conflates cultural learning with narrow (stereotypical) concepts of race, ethnicity and religion. The paper discusses the experiences of students undertaking placements in Uganda through Knowledge For Change, a UK charity hosting the Ethical Educational Placements project, to identify and critique this dimension of ‘learning’. Using an action-research approach combining observational research with qualitative interviews and surveys the paper uncovers the nuance of cultural learning. In important respects the behaviour that students are witnessing and attributing to culture is connected more to the specific organisational contexts that they are placed in and the patient groups they ‘serve’ than any connection to an homogenous ‘national’ culture. Poverty and gender inequality, amongst many other forms of structural inequality, result in ‘othering’ behaviour on the part of health workers towards patients that is a fundamental characteristic of public health organisations in residualised welfare systems. In this complex environment, cultural learning is not so much about celebrating difference. It is more about understanding social context and accepting that you don’t and can’t possibly know a person’s situation; and with that in mind you should treat everyone with the same degree of humility and respect. Adopting and practising ‘epistemic humility’ (Hanson et al 2011; Ahmed, Ackers-Johnson & Ackers 2017) is crucial to meaningful learning in any context. Further, a lack of understanding of the broader structural processes perpetuates inequalities between the Global North and South (Husih, 2012; Ahmed, Ackers-Johnson & Ackers, 2017) and impedes knowledge acquisition, particularly cultural learning. Moreover, hubris – or Western students’ assumptions of superiority over host health care workers (Bauer, 2017; Elit et al, 2011, Ahmed, Ackers-Johnson & Ackers, 2017) – may act as a further obstacle to cultural learning. Cultural learning is as much about learning about ourselves and what it feels like to be ‘othered’ as it is learning about others. International placements in LMICs create critical opportunities for relevant student learning. But achieving this and guarding against the risks of ‘mis-learning’ requires the level of cultural brokerage provided by ‘More Knowledgeable Others’ that we take for granted with clinical learning

Healthcare, frugal innovation, and professional voluntarism : a cost-benefit analysis

This book investigates what international placements of healthcare employees in low resource settings add to the UK workforce and the efficacy of its national health system. The authors present empirical data collected from a volunteer deployment project in Uganda focused on reducing maternal and new-born mortality and discuss the learning and experiential outcomes for UK health care professionals acting as long term volunteers in low resource settings. They also develop a model for structured placement that offers optimal learning and experiential outcomes and minimizes risk, while shedding new light on the role that international placements play as part of continuing professional development both in the UK and in other sending countries

Opportunities and challenges for improving antimicrobial stewardship in low and middle income countries ; lessons learnt from the maternal sepsis intervention in Western Uganda

This paper presents findings from an action-research intervention designed to identify ways of improving antimicrobial stewardship in a Ugandan Regional Referral Hospital. Building on an existing health partnership and extensive action-research on maternal health, it focused on maternal sepsis. Sepsis is one of the main causes of maternal mortality in Uganda and Surgical Site Infection, a major contributing factor. Post-natal wards also consume the largest volume of antibiotics. The findings from the Maternal Sepsis Intervention demonstrate the potential for remarkable changes in health worker behaviour through multi-disciplinary engagement. Nurses and midwives create the connective tissue linking pharmacy, laboratory scientists and junior doctors to support an evidence-based response to prescribing. These multi-disciplinary ‘huddles’ form a necessary, but insufficient, grounding for active clinical pharmacy. The impact on antimicrobial stewardship and maternal mortality and morbidity is ultimately limited by very poor and inconsistent access to antibiotics and supplies. Insufficient and predictable stock-outs undermine behaviour change frustrating health workers’ ability to exercise their knowledge and skill for the benefit of their patients. This escalates healthcare costs and contributes to Anti-Microbial Resistance

The impact of multidisciplinary mobilities on the effectiveness of global health and international development projects

The mobility of healthcare professionals from high-income countries (HICs) to low- and middle-income countries (LMICs) has been growing rapidly over recent decades. The ‘international elective placement’, which was once a preserve of medical student curricula, has now become increasingly common amongst nursing, midwifery and allied health professional students. International volunteering for healthcare professionals has shifted from being mainly missionary or altruistically driven to being a critically important component of clinical experience, professional development and subsequent career progression. Furthermore, there has been a large growth in international aid expenditure since the end of the Second World War and a more recent increase in the desire and ability of populations to travel internationally. These have acted as stimuli for the implementation of a multitude of international development projects designed to build the capacity of healthcare workers in LMICs in order to strengthen local health systems.However, despite the above, there is a distinct lack of research into the real benefits, costs and potential negative effects or externalities associated with such mobilities, or their ability to ethically and sustainably strengthen health systems in LMICs. Most existing literature is written by development actors themselves who often focus on the short-term and have a conflict of interest in proving that their interventions are positive and beneficial in order to justify current and future funding. This portfolio of six published works and eight supporting publications serves to bridge this gap in research and knowledge. Based on the author’s 10+ years of action research experience in the fields of global health, professional volunteering and international development, it suggests that the desired outcomes can be achieved in an ethical and sustainable way but only if certain policies and procedures are adopted and implemented.Combined, the publications generate a unique contribution to knowledge by offering tested, practical ways of enhancing the efficacy of international aid and professional and student voluntarism. For this reason, each publication is directed at key stakeholders and policy makers, providing clear conclusions and recommendations based on in-depth experience and concrete research findings

Antibiotic Resistance Profiles and Population Structure of Healthcare-associated and Community-associated Staphylococcus aureus isolated in Fort Portal, Western Uganda

Antimicrobials currently hold infectious pathogens at bay, but with cases of resistance ever increasing, those same pathogens have the potential to reverse decades of medical progress, creating one of the biggest threats to global health, food security and development in the world today. The impact of antimicrobial resistance (AMR) is of particular concern for low-income countries which already suffer from a high burden of infectious bacterial diseases in both humans and animals, with cost constraints preventing the widespread application of newer, more expensive agents. Tackling AMR is particularly challenging in settings such as Fort Portal Regional Referral Hospital (FPRRH), Western Uganda, where specific knowledge of local AMR epidemiology is required to inform evidence-based improvement of antibiotic stewardship measures in the local area.This study focused on the evaluation of Staphylococcus aureus, a commensal bacterium carried by roughly 30% of the human population commonly in the nasopharynx and/or on skin. S. aureus also acts as a major human pathogen frequently associated with nosocomial infections where the skin has been broken, for example from a wound or surgical procedure. The three core aims of this study involved the evaluation of clinical and community associated S. aureus resistance profiles; evaluation of the population diversity of clinically associated S. aureus; and the elucidation of key resistance associated genes through the whole genome sequencing (WGS) of 41 clinical isolates.A population structure for the 41 sequenced isolates was inferred by comparing their core genomes. Twenty isolates formed a tight cluster corresponding to multilocus sequence typing (MLST) clonal complex (CC) 152, a CC found to be particularly prevalent in northern Africa. In agreement with other studies, the occurrence of Panton-Valentine leukocidin toxin-encoding genes was significantly higher among CC152 strains than non-CC152 strains. However, it was also observed that the coagulase gene was over-represented in this CC, further defining the virulence strategy of this important pathogen.Initial analysis of antimicrobial susceptibility testing (AST) data of S. aureus isolated from both clinical infections at FPRRH and the hand swabs of people in the local community revealed 64% (45/70) and 83% (104/125) of isolates were resistant to one or more antibiotic and 26% (18/70) and 49% (61/125) were multidrug resistant (MDR) respectively. Methicillin-resistant S. aureus (MRSA) was isolated at rates of 38% (8/21) and 22% (27/125) for the clinical and community associated isolates respectively.WGS of the 41 clinical S. aureus isolates revealed resistance phenotypes were largely explained by the presence of antibiotic resistance genes. Although all isolates were susceptible to clindamycin, a 24% carriage of erm genes suggests potential for rapid development of resistance. The frequency of genes associated with methicillin, chloramphenicol and ciprofloxacin resistance were significantly lower amongst CC152 strains than non-CC152 strains; thus, in keeping with previous work, it was found that CC152 was almost exclusively methicillin-sensitive S. aureus (MSSA). By generating detailed information about the epidemiology of circulating S. aureus and their antibiotic susceptibility, this study has provided, for the first time, data on which evidence-based infection and AMR interventions at FPRRH can be based, including the procurement and prescription of antibiotics. Furthermore, this study was able to build and promote international collaborations between Salford University, FPRRH, Ugandan Infectious Diseases Institute and Makerere University for the effective transfer of knowledge and completion of advanced research

The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities : the role of absenteeism

Maternal mortality in low and middle income countries (LMICs) continues to remain high. The Ugandan Ministry of Health’s Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health (Millennium Development Goal 5) and, more specifically, in reducing maternal mortality (MOH, 2010:43). Furthermore, the UNDP report on the MDGs describes Uganda’s progress as ‘stagnant’ (2013: iii). The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the ‘3-delays’ model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or ‘staff shortages’ as a key component of this ‘puzzle’. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) ‘common sense’ presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years’ experience of action-research interventions in Uganda combining a range of methods have lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local ‘co-presence’ to be effective (author ref, 2014). Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOS have exacerbated this problem encouraging forms of internal ‘brain drain’ particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies

Anti-microbial resistance in global perspective

This open access book provides an accessible introduction to the mechanics of international development and global health text for policy-makers and students across a wide range of disciplines. Antimicrobial resistance is a major threat to the well-being of patients and health systems the world over. In fragile health systems so challenged, on a day-today basis, by the overwhelming burden of both infectious and non-communicable disease, it is easy to overlook the impacts of AMR. The Maternal Sepsis Intervention, focusing on a primary cause of maternal death in Uganda, demonstrates the systemic nature of AMR and the gains that can be made through improved Infection Prevention Control and direct engagement of laboratory testing in antibiotic prescribing

The BaSICS (Baby Skin Integrity Comparison Survey) study : a prospective experimental study using maternal observations to report the effect of baby wipes on the incidence of irritant diaper dermatitis in infants, from birth to eight weeks of age

Background Baby wipes have been shown to be safe and effective in maintaining skin integrity when compared to the use of water alone. However, no previous study has compared different formulations of wipe. The aim of the BaSICS study was to identify any differences in incidence of irritant diaper dermatitis (IDD) in infants assigned to three different brands of wipe, all marketed as suitable for neonates, but which contained varying numbers of ingredients. Methods Women were recruited during the prenatal period. Participants were randomly assigned to receive one of three brands of wipe for use during the first eight weeks following childbirth. All participants received the same nappies. Participants reported their infant’s skin integrity on a scale of 1 to 5 daily using a bespoke smartphone application. Analysis of effect of brand on clinically significant IDD (score 3 or more) incidence was conducted using a negative binomial generalised linear model, controlling for possible confounders at baseline. Analysts were blind to brand of wipe. Results Of 737 women enrolled, 15 were excluded (admitted to neonatal intensive care, premature or other infant health issues). Of the 722 eligible babies, 698 (97%) remained in the study for the full 8-week duration, 24.6% of whom had IDD at some point during the study. Mothers using the brand with the fewest ingredients reported fewer days of clinically significant nappy rash (score≥3) than participants using the two other brands (p=0.002 and p<0.001). Severe IDD (grades 4 and 5) was rare (2.4%). Conclusions Rarity of severe IDD suggested that sensitive formula baby wipes are safe when used in cleansing babies from birth to eight weeks during nappy changes. The brand with fewest ingredients had significantly fewer days of clinically significant IDD. Daily observations recorded on a smartphone application proved to be a highly acceptable method of obtaining real-time data on IDD