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Abstract
Objectives The study sought to explore the knowledge, attitudes and perceptions of healthcare providers and health programme managers regarding the benefits, challenges and impact of international medical volunteers’ clinical placements. Views on how to better improve the work of international medical volunteers and the volunteer organisation Voluntary Service Overseas (VSO) for the benefit of local communities were also explored.
Settings Public healthcare facilities, VSO offices in Gulu and VSO offices in Kampala, Uganda.
Participants Ugandan healthcare providers (n=11) and health programme managers (n=6) who had worked with or managed international medical volunteers.
Interventions Data collection was conducted using key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis using NVivo identified emerging themes.
Results Both healthcare providers and managers reported a beneficial impact of volunteers and working with the volunteer organisation (clinical service provision, multidisciplinary teamwork, patient-centred care, implementation of audits, improved quality of care, clinical teaching and mentoring for local healthcare providers); identified challenges of working with volunteers (language barriers and unrealistic expectations) and the organisation (lack of clear communication and feedback processes); and provided recommendations to improve volunteer placements and working partnership with the organisation (more local stakeholder input and longer placements). Most healthcare providers were positive and recommended that volunteers are enabled to continue to work in such settings if resources are available to do so.
Conclusions Healthcare providers based in a low-resource setting report positive experiences and impacts of working with international medical volunteers. Currently, there is lack of local feedback processes, and the establishment of such processes that consider local stakeholder reflections requires further strengthening. These would help gain a better understanding of what is needed to ensure optimal effectiveness and sustainable impact of international medical volunteer placements.
- health services administration & management
- quality in health care
- international health services
- medical education & training
- human resource management
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- health services administration & management
- quality in health care
- international health services
- medical education & training
- human resource management
Strengths and limitations of this study
We interviewed 11 healthcare providers and 6 health programme managers who had experience of working with or managing international medical volunteers during their clinical placements in Uganda.
We conducted key informant semistructured interviews to explore the opinions of local stakeholders: programme managers and a range of healthcare providers, including nurses, midwives and doctors.
This is one of the first studies to explore the impact and to offer recommendations regarding how to better improve the impact of international medical volunteering for the local community in the host country.
We only interviewed healthcare providers and programme managers who had experience of working with international medical volunteers from the development organisation Voluntary Service Overseas (VSO) in Uganda and did not explore the views of other communities who have worked with VSO in the 22 other countries where the organisation works.
We did not explore the views of local communities who may have experiences of working with other types of volunteering organisations (medical and/or non-medical), who may have alternative perspectives or different insights.
Background
The burden of disease is significant for people living in low- and middle-income countries (LMICs).1 2 In many LMICs, healthcare systems infrastructure and human resources require strengthening, and a lack of highly trained and skilled healthcare providers impacts the quality of care patients receive when they do access care.1 3 There are many international medical volunteering organisations that offer clinical support and facilitate knowledge and skills exchange between healthcare providers working in both high-income countries and LMICs in order to improve patients’ health and well-being.4–9 With these organisations, many healthcare providers from high-income countries and across a range of medical specialties (including nursing, midwifery, general medicine, surgery, obstetrics, paediatrics) are facilitated to travel and undertake international medical volunteering placements in low-resource countries every year often motivated by altruism, with many also perceiving volunteering as a valuable opportunity to develop their skills in leadership, teaching and communication.10–17
One such organisation that facilitates long-term medical volunteers is Voluntary Service Overseas (VSO), an international organisation with the vision to end poverty around the world.6 In 2018, VSO coordinated almost 7500 volunteers working with 1.5 million people at local, regional, national and international levels, including partnerships with over 500 organisations.10 18 19 VSO recruits most volunteers through centres in high-income countries, including the UK, to work in 23 LMICs, with the recommended length of placement of 1 year, in three programmes: health, education and livelihood.6 10 18 19 VSO also facilitates national volunteers in LMICs to support programmes in their own country and/or in other LMICs.
Many international volunteer organisations describe international medical volunteering in different ways.4–9 For the purposes of this study and similar to VSO’s ethos, we have considered international medical volunteering as ‘highly skilled international healthcare professions from the global north or south, working unpaid with an organisation in low-resource settings for over three months on development-based programmes’.10 11
Regarding sustainability, it is best practice that all international volunteering organisations demonstrate how the partnership between international medical volunteers and local partners works best for mutual benefit.6 20
Many international medical volunteers report positive clinical placements that contribute to their personal and professional development, and that their new skills and perspectives benefit their working environments in their home countries on their return.17 21–25 However, the impact of the international medical volunteer placement is often only one component of a larger monitoring and evaluation framework within international volunteer organisations to report information at a higher programmatic level, for example, to donors.22
Currently there is limited evidence regarding the views and opinions of local communities towards the impact of international medical volunteering in general. Much of the evidence available is obtained from programmatic internal evaluations and reports.21 22
This study therefore sought to explore the knowledge, attitudes and perceptions of healthcare providers and programme managers towards international medical volunteers who provided routine and emergency healthcare in a 370-bedded tertiary level healthcare facility in Uganda. In addition, enabling factors and barriers to international medical volunteer placements were explored, and how these can translate into recommendations for clinical practice and to strengthen the relationship and feedback processes between volunteers and local partners was considered.
Methods
Study design and setting
Data collection used a qualitative descriptive approach and semistructured interviews were conducted with healthcare providers and programme managers in June 2019. All interviewees were Ugandan and had experience of working with or managing international medical volunteers in the largest teaching hospital in Gulu, Uganda. All interviews were held in a private location (eg, an office in the healthcare facility) that would ensure privacy and that was convenient for the participants.
Participants
Ugandan healthcare providers and programme managers were included if they had experience of working with or managing international medical volunteers in the chosen study site. Programme managers were included to enable the triangulation of data and broadened the scope of the topic. Snowballing and opportunistic techniques were employed to identify the participants. Participants were chosen purposively, based on their ability to speak English and experience of working with international medical volunteers, and were recruited sequentially until data saturation was met.
Patient and public involvement
No patient or member of the public was involved in the design of this research.
Topic guide
The topic guide was designed and piloted with healthcare providers in the UK who had completed international medical volunteering placements within the past year. This aided improvements to question phrasing and flow and general interviewing technique. The topic guide was a flexible tool that enabled the interviewer to explore healthcare providers’ responses, as well as acting as a cue to probe further to develop an understanding of participants’ perceptions and experiences. In addition to sociodemographic questions, the topic guide included five main subject areas: (1) knowledge and experience of working with international medical volunteers and VSO; (2) benefits of working with international medical volunteers and VSO; (3) challenges of working with international medical volunteers and VSO; (4) experience of feedback processes in place to assess the impact of international medical volunteers; and (5) recommendations to improve the work of international medical volunteers and VSO programmes for the benefit of local communities.
Data collection
Participants were approached by the data collector face-to-face prior to the interview and were provided written and verbal information about the study. The information included an overview of the research aims, objectives and questions. An appointment was then scheduled in a convenient place and time for each participant. All participants were interviewed in English and the interviews lasted on average 30 min. Interviews were conducted face-to-face, recorded on a digital recording device and transcribed on completion. Anonymity and confidentiality were emphasised to reassure participants’ confidence in providing honest answers.
Analysis
Interviews were transcribed and electronically coded using NVivo. A second reviewer independently reviewed all transcripts. The analysis followed social science theory, and identified codes were grouped into categories and reviewed by all researchers to ensure consistency and to check for inter-rater reliability.26 27 We used the Standards for Reporting Qualitative Research guidelines in reporting the analysis.28
Written informed consent was obtained from all participants of the study.
Results
Participants’ characteristics
Eleven healthcare providers at Gulu Hospital (one doctor, four nurses and three midwives) and two rural healthcare centres (three midwives), along with six health programme managers (one from Gulu Hospital, two from the VSO office in Gulu and three from the VSO office in Kampala), participated in the study. All 17 participants (13 women and 4 men) were Ugandan and were interviewed in English.
Emerging themes
The emerging themes were (1) the beneficial impact of volunteers and the organisation; (2) the challenges of working with volunteers and the organisation; (3) a lack of feedback processes for the local community; and (4) recommendations to improve volunteer placements and working partnership with the organisation.
There were significant overlap and agreement between the responses from the healthcare providers and programme managers, even though these stakeholders had different working relationships with the international medical volunteers. The only noted difference in the responses was regarding the perspectives of the impact of international medical volunteers. For example, healthcare providers described the impact on local clinical care, whereas health programme managers highlighted the larger impact of volunteering on the overall effectiveness of a health programme at the local and national level.
Benefits of working with international medical volunteers and VSO
The benefits of working with international medical volunteers were that they supported service provision, strengthened multidisciplinary teamwork, encouraged patient-centred care and improved the quality of clinical care (table 1, Q1–Q3). Other benefits included the provision of clinical teaching and mentoring (table 1, Q4–Q6). The ‘train the trainers’ teaching model, where local trainers are trained as facilitators to train other local healthcare providers, creating sustainable change, was highlighted (table 1, Q6). Other benefits of international medical volunteers were their demonstration of a good work ethic, which resulted in positive attitude and behaviour changes from the local healthcare providers, such as increased clinical confidence (table 1, Q3, Q7–Q9). Healthcare providers reported that they valued volunteers’ contributions and appreciated their desire to help (table 1, Q10-Q11). Programme managers reported that international medical volunteers introduced and implemented standard-based audits; reported that their different perspectives brought diversity to the project development process and improved healthcare facilities; and highlighted that volunteers have a much wider impact on the healthcare system, not just at the local level (table 1, Q10, Q12–Q13). Local healthcare providers acknowledged and valued VSO as a reliable source of resources and support (table 1, Q14–Q16). Within these themes, there was an underlying willingness of the local healthcare providers to work with international medical volunteers to provide better clinical care. However, several challenges were also reported.
Benefits of working with international medical volunteers and VSO
Challenges of working with international medical volunteers and VSO
A key challenge was the language barrier between international medical volunteers, staff and patients, which caused frustration due to the need for a translator (table 2, Q17). Healthcare providers highlighted that some volunteers lack cultural understanding as well as understanding of differences in local clinical policies compared with international guidelines (table 2, Q18–Q20). Other challenges included some volunteers’ personalities and negative attitudes (table 2, Q21–Q22). Programme managers reported challenges when international medical volunteers had high expectations which were different from the reality of day-to-day working, leading to poor partner relationships and early departure (table 2, Q23–Q24). Some programme managers suggested that local partners were suspicious of international medical volunteers (table 2, Q25). Two programme managers suggested a negative shift in the work ethic of some local healthcare providers when international medical volunteers were present in healthcare facilities, as local staff relaxed and contributed less to patient care (table 2, Q26).
Challenges of working with international medical volunteers and VSO
Difficulties working with VSO as an international development organisation included a perceived short length of international medical volunteers’ placements (table 3, Q27). Local staff preferred placements longer than 1 year to optimise volunteer impact and accommodate for staff rotations ensuring all healthcare providers could benefit from training.
Challenges of working with non-governmental organisations such as VSO
Good effective communication from VSO to all levels of local partners was highlighted as a challenge (table 3, Q28). A small number of local healthcare providers highlighted limited stakeholder engagement and a lack of clarity of understanding of the roles and responsibilities of international medical volunteers (table 3, Q29). If there were no clear roles, there was a lack of transparency and poor accountability, and local healthcare providers felt less able to provide effective feedback to VSO regarding the impact of international medical volunteers’ placement (table 3, Q30–Q31).
Programme managers reported concerns regarding possible dependency of the local healthcare facilities on VSO, due to the demand for equipment, commodities, low staffing levels and annual staff rotation (table 3, Q32–Q33). Programme managers highlighted that specific requirements from donors who fund international medical volunteers’ placements caused delays in recruitment and programme initiation; travel costs for international medical volunteers were expensive; and that some donors preferred to use local volunteers as these placements are cheaper (table 4, Q34–Q35).
Recommendations to improve international medical volunteering placements with VSO
Solutions
Many healthcare providers were keen to discuss solutions and recommendations regarding how to improve international medical volunteers’ placements. Improved communication, increased stakeholder involvement in planning and clearer feedback processes were suggested to encourage a more sustainable and equitable approach to developing stronger volunteer partner relationships (table 4, Q36–Q39). This could be through the development of strong, culturally relevant feedback processes with clear management to increase accountability to local healthcare staff. Healthcare providers expressed a desire for more presence of international medical volunteers, either through increased length of volunteer placements, shorter gaps between volunteer placements and/or increased frequency of volunteers to ensure all staff can benefit from the training provided (table 4, Q40–Q44). This included suggestions of increased duration of placements, scaling up of programmes to more areas and a continuous cycle of volunteers coming and going to ensure there were no gaps in the programmes (table 4, Q45–Q46). Programme managers focused specifically on improving orientation both prior to travel and arrival in country, which they believe would reduce the challenges they experience working with international medical volunteers (table 4, Q47–Q48).
Discussion
Statement of principal findings
A large number of benefits of international medical volunteering for the local community were identified: increased service provisions and clinical care, decreased workloads of the local staff and reduced waiting times for patients; excellent work ethic and attitude towards work; and teaching, mentoring and implementation of clinical audit, resulting in increased quality of care, which subsequently was perceived to have improved community acceptance and uptake of healthcare services.
Challenges experienced when working with volunteers and their organisation included language barriers, volunteers’ perceived superior attitudes, volunteer expectation management, lack of feedback processes and clear accountability with local healthcare providers and stakeholders. It was suggested that many of these could in principle be overcome through recommendations for and improvements in VSO policy and feedback processes.
Strengths of the study
This study to the best of our knowledge is one of the first studies to assess this subject in Uganda. This study provides information to help support future healthcare programme development, including the recommendation to introduce, develop and implement feedback processes for the host partners to the sending organisation. Most healthcare providers interviewed welcomed the discussion surrounding the impact of international medical volunteers’ placements and were keen to contribute to solutions in their settings.
Limitations of the study
The interviewer was a young female British master’s student and this may have had an influence on how the interviewees responded. However, the interviewer emphasised that she did not work for VSO and that all responses were in strict confidence to enable freedom of speech. The topic guide was not piloted with Ugandan healthcare providers to ensure complete understanding of the language used to ask questions, but there were no misunderstandings of questions during the interviews. The study population comprised mainly of nurses and midwives providing routine maternity care in a large teaching hospital with a good level of English. This excludes other cadres and specialties of healthcare providers who may have alternative perspectives or different insights. The study was mostly carried out in urban settings and findings cannot be assumed to be the same in other settings. However, many health volunteer placements with VSO are in hospitals that are based in urban settings. It would be valuable to explore the views of healthcare providers who have worked with other non-governmental organisations in different settings and who may have different cultural perceptions, beliefs and experience. Their opinions would also help understand and develop sustainable and equitable partnerships with other volunteering organisations, and with further stakeholder engagement and development of local feedback processes.
How does this study relate to other literature?
These findings are like other reports that document the skills and attributes of international medical volunteers that are desired by the local community, and their positive impact in terms of service delivery, knowledge sharing and increased quality of care.10 29–34 A new finding in our study is the appreciation from local healthcare providers of international medical volunteers for providing clinical support and local suggestions of how to develop stronger volunteer partner relationships. Other studies have highlighted that the limitations to positive partnerships are that placements could be longer to enable more sustainability and the challenges when international medical volunteers have unrealistic expectations of what is available and achievable in low-resource settings.25 31 32 In contrast to existing literature, no participant in our study described an increase in clinical burden due to underqualified or inexperienced international medical volunteers.10 20 29 30 32 This is likely due to VSO’s rigorous recruitment process allowing only those with enough experience and qualifications to undertake clinical placements. In our study, any criticisms of international medical volunteers tended to be at an individual level rather than volunteering as an effective intervention like other studies.35
Similar to other studies, our study supports the view that it is essential that international medical volunteers, while remaining adaptive, have clear focus with goals and targets, and work with local partners to ensure they collaborate in partnership and within the cultural context to ensure sustainability.22 32 33 36 In our study, we note that international medical volunteers can be viewed by the local community to be in a position of power, with different knowledge and privilege, and therefore principles such as ensuring mutual benefit, strong volunteer management, upholding international safeguarding and ethical standards and stakeholder engagement are particularly important.29–36 In our study giving constructive feedback regarding the international medical volunteers was a challenge for local healthcare providers, as this may not be perceived to be culturally appropriate. Healthcare providers found it easier to give feedback after the volunteer has left, which misses the opportunities to improve and maximise the effectiveness of the placement while it was ongoing. This lack of feedback processes may explain why participants in this study were so keen to discuss and provide solutions and recommendations to improve international medical volunteers’ placements.
Unanswered questions and future research
There is currently a lack of consensus on best practice on how to conduct and support both short-term and long-term effective international medical volunteer placements in low-resource settings.17 32–34 It would be beneficial to understand better how the sharing of expertise between different health systems can be facilitated and how this sharing is supportive and sustainable over time between countries to benefit both communities.
Conclusion
This study highlights the need to understand the complexity of factors associated with international medical volunteering. Ensuring clear and concise roles and responsibilities and opportunities for feedback processes would enable a more measured positive impact and shape the role of international medical volunteers within the local community to maximise mutual benefit, for both short-term and long-term placements. Further research is required on how to best develop and implement effective, equitable and sustainable partnerships to enable equitable knowledge and skills exchange between local healthcare providers and international medical volunteers to better improve the availability and quality of care for people living in low-resource settings.
Acknowledgments
We would like to thank VSO Uganda and VSO UK for their help and support with the development and completion of this project. Thank you to all the healthcare providers and health programme managers who participated in this study.
References
Footnotes
Contributors MM conceived the study idea and design. FH developed the topic guide, conducted the interviews, transcription and data analysis, interpreted and presented the results, and contributed to the manuscript. JC contributed to data analysis and interpretation of the results. MM coordinated and supervised the research activities, contributed to the interpretation of the results and wrote the manuscript. All authors have read, edited and approved the final manuscript for submission.
Funding This study was self-funded by FH as part of her dissertation for the Master’s in International Public Health programme at the Liverpool School of Tropical Medicine.
Competing interests FH declares no competing interests. MM previously volunteered as a doctor with VSO Ethiopia, and JC previously worked as an employee of VSO UK.
Patient consent for publication Not required.
Ethics approval The Liverpool School of Tropical Medicine, Liverpool, UK (LSTM14.025), the Gulu University Research Ethics Committee (GUREC-050-19) and the Uganda National Council for Science and Technology (HS389ES) all granted ethical approval.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.