Abstract
Harvard School of Dental Medicine (HSDM) estimates that nearly 25 percent of its predoctoral dental students have expressed an interest in global health, including traveling abroad to conduct research or to volunteer in a project. This article addresses the important differences between “voluntourism” (combined volunteering and tourism) and responsible engagement in global health, reports on a pilot workshop at HSDM to promote responsible volunteering, and provides a recommendation on how to address these issues in the context of a dental curriculum. The pilot Workshop for Ethical Volunteering in Global Health was designed as a discussion-based, interactive program that included lectures, small-group activities, and personal reflection. The aim of the workshop was to provide students with a systematic approach to ethical volunteering, critically reflecting on their motivation and attitudes related to conventional models of volunteering and facilitating alignment with principles of global health. Students participated in an anonymous written survey at the start and the close of the workshop. After the workshop, survey results demonstrated a significant increase in understanding the value of applying principles of global health when volunteering in order to avoid negative and unintended impacts on communities. All of the students reported that the workshop influenced the way they view volunteering in dentistry.
Trends in medical education demonstrate a growing student interest in matters related to global health, including participation in experiential learning activities abroad.1–5 Currently, 20 to 25 percent of medical students in the United States participate in health-related activities abroad1,3,6 compared to only 6 percent in 1984.1 The number of global health-related courses being taught in medical curricula throughout the United States also continues to increase.1,4 Though less is known about the figures for dental schools, a survey conducted by the American Dental Association (ADA) in 2009 indicated that nearly half of all dental schools offer international volunteer opportunities to their students.5 Members of the Faculty Advisory Committee in Global and Community Health and the Office of Research at the Harvard School of Dental Medicine have witnessed this trend in dental students and in dental education over the past several years.
The Harvard School of Dental Medicine estimates that nearly 25 percent of its predoctoral dental students have expressed interest in global health, including traveling abroad to conduct research or to volunteer in a project. Many opportunities for international volunteering, particularly those identified by students, are with non-academic outreach programs and non-governmental organizations (NGOs). As student interest in international charitable and volunteer organizations is increasing, so have faculty concerns over accountability and impact on communities and the local health system, as well as project alignment with important global health principles and policies in the host country. The high demand of the student body to engage in global health-related activities creates a responsibility for dental educators to enable students to critically evaluate volunteer opportunities and to distinguish potentially harmful voluntourism from responsible activities based on global health principles. Ultimately, the goal of educators should be to promote student engagement in long-term, sustainable, empowering, and ethically sound solutions to reduce and eliminate health disparities globally. This article addresses the important differences between “voluntourism” (combined volunteering and tourism) and responsible engagement in global health, reports on a pilot activity at Harvard School of Dental Medicine to promote responsible volunteering, and provides a recommendation on how to address these issues in the context of dental curricula.
Voluntourism and Unintended Consequences
Voluntourism, an emerging trend in international volunteering, is defined as a combination of volunteering and tourism.7 Mission trips, outreach expeditions, and other short-term (several weeks or less) global health-related activities fall under this definition. Oftentimes, such trips are expensive for students, and agencies taking care of practical arrangements charge significant fees. A variety of factors may motivate students to participate in voluntourism, including previous international travel and increased media coverage on global health issues.1 Being aware that many populations lack access to adequate oral health care or that it is expensive and unaffordable for many in need also encourages some students to make a contribution by addressing these inequalities.8–10 As dentistry has a long tradition of volunteering, students may simply have a desire to give back,1,8 inspired by the charitable history of the profession.10
Additionally, students may be seeking adventure and exposure to new and exciting encounters. They may expect that voluntourism will combine excitement and the opportunity to address oral health needs, an experience they may feel will bolster their resumes. Despite positive intentions, these motivations are extremely short-sighted, are mostly fulfilling self-interests, and are violating principles of professionalism. These include adhering to the principle of doing no harm, patient autonomy, using sound clinical judgment, and practicing within one’s scope and level of training.11 A growing amount of evidence demonstrates that all too often the intentions of volunteers do not match their impact on the local communities they visit. The nature of such activities does not provide adequate time to ensure alignment with the local health care system or for students to develop a deeper understanding of their host community’s resources, needs, and expectations. Frequently, the sending organizations also lack planning, preparation, and a proper strategy for integration with the local health care system.10,12 Due to lack of broader understanding and knowledge of basic public health principles, volunteers may not see the dangers that lie in their activities.
The provision of service from high-income to low-income (or low-resource) countries often competes against rather than compliments the host community’s health system, which is often fragile and weak. Donating technologies, services, and materials that a community cannot procure or sustain on its own creates unrealistic expectations, promotes dependence,13 and fails to address the cause of the problems. Furthermore, it may even devalue current practices being conducted14 or negatively impact the income of local providers.3 As a consequence, a number of governments, such as Guatemala for example, make it illegal for foreign NGOs to implement programs without government coordination and alignment in an attempt to avoid duplication, contradictory efforts, and wasted resources. Unfortunately, a number of NGOs continue to practice illegally, often unknowingly, due to lack of awareness of local policies and practices.3
Additionally, voluntourism is limited to short-term and sporadic treatments—i.e., “band-aid” approaches—rather than investing the time necessary to address the underlying causes of the problems.3,15 One example might be childhood caries treatment and extraction camps in areas without access to healthy foods low in sugar, not to mention clean water with appropriate levels of fluoride. The focus on curative and emergency care alone neglects the important determinants and risk factors of oral diseases and often fails to include preventive activities and long-term capacity building, including community-based mechanisms such as appropriately designed school programs integrated with other hygiene-related programs and advocacy for healthy public policies in all government sectors.3,16 Such efforts are thus not sustainable, meaning once the volunteers leave, the efforts cannot be maintained. Furthermore, there are simply not enough volunteers worldwide to adequately address the oral health disparities that exist.15,16 The cycle of voluntourism based on clinical treatment “missions” keeps communities dependent on charitable donations, often impeding their progress and chances for development in the long run.13
Principles of Global Health
Although a variety of definitions exist, there is growing consensus on the meaning of global health and several guiding principles. The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being and not merely the absence of disease.”17 Based on this definition, global health refers to the “scope of problems, not their location,” meaning global health addresses local determinants of health and disease as well as those that cross national boundaries.18 The guiding principles of global health include the underlying, upstream, common risk factors for disease,15,19 allowing for the fusion of population-based prevention and individual patient care.5 Also, they encompass collaboration with local community partners through a social contract11,19 when designing and implementing an intervention, as well as taking a multidisciplinary approach to incorporate not only health but also education, economics, and politics.5,15,18,20,21 By operating under these guiding principles, the aims of any global health-related activity are not determined by merely being based in an international locale or a low income region, but rather address health through ethical soundness, sustainability, local empowerment and leadership, and evidence-based, prevention-oriented approaches21 wherever the needs are located.
Voluntourism contradicts many if not all of these principles, so students must be encouraged to critically reflect on global health activities so they learn how to avoid the unintended consequences of voluntourism. A sole motivation for adventure and travel should be discouraged altogether; rather, motivations should be cultivated to align with the above principles of global health. This can be done largely through defining global health objectives and subsequent curriculum development. This approach is not new, even in dental programs,22 and many schools have implemented educational activities.5 However, the trend towards dental voluntourism is still on the rise. We believe that a disconnect exists between curriculum objectives and impact of actual engagement of students in global health-related activities.
Most likely, the explanation for this disconnect is that students pursuing voluntourism are in clinical training programs designed around treatment-centered competencies and board examinations focused on patient-based approaches. Dental programs are training students to become competent in traditional clinical skills, such as examination, diagnosis, and treatment of the individual patient. It is, therefore, not surprising that students are most comfortable with service- and treatment-oriented activities that are in line with their training.8 Educators need to facilitate the required switch from patient-centered background care, which is the major part of the dental curriculum, towards a culturally relevant, population-centered way of thinking. Students must be given a mechanism they can use to connect their patient-oriented mind frame to a population-based approach, focusing their ambitions on a more reflective and critical evaluation of volunteering. Such an approach will allow students to better match their global health-related motivations and interests with the objectives of global health.
With these problematic areas in mind, it should be noted that there are numerous positive effects on students as a result of working abroad.10 These include, among others, an improvement in skill level, greater cultural sensitivity, and a deeper appreciation for public health issues.23 While these benefits have been reported for students, more research is needed to determine if the programs are having long-term positive effects on the communities visited.
Pilot Workshop on Ethical Volunteering in Global Health
In spring 2012, in conjunction with a leadership course in dental ethics and as part of the emerging global health curriculum, Harvard School of Dental Medicine developed and piloted a Workshop for Ethical Volunteering in Global Health. The workshop was designed as a discussion-based, interactive program that included lectures, small-group activities, and personal reflection. It focused on volunteering according to global health principles in any location, whether locally or abroad. The aim of the workshop was to provide students with a systematic approach to ethical volunteering, providing ways for them to critically reflect on motivation and attitudes related to traditional models of volunteering and facilitating alignment with principles of global health. The workshop was mandatory for all third-year dental students. The objectives are outlined in Table 1. The workshop compelled students to reflect on and think critically about factors that should be known about a community prior to undergoing any activity, especially in the form of voluntourism. The workshop also addressed how to avoid possible unintended negative impacts and included overarching themes such as sustainability and local empowerment.
Learning objectives for a pilot workshop on responsible volunteering at Harvard School of Dental Medicine
Students participated in an anonymous, written survey at the start and close of the workshop. Results were then compared in order to track the impact of workshop messages. Students were asked to rate the importance of various components of volunteering on a scale from 1 to 5 (1=not important, 2=somewhat important, 3=important, 4=very important, 5=extremely important). Volunteer work components on the survey consisted of the following: A) bringing donated supplies; B) providing hands-on emergency clinical care; C) seeing as many patients as possible; D) providing oral health education; E) providing preventive measures such as fluoride; F) working with the local government; G) participating long term (more than a few weeks); H) volunteering with a well-established organization; and I) learning all about the community, including local customs and culture. We considered components A, B, and C as conventional, more traditional components of dental volunteering similar to voluntourism. Components D and E were also considered conventional but could be included in new volunteering models if done as part of ongoing efforts. Components F, G, H, and I were considered the new standard for ethical volunteering in global health. These considerations were not directly communicated to students when the surveys were distributed, but rather were conveyed through the workshop learning objectives.
Thirty students submitted surveys, both before and after the workshop, that were evaluated for this study. Ordinal data scores were compiled and weighted according to frequency distribution and magnitude. Numerical summary measures for the volunteer components addressed in the workshop are shown in Table 2. This study was assigned CHS number M22633-101 and was granted the status of exempt by the Harvard Medical School Human Subjects Institutional Review Board. According to the survey results, 97 percent of the students reported that they were very likely or extremely likely to volunteer in the future, whether locally or abroad. After workshop participation, the mean scores of importance for all conventional concepts decreased, and the mean scores of importance for all new components increased. All of the students reported that the workshop influenced the way they viewed volunteering in dentistry.
Numerical summary measures of students’ ordinal scores rating components of dental volunteering (N=30)
Conclusion
Educating students based on global health competencies, and thereby enabling them to critically evaluate volunteering programs, is challenging, especially when most dental curricula are already clinically demanding and allow little room for new coursework. Although this workshop was an important step, the limits of a single workshop in preparing students for experiential learning such as volunteering are apparent. Ultimately, the principles and practices of global health must be integrated into existing curricula and other courses already in place through case- and problem-based learning modules.
To be prepared to engage in global health experiential learning, students need mentored experience and public health knowledge beyond the scope of a single workshop or one or two global health courses. Experiential learning through volunteering also requires a proper risk assessment to reduce possible negative effects of activities. The pilot workshop described should be seen as only one component of a number of global health curricular elements currently under development at Harvard School of Dental Medicine. It is also important to recognize and appreciate existing international guidance on ethical volunteering issued by dental professional organizations and the FDI World Dental Federation, which provide authoritative guidelines for dental volunteering.24–26
The fact that 97 percent of the students who participated in our workshop reported that they plan to do volunteer work in the future emphasizes the importance of training students for responsible volunteering. Perhaps the best guidelines for a dental student volunteer may be the following: 1) think critically and reflect intensively before engaging in any volunteer activity, and be clear about motives and conscious of limitations; 2) engage only in activities that are relevant and sustainable in the host/recipient communities based on sound public health principles and evidence; 3) do as little harm as possible with any activity chosen; and 4) make sure that the volunteer activity benefits the community and is a challenging experience that leads to personal reflection and growth.
There are several limitations to this study, including a small sample size of only thirty students. Additionally, this study only measured student perceptions rather than outcomes from actual volunteer experiences. Future studies could measure actual student outcomes from volunteering to ensure that the knowledge gained from this workshop translates into practice. This becomes particularly relevant because there is general consensus that medical curricula should include exposure to working with disadvantaged populations internationally. As we enter into a new generation of systems-based medical educational reform, “Active student exchange can strengthen the bonds of empathy and solidarity that an interdependent but highly inequitable world so greatly needs.”4 International student activities, while encouraged, must adhere to the principles of global health just as local and domestic activities should. The workshop approach described may be one way for students to thoughtfully and systematically apply these principles to any volunteering activity. It should be part of a structured approach that includes critical evaluation of community activities, thus enhancing students’ ability to adapt their clinical training background to the needs of the populations they aim to positively impact through community service and global health-related activities.
REFERENCES
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