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2014 The Gambia-McDiarmid team
Health system strengthening in the Gambia
Led by Melissa McDiarmid, MD, MPH, School of Medicine (Occupational and Environmental Medicine)
Student (school affiliation): Alisha Ellis (law)
The aim of the global interprofessional education project, “Health System Strengthening in the Gambia” was to gain insight from Gambian counterparts regarding the utility, clarity and appropriateness of a series of three draft tools designed by UMB SOM Occupational and Environmental Health faculty and staff to assist hospitals and other healthcare facilities in providing WHO recommended prevention and treatment services to health workers in low and middle income (LMI) countries.
During our two week stay in the Gambia, faculty team leader Dr. Melissa McDiarmid and law student team member, Alisha Ellis, MSW, together with the larger UMB delegation attended overviews on the Gambian health system, provided by Gibril Sumbunu, Head of Health for Peace Corp, in the Gambia and on traditional medicine in the Gambia, provided by practitioner, Abubakarr Sillah. We also visited a variety of clinics and hospitals, including public, private and NGO-sponsored facilities. Several visits to the Edward Francis Small teaching hospital of the University of the Gambia (UTG) Medical School were made which allowed conversations with its senior leadership, including Chief Medical Director, Dr. Ammar Al-Jafari and Provost of the School of Medicine, Dr. Ousman Nyan.
The initial visits to these facilities were primarily “get acquainted” sessions, during which both of the UMB projects were described to our Gambian hosts–this present project on health worker protections, and Dr. Greg Carey’s project, related to identifying potential opportunities for bi-directional collaborative research, educational activities and service learning placements. The two week schedule of hospital and clinic visits and key informant interviews can be found in Appendix 1.
Interprofessional Education Factor:
The synergies of the multiple professional disciplines represented on our IPE team were evident by the high interest all team members displayed for the two UMB projects and also the complementarity and benefit both groups derived from the shared hospital meeting sessions.
The domain of Occupational Health is, by nature, an inter-professional discipline and is especially so in the healthcare environment. Beyond the clinical aspects of prevention and treatment of work-related injuries, diseases and disability, there are social and legal implications and ethical conflicts of interest when a worker must choose between accepting unsafe work or unemployment, for example. Also, the societal expectation that the worker must ‘sacrifice themselves’ for their patients, contributes to the suspension of usual self –preservation behaviors and requires workers to make a ‘false choice’ between providing competent care for their patients and protecting their own health. Clearly both outcomes can be achieved in a system of safe work.
As well, the precarious system (where it exists at all) of compensation or worker rights in LMI countries, further argues for an IPE analysis and a multi-disciplinary intervention model to address such challenges. Finally, the larger domain of public health, the disciplinary ‘home’ of occupational health, also lends credence to an IPE approach to analyzing and solving work-related societal threats, given its own multi-disciplinary make up.
Occupational Health as a Value:
The recognition of the importance of providing occupational health prevention services for health workers was quite apparent at every in-country visit, especially so when explained in the context of "Health System Strengthening," a current WHO global campaign and long term goal. Indeed, this awareness was particularly evident during our meeting with WHO country representative, Dr. Momodou Gassama, who visited with us on his way to join WHO regional colleagues in Sierra Leone to assist with health worker protections, where four nurses had already died from Ebola due to inadequate personal protective equipment (PPE) and training. Many Gambian colleagues reflected on the need for a change in behavior among health workers, and perhaps, even among staff leadership tasked with providing prevention services for other workers. Barriers to providing safe work were not explained only by a lack of resources, but were also linked to attitude by some informants who stated that attitudes needed to change. One nursing leader reflected, "I’m frustrated a lot."
Because the health worker project required key informant reviews of draft materials we prepared for our Gambian hosts’ comments, we requested to make follow up visits for this purpose during our initial hospital meetings. Each of the principal hospitals granted our request to make return visits to meet with key informants, including nursing leadership, infection control staff and where present, occupational health personnel.
Not until the last day of our visit were we able to meet with Ministry of Health, Chief Nursing Officer, Margaret Gomez. However, she had received our project packet and had already reviewed the thumb drive contents we had delivered to her office the previous week and she invited us for a second visit on our last day in the Gambia. At this visit, which was cut short by her being summoned by the Minister, she expressed her high enthusiasm for this project and we spoke of implementation options including the use of more well-resourced facilities as regional “champions” acting as training hubs.
The three draft tools included:
1) Occupational Health and Safety (OHS) dashboard;
2) Employee Workplace Safety Climate survey, and
3) Occupational Health Services asset map which can be found in Appendix 2.
Because the key informant interviews were a lengthy process, we decided to limit our request for feedback to the first document in the tool kit listed above, the OHS Dashboard, as it was the principal document in the draft tool kit and it outlined the elements of a draft OHS program which required consideration prior to establishing such services in a clinic or hospital.
We also determined during our interview process, that several important key points made by the Gambian colleagues were global and thus, applied to more than one document in the tool kit. The overall comments by key informants revealed that the language level and degree of professional expertise required to complete the dashboard, generally tracked with the training sophistication of the higher resourced settings (i.e. the MRC) where nursing leadership had more extensive education, often in European institutions. In the other settings, for example, there are at least three levels of nursing preparation in the Gambia, with many nurses functioning at a practical nurse or nursing assistant level or in lesser clinically-skilled roles, reflecting shorter and less clinical depth in educational preparation. Therefore, certain language choices, standard medical abbreviations used and some topic introductions will require clarification in the next iteration of the draft dashboard. For example, we will need to spell out Hepatitis B virus vaccine, and not just list HBV, in a checklist. In addition, it was suggested that we include a glossary of terms and to add legends in checklists. We will generally need to use more explanatory language.
Appendix 3 contains composite feedback for the Occupational Health and Safety Dashboard gained from three key informant interviews from: 1) Medical Research Council (MRC) hospital—a private entity enduring from the British colonial period and still the location for British MRC-funded infectious disease and vaccine trials (Matron Pamela Colliera and a contract occupational health physician); 2) Bafrow Clinic (Foundation for Research on Women’s Health, Productivity and the Environment), an NGO-with international and private support (Deputy Director Yassin Sompo-Ceesay and Nurse Catherine Dalliah); and 3) Edward Francis Small Teaching Hospital, the hospital of the medical school of the University of the Gambia and the largest public hospital in the country (Infection Control Officer, James Gomez). Responses are color coded to allow tracking of the key informant source.
The remaining two documents in the tool kit were explained to the Gambian key informants to be "readiness” exercises for facilities contemplating the addition of a staff safety and health program. The employee safety climate survey (document #2 in the tool kit) can provide insightful feedback to nursing leadership on the perceptions of job safety held by the staff, thus permitting targeted refresher training on specific topics or other types of safety interventions. The asset map (document #3) permits exploration of resources available to begin or enlarge a staff safety program, where they might not appear readily apparent initially. While these documents were not reviewed in detail during key informant interviews, some of the global comments received regarding the health and safety dashboard can be applicable generally to these other two documents, as well.
Summary: The aim of this project, to obtain feedback on the appropriateness and applicability of a Health Systems Strengthening draft tool kit was realized through the conduct of key informant interviews with Gambian health system professionals and through some other informal conversations with Gambian health workers and public health officials. This input will guide revisions to the tool kit contents, which will hopefully enhance the benefit which can be derived from these resources, perhaps not only for the Gambia, but more broadly in LMI countries which share some of the same resource constraints.
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