Dissertation

Why do health professionals volunteer in lower and middle income countries? Leswell D, (Supervisors: Inman A, Collett, T)

Background: The UK is committed to encouraging the practice of NHS health workers volunteering in lower and middle income countries (LMICs) around the world, particularly in health partnership schemes. Despite thousands of doctors, nurses and other health professionals volunteering each year there is limited information as to why those individuals do so. Understanding their motivation would provide valuable insight into this area of medical practice. The aim of this study was to explore health professional’s motivation for volunteering globally and to explore some of the enablers, hinderances and barriers for this practice.

Methods: This qualitative design of study used Voice over Internet Protocol software, Skype™ to conduct exploratory semi-structured in-depth interviews with 10 UK based doctors with a history of volunteering in LMICs. Participants were identified through response to an email invitation issued via a university health collaborative with subsequent snowball recruitment being employed. Following verbatim transcription of the interviews a framework for thematic analysis addressing participants motivation was developed with the assistance of NVivo™ qualitative data analysis software. A further thematic analysis of enablers, barriers and hinderances for volunteering was also performed.

Results: Clinicians interviewed were from varying specialties and levels of training. Participants were mostly consultants, but all levels of training from 4 years post qualification were represented. Volunteer experiences varied in terms of type of medical practice, number, duration and location of volunteer trips. Countries worked in included Sierra Leonne, Kenya, Nepal, Ghana and Tanzania amongst others. The key themes identified relating to the clinicians motivation for volunteering were; making an impact, the volunteer's own professional and personal development, recognising and seeking to address inequality, the influence of personal and professional relationships, organisational considerations, disillusionment with the NHS, the role of undergraduate medical electives and the personal characteristics and values of the volunteer. Barriers, hinderances and enablers are also described.

Conclusion: It appears that clinicians find a renewed sense of vision and meaning for their medical careers through their volunteering overseas. Often citing these volunteer experiences as the means by which they re-engage with their initial motivation for originally pursuing a medical career. Contributing in a meaningful way in LMICs provides lasting benefits both personally to the volunteer and to their NHS careers, especially in terms of leadership development. Participants were often introduced to volunteering through an undergraduate medical elective. This link appearing to be an under-reported benefit of such undergraduate electives. Participants volunteer in a variety of global health schemes, with most demonstrating a clear preference towards global health partnerships, often citing the reciprocal benefits of these. Understanding the motivation and benefits of medical volunteering could provide a way to encourage this practice. It's reported potential to bring increased satisfaction and motivation to NHS clinicians working in the UK should not be overlooked in potentially aiding with the retention and recruitment of junior doctors in the NHS.

‘The use and misuse of the Lake Louise Score in the mountains: does removing sleep improve specificity and utility?' Moore J. (Supervisors: Harrop T and external expert)

Background: The Lake Louise Score (LLS) for the assessment of Acute Mountain Sickness (AMS) was introduced following the 1993 7th Hypoxia Symposium1 as a research tool. By scoring the five most common AMS symptoms (headache, gastro-intestinal change, fatigue, dizziness and sleep-quality), AMS was defined, with measurement becoming immediately more simplistic and accessible to medics and non-medics alike. In recent years, the score’s specificity has been called into question.2 Following the publication of two key papers,3, 4 a revised LLS was published,5 reflecting research suggesting sleep-quality was the less-related clinical component. This study re-examines LLS specificity, investigating other potential causes of false-positive AMS diagnoses in a low-altitude population. 

Method: Retrospective statistical analysis of data from a population of 123 adolescents trekking at low-altitude was undertaken to establish the predominant cause of false-positive AMS diagnosis. Removal, in turn, of each LLS component provided insight into the contribution each component played in the final score. Utilising the same statistical analysis techniques as MacInnis et al,4 exploratory factor analysis (EFA) was applied to low-level data to establish the existence of LLS component groups.

Results: Females were significantly more likely than males to report symptoms commensurate with a diagnosis of AMS at low-altitude (p = .002). However, there was no statistical difference in the severity of symptoms reported. Removal of the LLS components showed that fatigue contributed more to a false-positive AMS diagnosis than sleep-quality in this group. EFA from morning data highlighted sleep-quality as a stand-alone factor in the measurement of AMS. Although of smaller significance, this result was in-keeping with MacInnis et al.’s results4. EFA of the evening data highlighted fatigue as a stand-alone factor.

Conclusion: These findings supported previous work that led to the removal of sleep-quality from the LLS. Furthermore, analysis of the low-level data demonstrated that fatigue had an equal place to play in the mis-diagnosis of AMS in the low-level, normobaric-normoxic population (ie. those without disease), and was likely to play a significant contribution to an AMS diagnosis at altitude. Fatigue caused by hypobaric-hypoxia, undistinguishable from that caused by jet-lag, physical exertion and psychological stimuli, undoubtedly adds to LLS poor specificity, making its inclusion in the scale unwarranted. Furthermore, the subjective nature of its other components, make the LLS validity unsound and, as a consequence, its value as a clinical decision tool is unjustified.

The Incidence of Injury in British Antarctic Personnel between 2007 and 2016. Rudd J. (Supervisor: Smith S)

Introduction

Antarctica is hazardous and remote with limited medical infrastructure. Planning and equipping remote Antarctic bases is aided by knowledge of an accurate profile of injuries. The last study into the incidence of injury in Antarctica used data that is now 23 years old. A recent incidence of injury in the British Antarctic population is not known, neither whether changes to health and safety policies have reduced the incidence of injury. Thus the aims of this study were to describe the profile of injuries experienced by British Antarctic Survey (BAS) personnel between 2007-2016. The objectives were: to determine the incidence of injury; between 2007-2018; before and after introduction of the AINME system and to assess the injury pickup rate of the AINME system. Also to determine the pattern of consultation rates, profile each BAS location in Antarctica determine the distribution of injuries by location (grouped into bases versus ships); specific bases and ships; types of injury; proportions of injury; severity of injuries and contributing factors to injury to build a profile of injuries experienced by the BAS population. 

Methods 

An exploratory analysis was conducted through a retrospective review of medical records utilizing travel itineraries to calculate the incidence of injury. Frequency of injuries reported by the British Antarctic Survey (BAS) accident, incident, near miss and environmental (AINME) system were also analysed.

Results 

The incidence of injury in British Antarctic Personnel reduced from 661.7/1000 person-years (1986-1995) to 529.3/1000/year (2007-2016). 504 (44.9%) AINME reports were made for accidents in the same period as 1122 injury consultations were recorded in the BAS Medical Unit (BASMU) database. New injuries were 21.1% of all new consultations, and follow-up injuries accounted for 35.5% of all trauma consultations. There were on average 65.1 consultations each month, with a mean minimum in September and maximum in January. Mean incidence of injury on ships was 334.6/1000/year and 657.8/1000/year on bases. Peak incidence was at South Georgia (1182.6/1000/year) and lowest at Signy (130.2/1000/year). Peak major trauma was at Halley with 212/1000/year and peak work related injury at Halley also (547.5/1000/year). Commonest injuries were sprains(47.9%), superficial(15.1%), wounds(11.1%) and fractures(8.5%). The most frequently affected occupational group were crafts and trades workers(32.4%), then professionals(22.1%). 

Conclusion 

Incidence of injury has decreased compared to a similar study from 20 years prior. A report was created that profiles the incidence and types of injury at each BAS location with contributing factors of injuries in the BAS population in Antarctica. It can be used to train and inform doctors travelling South but also inform management and senior BASMU decision makers to enhance operational and strategic decision making and is useful as a baseline comparison for health care interventions. Given that it is an exploratory analysis of the British population in Antarctica with no similar project conducted in the last twenty years, nor any study of comparable populations performed in this way and of this scale, in the recent past, it produces a picture of injury that is also potentially of use to other national Antarctic programs.

A qualitative study to explore pregnant and postnatal women’s perceptions of a midwife-led biomass smoke education programme in rural Uganda. Ward B. (Supervisors: Jones R, Westlake D, Inman A)

Background, aims and study design

Indoor burning of biomass fuels has devastating environmental, health and socio-economic consequences, disproportionately affecting poor, low-educated women in rural areas of low-income countries. Addressing widespread deficiencies in awareness and knowledge of biomass smoke is believed to be key to promoting behavioural change and reducing smoke exposure among those at greatest risk. However, evidence of studies aiming to address this aspect are lacking.

FRESHAIR research group implemented an education programme in rural Uganda to raise pregnant and postnatal women’s awareness of the risks of, and methods to reduce biomass smoke exposure during pregnancy. Women attending maternal or neonatal clinics in Jinja district were offered to attend education sessions. During FRESHAIRs implementation study, purposive sampling recruited 21 women for interviews to explore their perceptions of the programme’s feasibility and acceptability.

This project is a qualitative secondary analysis of this interview data, aimed at exploring pregnant and postnatal women’s perceptions of a biomass smoke education programme. Four research objectives were developed. To explore: factors influencing session attendance; perceived change in knowledge pre-post programme; factors influencing implementation of smoke-reduction methods; and opinions of the session’s delivery and suggestions for programme development. 

Transcripts of all 21 semi-structured interviews were thematically analysed. An inductive approach ensured that themes generated were grounded in the data, and reflected participant’s own perceptions rather than existing theories or researcher preconceptions. NVivo software assisted the development of a coding and thematic framework and in-depth analysis, with intercoder agreement adding rigor.

Results and discussion 

The four themes identified related to the aforementioned research objectives. 

The sessions were unanimously perceived to improve biomass smoke awareness, with women also describing willingness to, and influencers of sharing the knowledge acquired with other community members. Significantly, women universally described subsequently implementing a range of smoke-reduction methods, including behavioural, structural and fuel modifications.
Factors influencing both session attendance and implementation of interventions encompassed environmental, structural, economic and cultural categories. Importantly, real facilitators to both were the perceived importance of health education and increased biomass smoke awareness. 

Perceptions of the sessions were generally positive. Suggested programme improvements focussed largely on ways to facilitate attendance and implementation: prior notification of sessions; sessions occurring within local communities outside of health centres; involving other population groups; and governmental support. 

Conclusion 

By raising biomass smoke awareness, FRESHAIRs education programme produced health-promoting behavioural change, evidencing the need for programme development and expansion. Through understanding user’s perceptions and making recommendations, these findings could assist the development of locally-tailored, acceptable and equitable biomass smoke programmes, potentially capable of eliciting largescale health improvements to those in greatest need.