Final Year Medical Student, Kings College London, UK The UK has one of the oldest populations in the world, Uganda the youngest [1]. How do they support their elderly? • An eight week placement in two equal parts conducting 2 needs assessments interviewing a total of sixty patients . • Visiting other organisations to learn about their models of care provision and working with experts in best practice. • Comparing and contrasting challenges in each country, and reflecting on roles that would suit me in tackling these.
WHY THIS ELECTIVE? Caring for our ageing population is a key challenge of our time. Across the world, societies are ageing, with wide-ranging impacts. [1]. The World Economic Forum suggests that the percentage of the global population that is 60 or older is projected to rise from 8% (200 million people) in 1950 to 22% (2 billion) by 2050 [3]. Globally health systems are poorly prepared for this change and there is a need to redesign services, particularly through increasing community programmes, and to train a new generation of geriatricians equipped to meet these challenges. [4] I want to be one of these!
WHAT DID I HOPE TO ACHIEVE IN THE UK & UGANDA?
• • • • •
VOICES OF THE ELDERLY (UGANDA) • Voices of the Elderly is a grassroots network across Kabale district, south-west Uganda. • Current activities revolve around awareness-raising, advocating for increased funds and resources, key events, and outreach of advice and social support to local villages. • My needs assessment focused on health needs and development of a day care centre. • I made recommendations around a revolving equipment store, increasing geriatric training for the nursing lead and generating financial applications to Western funds.
• • My needs assessment evaluated service usage and development of a day care centre. The benefits of volunteering described were mapped to the key • I made recommendations around health promotion, integration of the community outcome indicatorsoffor five different livers, and consultation residents, and a newUK fallsprofessional prevention & referral service.
development structures.
RESULTS FROM MY NEEDS ASSESSMENTS: COMPARATIVE RESULTS OF MY NEEDS ASSESSMENTS
INTERNATIONAL COMPARISONS: A further framework was developed to demonstrate the link
• • • • •
Number of Health Issues Seriously Key Concerns of Patients Before Accessing Services England between volunteer experience within partnerships and improved Impacting upon Quality of Life UKUganda service delivery outcomes. 30
Number
Number
6 4 2
20 10
0
0 55-65
65-75
75-85
85-95
Health
Daily Tasks
Mobility
Overview of Results
Age of Patient
- Ageing in the 21st Century, 2012 [2]
To gain an overview of the challenges arising at a societal level from the ageing population and relevant policy To explore and compare the needs of the elderly particularly focusing on both the health and social care needs To learn about several models of community care provision for the elderly and visit examples of better practice To develop my research skills through designing and conducting needs assessments of community organisations To explore the role of a community geriatrician and to consider career pathways in this field that would suit me
A systematic review of both published literature and grey MORDEN COLLEGE (ENGLAND) literature was conducted. Content relating to costs or benefits to Morden College is a Christian charity which provides a range of services through both a the UK at an individual, institutional or system level was residential and nursing home and a community of ~400 independent / assisted livers. extracted and analysed thematic synthesis. Has on site medical centre withby occasional GP clinics, physiotherapy and nursing teams.
•
“Ageing is a megatrend that is transforming economies and societies around the world”.
Loneliness
Safety
Emergency
Ugandans had more health issues than English at all ages; the gap reduced over time. Both populations were very concerned about emergencies prior to accessing services. Ugandan patients had more concerns and were particularly worried about their health. However, English patients were 1.6 x more likely to be lonely than Ugandan patients. Safety was a significant concern for the Ugandan elderly (12 out of 30 patients) but it was only raised by one English patient who reported they had lived in a ‘rough’ area.
Overview of Costs
Area of Concern
The literature review (including citation mapping) returned 9 Domain Initial Codes published papers and 32 pieces of grey literature that met all Financial Financial cost inclusion criteria. Most literature does not meet high standards Loss of Staff Loss of staff from other areas of work, of formal academic rigor. Methods: The workshop was developed by a group of students from the UK, America and Quebec, and delivered prior to the IFMSA
Imposing upon others when finding cover, Challenges of organising cover, Trained staff international conference in 2013 on the theme ‘Advocacy and the Physician-in-Training’. Content included introductions to key topics leaving their post following links, including advocacy, leadership, global health, vision-building, strategic planning and team-building and skills-based training in advocacy
- 95% of sources cited benefits and 32% cited costs. techniques such as engaging with the media and policy-writing. Reputational Negative perception of the UK Institution where links are run -A 40 initial individual benefits codes elicited. range of methodological styles were usedwere including peer and expert-led lectures, small group interactive badly, workshops, debates, and of the UK where links are run badly, Negative perception site visits. Learning was thenbenefits applied to outcome-focussed campaigns such as changing medical school curricula and ethical -thematic 10 Institutional and national were extracted. These Health and Accidents/Injury,electives. Management of security risks, student seem to arise both directly from the existence of links (e.g. Pre and post-workshop questionnaires assessed impact on student knowledge, skills and attitudes.Security Exhaustion/Burnout/Stress, Culture shock Improved reputation) and from workforce engagement in links.
on
-
Opportunity
Staff distracted from areas of UK work, Neglect of 15 initial cost codes arose, which were grouped into 5 domains: relationships/Burden of Family or friends, Loss of annual leave, financial; reputational; health & security; loss of staff; and Learning about pit latrines in Jinja, East Uganda. Meeting a grassroots group in Kabale, West Uganda. Negative effects on career, costs Visiting aOpportunity disabled group in Mbale, East Uganda.
An effective public health initiative, but a real challenge to use opportunity costs. for those with impaired balance, muscle strength and mobility.
a
The lack of support from national programmes and their children (HIV epidemic and urbanisation) leads to reliance on these groups.
Benefits to Individuals and Workforce
All people with disabilities face a lot of stigma and challenges in Uganda, but this is significantly greater in the elderly.
Conclusions
- The 40LEARNING individual benefits codes were grouped into 7 keyCAREER REFLECTIONS AND There is little published or unpublished literature on the impact CONCLUSIONS PERSONAL POINTS
my interests in geriatrics, health • Services for the elderlyskills; are increasingly movingskills; to daycommunication centre and • This domains: clinical management & elective strengthened of volunteering within health global partnerships. The existing evidence health-systems improvement. I hope to combine home-based models to reach a greater number of olderpolicy; individuals. teamwork; patient experience & dignity; academicand health policy /base is descriptive and focuses on the benefits. these in the future, and have found new ways this may be possible. • Best practice has not yet been established but increasing numbers of skills; and personal satisfaction & interest. workinequity is required to quantify theand costs and benefits of • I was frustrated byMore the health I personally witnessed innovative models of community service provision are arising. aid organisations againsthealth the elderly in Uganda. for individuals and • - Loneliness in the elderly is a real problem the UK,between affecting over volunteering within partnerships Ardhigh degree of concordance wasinshown benefitsdiscrimination by key 1/3 of my interviewees. Up to 13% of UK over 65s are very lonely [5]. • I became more aware of the limits of what I can achieve in the institutions, and the associated challenges and barriers. cited and professional development indicators within UK Ugandan context; self-awareness key both as a clinician and academic. • It is also becoming an issue in Uganda due to urbanisation and a workforce development frameworks, the Knowledge • Tangible outcomes were important to limitations me so I have given break-down in traditional family structure throughincluding Western influences. Despite these our presentations analysis suggests that skills acquired about written a blog for the British Geriatric Society. • Age discrimination is widespread both countries but particularly in & skills framework (KSF), inThe NHS Leadership framework and my elective and through volunteering map closely to workforce development • My careers reflections following my elective led to me attending Uganda’s development agenda, where the elderly are often excluded continuing professional development competencies. frameworks and geriatrics, can be theoretical linked a national conference on community beginning some e- to improved service from both national and international poverty-reduction programmes. delivery and within thepolicy NHS.and Benefits health applyingcould for anbe maximised by formally • - Help Age international is the best-known charity working specifically A theoretical trajectory from volunteer experience to UK learning on health-systems academic foundation post researching global healthwithin for the health elderly. partnerships within with the elderly and has significant programmes in both countries. embedding volunteering
service delivery outcomes was demonstrated in most areas, but not all (see Model of Transferring Benefits).
References [1] The World Health Organisation and US National Institute of Aging (2011) Global Health and Ageing, Geneva. [2] United Nations Population Fund and HelpAged International (2012) Ageing in the 21st Century: A Celebration and a Challenge, New York. [3] World Economic Forum (2011) Global Population Ageing: Peril or Promise?, Geneva. [4] The UK Select Committee on Public Service and Demographic Change - First Report (2013) Ready for Ageing?, London. [5] Age UK (2012) Loneliness: The State We Are In, Abingdon.
continuing professional development processes.
Acknowledgements I thank Ian Sanderson of Afrinspire and Dr Tina Challacombe and Dr Ann Wyllie for their support in the design of this elective. I thank Zadok Kamusiime, Bachu Mubarak, Willy Nkamuhebwa and Franco Kashaija for their support of my Ugandan attachment. I thank Matron Sharon Herd for her direction, and all the lovely staff at Morden College for their support of my UK attachment. I thank the 60 patients who gave up their time to contribute to needs assessments, and gave consent for their photos to be used. I thank Daniel Knights for his continued support and encouragement of me and this project throughout this elective placement.