NEWSLETTER Newsletter Volume 30/no. 1/July 2012
Editorial Dear Readers, Another Newsletter made it to the press!
In this issue, among others:
• India’s Missing Girls • Interview with Meenakshi Menon, GHETS • Rooms to the Mountains • The Wall of Fame
The second one in a new format but the first “new” one with the content you were used to! As always, we tried to get as many stories as possible from our very active members. Be inspired by Kamayani and her quest for India’s missing girls (see page 10) or by Sharmie, a very motivated student, who wrote a story about her project in the Philippine mountains (see page 24)! But of course you can also find information about your favorite taskforce, the move to India of Education for Health and, new in our Newsletter, a wall of fame where we listed some of your recent publications! Do not hesitate in the future to keep on sending your stories! This Newsletter is the ideal place to share them with other Network members and sharing is one of the things The Network:TUFH is all about!
Enjoy your reading!
Julie Vanden Bulcke, Editor
In the Newsletter we refer to The Network: Towards Unity for Health as The Network: TUFH.
Contents Foreword 3 Innovation in Health Professionals’ Education: Now More than Ever!
The Network: TUFH in Action 4 Annual International Conference 4 New Initiatives 5 Education for Health
Conference News Stella Mini Grant Goodbye and Hello
Improving Health 6 7 8 9 10 11 12
Health Services Health Promotion Health Promotion Mental Health Women’s Health Integrating Medicine and Public Health Yellow pages
The „Marienambulanz“ Promoting Oral Hygiene among Primary Four Pupils by University Students Resocialization Project of Homeless People in Bogota, Colombia Gender Patterns and Mental Health India’s Missing Girls Promotion of Public Health by Disseminating Effective Health Messages Urbanization and Health in Greater Khartoum
International Health Professions Education 14 15 16 18 19 20 21
Medical Education Accreditation and Quality Assessment New Institutions and Programs New Institutions and Programs PBL and Community-based Education Leadership Column Yellow Pages
Sowing the Seeds of Public Health and Medicine to Create a Hybrid Continuing Professional Development: a Study of Doctors’ Perceptions Gezira\Sudan Family Medicine Program from Trial to Reality Introducing the Women and Health Learning Package in Uganda Straight Internship Program in Family and Community Medicine Dr.Olayinka Ayankogbe, Nigeria Climbing the Ladder of Integration
The Like-Minded Working Together 22 Like-Minded Institutions 23 Like-Minded Institutions
Interview with Meenakshi Menon, GHETS The Karolinska Institute
Students’ Column 24 Students speakers corner 25 Student Interview: The Big Five 26 Out of the SNO Pen
Rooms to the Mountains Daniela Klobassa, Austria SNO @ Rendez-Vous is Well Underway!
Member and Organisational News 26 28 28 29 30 32
Taskforces Taskforces Taskforces Taskforces Education and Research Introducing Members
Integrating Public Health and Medicine Interprofessional Education Updates from the Women and Health Taskforce Social Accountability The Wall of Fame New Members
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Message from the Secretary General Innovation in Health Professionals’ Education: Now More than Ever! The report: “Health professionals for a new century: Transforming Education through strengthen health systems in an interdependent world” published by The Lancet commission on December the 4th, 2010 (Lancet 2010;376:192358) has stimulated a lot of developments in the field of health professionals education worldwide. First of all, the report challenges us to define what we mean by “transformative professional education”. In my vision, it is a process, where insti- The Secretary General Jan De Maeseneer meetutions for health professional education ting with Mario R. Dal Poz and Erica Wheeler respond to the needs of the population through a series of socially accountable change actions, focusing at 3 levels: maInstitute of Medicine in Washington in cro, meso and micro. At the micro-level March 2012, where the Network actively the focus is on educational transformatiparticipates (http://iom.edu/Activities/ ons that prepare health care providers to Global/InnovationHealthProfEducation. practise more person- and people-centeaspx). red care, combining appropriate knowOn the 19th of April 2012, I visited the ledge and skills training in a process of new Department for Health Systems, self-directed learning towards reflective Policies and Workforce (HPW), at the practice. At the meso-level transformaWHO-Headquarters in Geneva. Under tive education looks at interaction with the leadership of dr. Wim Van Lerberghe, health services, providers and citizens in director of the Department HPW, the huthe community, including the establishman resources have been integrated in ment of community-based training comthis new department. During the meeplexes with special emphasis on those ting dr. Mario R. Dal Poz emphasized the areas most in need (rural areas, deprived importance of transformative learning urban areas,…). At the macro-level, it is and the need for guidelines on medical about an active participation in proceseducation. Dr. Erica Wheeler, the official ses of health policy development (with contact person for the Network: TUFH at special attention to human resources WHO, emphasized the importance of the planning) and a contribution to make Network as one of the oldest organisahealth systems worldwide increasingly tions involved in innovation of medical based on relevance, equity, quality, costeducation in the world. effectiveness, sustainability, person- and people-centeredness and innovation. Innovation in health professionals’ education, will not be sufficient to make A lot of the member-institutions of change happen in the health status of The Network: Towards Unity for Health populations. This will require a new apcan illustrate the theory of transformaproach to health care organisation, startive health professional education with ting from a strong integrated approach to examples from daily practice. It will be primary health care and public health. At important to document these examples, the Geneva Health Forum (www.GHF12. so that we can report them at the Gloorg) we emphasized once more that bal Forum on Innovation of Health Protransferring concepts and experiences fessionals Education, launched by the wholesale from vertical disease-oriented
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programs on HIV/AIDS to tackle chronic conditions is misleading and scientifically incorrect. Though HIV/AIDS and other infectious diseases could theoretically be eliminated by stopping the transmission of the infection, such elimination is not yet possible for chronic conditions such as diabetes, multiple sclerosis or heart disease. Thus, for the time being Non Communicable Diseases (NCDs) will remain part of “La condition Humaine”. Looking actively for a “best buy” for NCDs, without assessing the impact on the health system as a whole, is inappropriate. We must look for a strong, comprehensive health system, that integrates rather than separates all common conditions, irrespective of etiology and course overtime, including NCDs, focusing on the goals of individuals and communities to achieve optimal quality and quantity of life. There is increasing evidence that such a health system should be based on strong primary health care, that uses an effective Community-Oriented Primary Care model (COPC), addressing ways to reduce the causes of NCDs and looking at social and political issues at the local, national and international level because of its emphasis on community input. The upcoming annual conference of the Network: Towards Unity for Health in Thunderbay, Northern Ontario, Canada (October 9-14 2012) will create the opportunity to exchange with like-minded organisations as Wonca-rural, FAIMER, Training for Health Equity Network, Global Health through Education Training and Service, Global Consensus for Social Accountability of Medical Schools,… on concepts, strategies and practices, that make change happen (www.rendezvous2012.ca). You are most welcome! Jan De Maeseneer, MD, PhD, FRCGP (Hon), Secretary General The Network: Towards Unity for Health. Email: Jan.DeMaeseneer@UGent.be
The Network: TUFH in action Annual International Conference Conference News Contrary to The Network: TUFH’s other annual conferences, this year’s conference is highlighting the collaboration of five conference organization partners, and their ability to bring together the planning of a conference with many perspectives from around the world. This approach will lead to a unique international conference, called Rendez-Vous 2012, hosted in Thunder Bay, Northern Ontario, Canada, from October 9 to 14, 2012.
Working Party on Rural Practice, THEnet: Training for Health Equity Network, Consortium for Integrated Longitudinal Curricula (CLIC) and Global Community-Engaged Medical Education (partnerships of ICEMEN - Flinders University and the Northern Ontario School of Medicine). We share with you the enthusiasm of the Organizing Committee, the Northern Ontario regional communities, and all the health professional schools and organizations that will be part of this unique event.
Rendez-Vous 2012 – Together and Engaged, refers to the Francophone term, “Rendez-Vous” means “a place appointed for assembling or meeting.” It feels both appealing and appropriate to describe this event as a Rendez-Vous, as we convene communities from around the world in teaching, learning and networking about community participation in education, service, research, and health.
Check the website www.rendez-Vous2012.ca for continuous updates on the program, keynote speakers, pre-conference workshops, conference on the move opportunities, and postconference education sessions and trips! We hope to see you at Rendez-Vous 2012!
In the past few months, over 440 abstracts for workshops, oral presentations, thematic poster sessions and PeARLs have been submitted with the anticipation that 600 delegates from all over the world will participate in this exceptional Network: TUFH conference!
Warmest and kindest regards, Kaat De Backer, Executive Director, The Network: TUFH Email: kaat.debacker@ugent.be Sue Berry, Assistant Dean, Integrated Clinical Learning, Northern Ontario School of Medicine Email: sberry@nosm.ca
Filled with ample opportunities for a variety of learning and discussion, the preliminary program includes all well-known Network: TUFH conference formats as well as some interesting ‘fusion’ formats. Each day will bring new perspectives, building on the overall theme of the conference: Community participation in education, service, research, and health. The Network: Towards Unity for Health ‘spirit’ will be present throughout the entire conference, but there are also plenty of opportunities to experience the commitment of the other organizations that are co-hosting this conference: The Wonca
New initiatives Stella Mini Grant
Stella Dhondt was born on September 9, 2011, surrounded by highly trained health care workers, in the best health care facilities possible. Unfortunate, not every child comes into this world in the same circumstances, with every chance on a healthy and prosperous life. The Stella Mini-Grant came to life, by numerous donations from people who wanted to celebrate Stella’s birth in an alternative way: contribute to communityoriented health care, based on equity. We are pleased to announce this call for proposals for a Stella Mini-Grant.
Stella Mini-grant
How to apply
The Stella Mini-Grant is a grant to finance a small-scale community project, aiming to improve equitable health care. The goal of The Network: TUFH is to foster equitable community-orientated health service, education, research and policy. Therefore, the focus of the project can be one of these four areas. The Stella Mini-grant is available in three categories: 100 - 500€ / 500 – 1000€ / 1000 – 1500€
Go the website of The Network: TUFH (www.the-networktufh.org) and check out the formal and scientific criteria to apply for one of these mini-grants. Use the online form to describe your project proposal and submit it to the office of The Network: TUFH (secretariat-network@ ugent.be) before August 31st, 2012. The winning project proposals will be announced at the conference of The Network: TUFH in Thunder Bay, Canada and via our website, by the end of October 2012.
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The Network: TUFH in action Education for Health Goodbye and Hello
In March 2010 the Network: TUFH office moved from Maastricht, the Netherlands, to Ghent, Belgium. Two years later, the Network: TUFH journal Education for Health has left Maastricht as well. For 24 years, Maastricht University has served as Education for Health’s home. On January 1st 2012, the journal’s home was transitioned to the Maharashtra University of the Health Sciences (MUHS) in India. About a year ago, I met Payal for the first time. She was to become the new managing editor. It was the start of an exciting journey to transition Education for Health from Maastricht to Pune, giving it not only a new physical home, but also new personnel and a new publisher. Transitions are never easy. But meeting each other helped us to handle the transition with confidence. I feel privileged to have been working as Education for Health’s managing editor for 13 years, as I have come in contact with so many wonderful people from all over the world. Therefore I’d like to seize this opportunity to send my warm regards to the journal’s co-editors Michael and Don, the associate editors Jane, Jan, Bob, Noel and Pertti, the journal’s editorial board members and reviewers (many of whom have served EfH for more than 10 years), and all the authors who sent us their valuable contributions. Finally, I’d also like to thank the Australian journal Rural and Remote Health, which served as the journal’s online submission and publication platform for five years. I hope the transition has been smooth for all of you! Let me introduce to you the new journal team: The managing editor is Dr. Payal Bansal; Assistant managing editor is Dr. Gaurang Baxi. The new publishing platform is Wolters Kluwer Health / Medknow publications. The new email address is efh@muhs.ac.in. The journal website has not changed: www.educationforhealth.net. Readers can look forward to the first journal issue of 2012, which will be published in June. As Don Pathman mentioned in EfH’s last editorial (Vol. 24:3): “Those of us who have begun working with Dr. Bansal and her colleagues in India know the journal’s future remains bright.” Goodbye from Maastricht, and good luck to Payal and her new staff in India! Marie-Louise Panis Maastricht University, the Netherlands 5
Improving Health Health Services The “Marienambulanz“, an Innovative Primary Health Care Project for Marginalised Groups Austria is one of the richest countries in the world. Yet at the turn of the 21st century, the gap in health outcomes betweenthose at the top and bottom ends of the social scale remains large and, in some areas, continues to widen. Due to the crisis in ex-Yugoslavia, more and more refugees ended up in Austria. Some of them needed medical assistance but at that time most of them had no insurance and therefore access to the healthcare system was limited. This was one of the reasons that in 1999 the primary health care centre “Marienambulanz” opened in Graz, the second largest cityof Austria with more than 300,000 citizens. The objective was to offer medical and social assistance free of charge, to Austrian and non-Austrian citizens; to people with or without insurance; to those who have very little or no access to medical care. Five days a week, the out-patient department provides primary medical care, prevention and health promotion activities, psychological counseling, and further assistance with the integration into public health services and secondary care. Over the years the team has developed many strategies to meet the various needs of the target group. Specialists offer appointments for psychiatric disorders, diabetes and hypertension and a network of partners extends the range of free services and health promotion activities.
General practice, primary prevention and health promotion activities, counselling and social support are closely linked to address the needs of the significantly growing target groups.
Two days a week, a doctor and a nurse practice at a streetworkers’ place and once a week a mobile team visit different places in Graz to serve various people belonging to the fringe
groups of our society. Besides general medicine the team offers HIV-testing and hepatitis immunisation. All clients are treated anonymously and personally. There is also a mobile psychiatric team which visits shelters for the homeless on a daily basis. In the past 11 years about 73,900 consultations with over 9,000 people from 86 nations have been counseled, treated or accompanied by the multilingual team. Every year the “Marienambulanz” provides a range of services to a growing number of women (37%) and men (63%), at the average age of 30 years, one third of them local people and two thirds foreigners. Even though the “Marienambulanz” offers medical assistance, it works with a broad definition of health. General practice, primary prevention and health promotion activities, counselling and social support are closely linked to address the needs of the significantly growing target groups. Martin Sprenger, MD, MPH, Head of the Post graduate Public Health Program, Medical University of Graz, Austria Email: martin.sprenger@medunigraz.at
In action 6
Improving Health Health Promotion Promoting Oral Hygiene Among Primary Four Pupils by University Students
Introduction Babcock University (BU) is the first tertiary institution in Nigeria to offer a Bachelor of Science in Public Health, and the first private university to offer a Bachelor of Nursing Science in Nigeria. Right from the first year, students are taught the rudiments of community engagement and behavior change programming. In the 3rd and 4th year, students (in groups) conduct numerous community health education activities in partial fulfillment of the requirement for the award of the degree. At the 2010 Network: TUFH conference in Nepal, three BU students (two undergraduates - Victoria Oyewole and Nya Anwanane and one graduate student - Esther Umahi) presented lucid posters on different health interventions. The focus of this article is on oral health education, conceived and developed by Group 9 of the Field Work (Community Practicum) Class and presented by Mr. Nya Anwanane. The goal of the seminar was to increase awareness on the importance of regular teeth brushing among the pupils.
One of the pupils posing with Nya
Outcome Analysis of the result of the quiz given at the end of the seminar revealed 85% of the pupils had increased awareness on the right way to brush the teeth, the types of teeth and the importance of visiting the dentist compared to 65% at the beginning. Furthermore, the pupils learnt to ask more questions on oral health from their teachers and parents. The take-home gift (aside from serving as an incentive) opened up the door for pupils to discuss what they had learnt with parents/guardians at home.
Initial Steps The group met twice to develop their objectives. On approval by the course coordinators, the group members visited (face to face) the Head Teacher and Class Teacher to seek permission to conduct an oral health seminar for class four pupils. A suitable date and time was arranged.
Conclusion Promoting good oral hygiene among elementary school pupils can be a proactive way of ensuring that young people learn healthy dental practices early in life. University students in health professions schools, particularly final year students, can contribute immensely to the millennium development goals by defining class projects around addressing community health needs. A more consistent health promotion and education programs on other pertinent health issues affecting primary school pupils are envisaged.
Methods On the day of the presentation, the group assessed the knowledge level of the pupils on oral health by administering a ten item oral health quiz, followed by a one hour presentation on the importance of regular teeth brushing, regular visits to the dentist, and healthy eating. Cardboard drawings of the kinds and types of teeth and their functions were used to illustrate and communicate oral health messages to the pupils, including demonstrations on the right way to brush the teeth and the need for regular visits to the dentist. A post test oral health quiz (using the same set of ten item questions) was re-administered on the pupils for assessment purposes. At the end of the seminar toothbrushes, toothpastes and a variety of fruits were given to the pupils as incentives and take-home gifts.
Godwin N. Aja, Dr PH, CHES, Professor& Chair, Department of Public Health as well as Deputy Director of Research & International Cooperation, Babcock University, Nigeria Email: gndaja@yahoo.co.uk
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Improving Health Health Promotion Resocialization Project of Homeless People in Bogota, Colombia It is estimated that in Colombia there are over 14,400 homeless individuals. In Bogota, 8,385 individuals were identified as resident of the street (people who are living on the streets for at least two months), according to data provided by the Bogotá Social Integration Secretary Office. 86.9% of them are male, and they represent all age categories: 8.4% are under 18 years of age, 17.9% are youths (between the ages of 19 -25), 38.9% are adults (26-40) and 32% are seniors. Within this population it was found that approximately 5% are settled in the Barrios Unidos sector in Bogotá, Colombia, where the Fundacion Mi Hogar Asuncionista carries out a program to provide health care and education to homeless individuals. Together with other support networks the Fundacion tries to resocialize them and reinstitute their basic human rights which have been violated because of their vulnerable condition. During the year 2010, semi-structured interviews regarding health conditions using health records were performed by a health care group made up by a physician, third year medical students from the Fundación Universitaria Juan N. Corpas, and a voluntary team composed of a chief nurse, a psychologist, workshop providers, a priest and beauty school staff. A total of 250 medical consultations were carried out.
are marginalized as social outcasts. The Fundacion Mi Hogar Asuncionista registered the monthly attendance of an average of 150 homeless individuals to the comprehensive care program. This satisfied their basic needs (food, health care and first aid, personal hygiene, and clothing). Workshops were carried out to facilitate the process of recovery and rehabilitation of the homeless addressing issues such as affection, psychology, spirituality, self-care, relationships, management of emotions, communication, arts, dance, as well as seminars about psychoactive substances. But behind these data there are human faces. This is the case of Marcela, a college student in international trade, bilingual and from a high-income family, who one day falls in love with “Peluche”. Her new boyfriend introduces her to new “friends” but also the dark world of drugs. Little by little the situation deteriorates as she fails her semester exams and quits University. Marcela decides to leave everything behind and live with “Peluche”... in the street. His family tries to help her, but after several attempts they give up and decide to go live abroad. One day Marcela gets sick. A voluntary team of the Comprehensive Care Program finds her under a bridge. She looks
The following sad conclusions were found: Homeless individuals sleep in parks, sewers, under bridges and lack access to facilities to meet their basic needs such as health care, food, clothing and personal cleanliness. They have no access to public services. As a result, their sanitary conditions are precarious. They obtain their income by begging and criminal acts, and because of this they
The Fundación Universitaria Juan N Corpas supported this project to provide health care and education to homeless individuals thin, trembling and crying. They bathe her and give her clean clothes. In the medical consultation, she is examined by a doctor and three medical students. The doctor wanted to keep Marcela in the hospital, which was refused because she was known as a homeless person. With additional efforts of the doctor, Marcela was finally hospitalized for 15 days. However, she didn’t receive any psychological or psychiatric treatment for her drug addiction and other personal problems. Over time, Marcela, desperate and seeing no alternatives, returns to “Peluche”, which only leads to more problems, which finally results in a jail sentence. Cases like Marcela, make us conclude that state policies have failed to address this growing sociological problem and there is an urgent need for developing a solid approach towards homeless individuals in order to reduce the social problems of poverty and begging. Beselink Quesada Núñez; María Lucía Iregui Piñeros; Jenny Pinzón Ramírez; Facultad de Medicina, Fundación Universitaria Juan N Corpas, Bogotá, Colombia Email: beselink.quesada@juanncorpas. edu.co
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Improving Health Mental Health Gender Patterns and Mental Health: Differences between Rural Indigenous and Urban University Students Community-based educational programs in health have to take into account differences that exist among communities. These differences may be urban vs. rural areas, ethnic minority vs. hegemonic majority, etc. and go beyond quantitative epidemiological data. This is especially relevant in mental health. Depression is an important public health problem not only because of its high and increasing prevalence but also in terms of burden of disease for individuals. Depression is more prevalent among younger individuals, and almost twice more frequent in women than in men, both internationally and in Mexico. This sex gap in prevalence of depression depends on many factors, but there is agreement that a major factor is culture and gender roles socialization. Therefore, it seemed relevant to us compare genders patterns, self-esteem and prevalence of depression between university students from and in rural indigenous communities and those belonging to an urban community. We also tried to establish a relationship between depression and gender patterns (gender related personality traits) and between self –esteem and gender related personality traits. In 2009, we evaluated 459 indigenous and 954 urban students of both sexes through self-applying questionnaires intended to estimate depression, self-esteem and gender related personality traits. We found that indigenous students present a higher level of depression and lower level of self-esteem than urban students. Depression was more frequent in women than in men in both communities. Self-esteem was lower in indigenous women than in rural men, which is not observed in the urban student’s community. In these (urban students) self-esteem does not differ by sex. Regarding gender patterns, we used a classification system with four groups of personal traits. 1. Achievement orientation, also known as instrumentality or masculine traits; 2. Emotions and concern for the welfare of others –known as expressivity or feminine traits; 3. Aggressive-dominant behavior, “machismo”, or negative instrumentality; and 4. Passive-dependent behaviors, or negative expressivity. According to our data, rural indigenous students of both sexes had lower levels of instrumentality and higher level of expressivity than Mexican urban young people.
Women were less oriented to goals and achievement (instrumentality traits) than men in both communities. Women’s passive-dependent behavior traits were significantly linked with depression and low self-esteem. Our data provides basic information on mental health and illustrated relevant differences between urban and rural communities. Student’s belongings to rural indigenous areas represent a more vulnerable group in terms of their mental health than urban students. The study also has shown the differences in depression and self-esteem between men and women. In many societies gender relations are being transformed, but affective disorders are still more common in women than in men. From a psychodynamic perspective, it is proposed that the social identities typically assigned to women are not adequate in providing psychological resources for solving problems. The traditional feminine identity is characterized by passivity, dependence, emotion, and capacity to care for others, and with few possibilities for change. Therefore, differences in the socialization process in girls and boys could be relevant: girls, in comparison with boys, are not trained from childhood to have higher resilience, and to act with higher efficacy in the face of stressful situations. These patterns of socialization are still present in many societies and contribute to strengthening women’s emotional dependence as well as the fear of being alone, a low selfesteem and a subordinate passion. We believe that this study also can help to develop adequate mental health educational programs for both communities, including a gender perspective necessary to improve women’s mental health. Irina Lazarevich and Fernando Mora-Carrasco, Department of Health Care, Division of Biological and Health Sciences, Universidad Autonoma Metropolitana-Xochimilco, Mexico Email: iboris@correo.xoc.uam.mx
Indigenous and urban students following classes together 9
Improving Health Women’s Health India’s Missing Girls girls to every 1000 boys (2011 census); the expected ratio would be 950 and 975 girls per 1,000 boys. Absolute numbers of children between 0-6 years of age Number of children 158 789 287 aged 0-6 in India Number of boys 82 952 135 aged 0-6 in India Kamayani Bali Mahabal
There are several clear indicators of the fact that Indian women continue to be discriminated against: the sex ratio is skewed against them; maternal mortality is the second-highest in the world; more than 40% of women are illiterate; and crimes against women are on the rise. Yet, the women’s movement which gathered strength after the 1970s, has led to progressive legislation and positive change, spurred on by the participation of women in local self-government. For well over two decades, the ‘development’ sector in India has worked tirelessly in villages, mofussil towns and slum settlements running campaigns on the girl-child. In schools each year children do assignments and projects on ‘female foeticide’ and ‘female infanticide’, invariably focusing on practices in ‘villages’ where people are ‘uneducated’. The problem has persistently been traced to a lack of education and that wonderful word on which all social evils can be blamed -- poverty. Governments have put in place incentives for educating girl-children, subsidizing their food, awarding a rupee a day for each girlchild who attends school regularly. Most importantly, in 1996, the Pre-Natal Diagnostics Techniques Act made it illegal to use ultrasound technology to identify the sex of the foetus. Since then, at least by law, doctors are banned from revealing the sex of a foetus to expecting parents. In 1991, the number of females per 1,000 males in India was 927. In 2001, the number rose marginally to 933. The 2011 census put this figure at 940. However, a closer look at the census reveals that the steady rise in sex ratio is somewhat misleading, masking several practices that violate both the law and the rights of female children. The sex ratio in children aged 6 and younger is only 915
Number of girls 75 837 152 aged 0-6 in India There are 7 114 983 fewer girls aged 0-6 in the country as compared to boys in the same age-group. Sex ratio of children between 0-6 years of age Decade
Sex ratio
1991-2001
927
2001-2011
914
Thus, the sex ratio of children between the ages of 0 and 6 in the country has fallen in the last decade by 13 points. Interestingly, in 1961, the ratio was 976 girls for every 1,000 boys in this age-group. This means that over the last 50 years, the sex ratio has fallen by 63 points. Sex-selective abortions In situations where abortion is restricted for sex selection purposes, terminating a pregnancy for this reason is likely to involve an unsafe procedure carrying high risks. Even where abortion is legal, as in India, some health-care providers have reacted to sex selection by denying access to abortion – resulting in women seeking clandestine abortions with elevated risks to their health. The pressures to engage in sex selection in a gender discriminatory environment not only directly affect women’s reproductive decisions (with implications for their health and survival) they also put women in a position where they must perpetuate the lower status of girls through son preference. In addition, it is also women who have to bear the consequences of giving birth to an unwanted girl child. These consequences can include violence, abandonment, divorce (or being forced to live with an additional wife) or even death. They may have to continue with pregnancies until a boy child is 10
born, thus putting their health and life at further risk. If we accept the calculations in the Lancet study, there were fewer than 2 million sexselective abortions of girls in the 1980s. In the 1990s, this figure can be calculated to be as high as 4.1 million. And in the decade ending 2010, the number of sex-selective abortions is possibly 6 million! Where the first-born is a girl, the incidence of sex-selective abortions for the second conceived child is high. In 1990, the number of girls born second in the ordinal sequence was 906 for every 1,000 boys; in 2005, this figure dropped to 836. This amounts to an annual decline of 0.52%. Addressing the issue It is clear that the easy correlation between income, illiteracy and sex-selective abortions was camouflaging a deeper patriarchal worldview that cuts across class, region and caste. The campaign for the girl-child is now far more complicated -- the target audience has expanded, variability in its profile increased, and the languages it speaks have multiplied. Most disconcertingly, the discourses of rights and modernity are twisted to fit into the patriarchal framework and therefore become counterproductive. The approaches of both government and civil society will thus need to focus both on the symptoms and the structure that is nurturing them. Good, restrictive laws and policies implemented in isolation from efforts to change social norms and structures can have unintended harsh consequences, and may violate the human rights of women. Prohibitive legal responses should be seen as a demonstrable attempt on the part of government to redress sex-ratio imbalances, based on the hypothesis that combating the use of technology for non-medical reasons will lead to a rapid halt in sex selection. Yet there is wide agreement that the causes of biased sex selection lie in gender-based discrimination, and that combating such discrimination requires changing social norms and empowering girls and women. These long-term processes will require sustained effort and political commitment Ensure effective implementation of the law and - stringent punishments for doctors who disclose the sex of a foetus: Current punishment under the legislation is sealing
Improving Health Women’s Health
Integrating Medicine and Public Health
India’s Missing Girls
Promotion of Public Health By Disseminating Effective Health Messages in the Communities
the machine and a fine of a few thousand rupees. However, there is a need to ensure that every case that comes up is filed in court and that the punishment includes a fine as well as a conviction. If this occurs, the license of the doctor will be revoked and together with other aspects of the punishment will serve as a deterrent to others. Control over MNCs that sell machines to doctors: There is an urgent requirement to monitor the way ultrasound machines are sold. The company must be made accountable for whom they sell the machines to and how many are being purchased. Records need to be maintained in the public domain. Locating gender as a human rights issue: In the current framework, prospective parents are told: “Ladkiyaan bhi…” (“Girls too can…”) There is, therefore, an attempt to cast girls as more loving, kinder, more capable, a safer investment, etc. This instrumentality to the campaign on promoting girl-children needs to be avoided because it creates unnecessary pressure on women and girls to cater to an increasingly impossible model of girlhood/womanhood. The argument could instead be located in the principle of fairness and justice -- two values that the middle class is increasingly standing up for in the country. Civil society action: Gender activists argue that the very foundation on which we understand gender is flawed. Dr Sharada asserts the need for all civil society interventions to be based on gender equity. The fact that gender inequality structures and frames all aspects of life is something that must be recognised, accepted and worked on consciously by all social activists, no matter what their core area of focus is. Monitoring mechanisms: Regular and systematic monitoring of doctors and activities in clinics must be undertaken. Reports must be shared in the public domain. There is no excuse for aborting a foetus because it is female. The argument that a family is incomplete without both a son and a daughter is specious. The claim that only sons continue the family name is arguable, at best. The point of view that women have too hard a life to be born holds no water. Kamayani Bali Mahabal Email: kamayni@gmail.com
The faculty of medicine in Al-Gazira University- Sudan has been interacting with the community in many different ways since its establishment in 1978. It has created several advanced community-service programs which enable the students to contribute efficiently in the development of public health of their communities. This article describes the integrated field training and research development program, which is one of the most effective and interesting communityservice programs of the faculty of medicine. All medical students participate and are divided into 15 groups, each of them containing about 15 students. Every group is assigned to go to a certain village to develop their community-service program, which is done in three phases. During the different phases of the project, the student stays for about a week in ‘their’ village. So…What do the students do in these villages? 1) The first phase is the assessment phase: Student explore the village and find out its health problems and assess the medical needs of the people there. Subsequently, they make plans and projects to meet those needs and improve the health conditions. 2) In the second phase they execute the projects they developed and work according to the plans they made. 3) In the last phase, they evaluate the impact of their projects and assess the effects of their visits upon the health status of the village. Example projects that the students made are: planting trees to fight desertification, distributing large waste containers and teach people the safe way of disposing waste products, bringing used school books from the cities to cover the shortage of books in the villages’ school, and so many other things. However, lack of health knowledge among people and the presence of wrong practices often increase morbidity and mortality rates and prevalence of several endemic diseases. Therefore, raising awareness about several diseases has been a main component in most of the students’ projects, and their methods have been successful in disseminating health information and correcting the wrong ideas and practices if found. So… how do the students raise public awareness?? They set group discussions and organize big exhibitions containing posters, educational videos, one-to-one teaching, and many 11
other different methods. They arrange public meetings with men, women, children at schools, deliver informative health sessions, coordinate with the local health forces, and train volunteers to ensure the continuation of their programs. Results The following is an example of some of the results obtained after analysis of data gathered from the students’ visits in December 2008, 2009, and 2010 to “Bareeda” village where tuberculosis is the main health problem: In phase (1) the students found out that the percentage of people who think TB is infectious was 86% and in phase (3) it became 100%. People who think TB can be treated were 80% and became 100%. People who consider TB as a social stigma were 66.7% and became 26.6%. And the people who had TB in their family in the past year were 13.4% in the first phase and became 7.6% in the second. This is just an example of the increased awareness of people and its effect upon the morbidity of TB in that village. More than 3,000 villages have been covered since the beginning of this program, and similar results have been achieved in villages where AIDS, Malaria and Billharsiasis were endemic diseases. The overall results of this successful program were as follows: * The health knowledge about endemic diseases has significantly increased, and the social stigma of some health conditions is fading away. * Wrong concepts and practices have been corrected, and people are seeking medical treatment at an earlier stage. * Morbidity and mortality rates of some endemic diseases in the villages are decreasing after interventions. * The students became more capable of dealing with the health problems of the rural areas and they acquired leadership, team work, and research skills. Dr. Marwa Elamin, University of Gazira, Sudan Email: silentbeuty@hotmail.com Talking to the children about hygiene
Improving Health Yellow Pages Between those outstanding publications that were already published in leading journals, and some preliminary notes scribbled on the last page of an agenda, there are also papers or reports that belong to the in-between (‘grey area’) category. Papers that, for whatever reason, have not been published before. Within this ocean of ‘grey’ papers, there are some which by content are most relevant to the Network: TUFH’s mission and aims. We will pick those pieces of gold from the ‘grey’ ocean, change their status to ‘yellow’ (because we can’t print in gold) and publish these in this section.
Urbanization and Health in Greater Khartoum Introduction: Sudan is one of the fastest urbanizing countries in the world. Population figures show that the country was already 41% urbanized in 2009, excluding the displaced of Darfur and the large numbers of unregistered migrants and squatters in Khartoum. Migration to Khartoum started after Sudan independence in 1956. For some years, migration was seasonal, and migrants often returned to their areas of origin. But since the 1970s, most migration to Khartoum has been a response to natural and man-made disasters and the inequality of resource distribution. Throughout the 1970s and 1980s, Khartoum was the destination for hundreds of thousands of refugees fleeing conflicts in neighboring nations such as Chad, Eritrea and Ethiopia The Eritrean and Ethiopian refugees assimilated into society while some of the other refugees settled in large slums at the outskirts of the city. Due to the drought of 1983 a large number of displaced people migrated to Khartoum from drought areas. Migration continues due to the continuous degradation of the environment. Most of Sudan’s economic capital and social services are concentrated in Khartoum. Just as economic resources flow to the center and not the peripheries, so too do people move to the capital. The long civil war in southern Sudan destabilized communities and pushed millions of internally displaced persons northward. Today, more than 2 million IDPs live in Khartoum—almost one quarter of the city’s population. 500.000 IDPs are living in official camps and around 1.5 million are distributed in different squatter and peripheral areas. On the other side 16.5% of Sudanese are living in Khartoum with an annual increase rate of 4.3% (2005-2010). The increase in urban population has also been attributed to natural growth. The growth rate of the country is 2.5 (2010). The growth rate is a factor in determining how great a burden would be imposed by the changing needs of its people for infrastructure (e.g., schools, hospitals, housing, roads), resources (e.g., food, water, electricity), and jobs. Khartoum has a thriving economy. In recent years Khartoum has seen significant development, driven by Sudan’s oil wealth. The center of the city is well-planned, with tree-lined streets, but unfortunately this scene is surrounded by poor districts and miserable slums. The widening gaps between those living in peripheral areas and camps pose a risk that needs to be recognized and countered. The major threat in Khartoum is that many people live in poverty with high birth rates. The figure below shows the trend of increased population of Khartoum. This is not only due to a natural increase of population but also due to immigration of IDPs from conflict areas. It is a pathological urbanization. It is the aggregation of people without their integration into a social and political system. Year
Population of Khartoum
1956
245,800
1973
748,300
1983
1,340,646
1993
2,919,773
2007 8,363,915 The figure indicates clearly the level of urbanization in Khartoum. Total population of Sudan is 36.2 m Effects of urbanization on health in Khartoum: Urban health encompasses social determinants of health, environmental health, violence, road safety, healthy lifestyles, food safety and security, healthy housing and space, facilities for recreation and a sense of belonging to the community among individuals. With the overwhelming influx of displaced and migrant families into Khartoum and the rapid urban expansion, Khartoum State authorities have been faced with many challenges. They have lacked adequate capacity to develop a timely response to the rapid urbanization. The large and sudden population influxes have also put pressure on the city’s infrastructure, resource distribution and stability and have created pockets of abject poverty. Squatter settlements are often spontaneously created to absorb recent migrants and people displaced from inner city locations. 12
Improving Health Yellow Pages Specific effects of urbanization in Khartoum have not been traced but the environmental burden of diseases in Sudan shows high prevalence of the following diseases and reflect to some extent the problem of urbanization: Environmental burden of disease (preliminary) per year Disease group
World’s lowest country rate
Country Rate
World’s highest country rate
Diarrhoea
0.2
17
107
Respirator indicators
0.1
9.1
71
Malaria
0.0
11
34
Other vector-borne diseases
0.0
1.5
4.9
Lung cancer
0.0
0.1
2.6
Other cancers
0.3
1.7
4.1
Neuropsychiatric disorders
1.4
1.6
3.0
Cardiovascular disease
1.4
3.7
14
COPD
0.0
0.9
4.6
Asthma
0.3
1.2
2.8
Musculoskeletal diseases
0.5
0.6
1.5
Road traffic injuries
0.3
6.8
15
Other unintentional injuries
0.6
9.1
30
3.7
7.5
Intentional injuries 0.0 % of total environmental burden = 24%
In the state of Khartoum, piped water is available to 71 per cent of households: 73 per cent of the urban and 58 per cent of the rural households. Seventeen per cent still obtain their drinking water supply from wells, rivers and canals. Since the early 1980s, the quality of piped water has ceased to meet World Health Organization (WHO) standards. The majority of the state’s households (69 per cent) are served by pit latrines while only 3 per cent have public sewerage systems and 15 per cent have no toilet facility of any sort. Seventy-four per cent of the state’s households use charcoal as fuel (77 per cent of urban and 56 per cent of rural households). Lessons: It has been estimated by UNICEF and other UN agencies that the total cost of providing basic social services in developing countries including health, education, family planning, clean water, and all of the other basic social goals agreed upon at the World Summit for children in 1999 would be around $ 39-40 billion a year, two thirds of which could come from the developing countries themselves. Sudan is rich enough to carry out the needs of its population through control of conflicts, social justice, equitable distribution of resources and developing practical strategies for provision of health services in Khartoum. Evaluations of health care services provided to the displaced have taken place for years in many workshops. The effectiveness of these evaluations has been limited by shortfalls in the information system, by the fact that they did not reach community and facility levels and due to the ongoing internal conflicts. The range of health services activity in Khartoum is, however, wide enough to embrace an advance in occupational and environmental health and at the same time training of TBAs and the control of Shistosomiasis. Different functions for different Health Areas may improve provision of health services and reduce the effect of urbanization on health. Urgent and drastic action is needed to combat poverty. Dr Abdelmageed Osman Musa, Associate Professor/Community Medicine Faculty of Medicine; International University of Africa; Sudan Email: majeed_osm@yahoo.com 13
International Health Professions Education Medical Education Regional Medicine-Public Health Education Centers (RMPHEC) - Graduate Medical Education (GME): Sowing the Seeds of Public Health and Medicine to Create a Hybrid Unified efforts are needed to improve health care and the health status of patients and populations. Similar efforts are needed to promote the development of systems and cultural change among medical schools and public/community health entities. The venues for change include a more systematic and pronounced effort to support, incorporate, and sustain public health principles, knowledge and skills in the medical school curriculum. Courses such as biostatistics and epidemiology may be offered in current medical curriculae, but, an added attempt to expand the course content throughout medical education and sustain the value over time is best maintained with the incorporation of policies, partnerships, a broader array of population health courses, and service opportunities. Two United States entities: the American Association of Medical Colleges (AAMC) and the Centers for Disease Control and Prevention (CDC) joined forces to initiate a countrywide collaborative. The initiative has opened doors of opportunity for faculty, staff, students, and practitioners to change the landscape of 21st century medical education. The cooperative agreement between the AAMC and the CDC launched the financial, intellectual, and collaborative support to plan, develop, and implement population health, community health, disease and injury prevention, and public health principles within the undergraduate medical school curriculum. The AAMC/CDC issued a Request for Proposals to all medical schools. In 2003, 16 medical schools were selected to be part of the Regional Medicine – Public Health Education Centers (RMPHEC). Each medical school grantee partnered with local, state, or regional public health departments to begin the process of curricular and/or policy change. In 2008, 13 graduate medical education programs joined the initiative as a means of systems change. The seed of the RMPHEC laid the foundation for a new crop of undergraduate and
graduate medical education. Grantees of the RMPHEC came together via face-to-face conferences, workshops, teleconferences, and other communication venues to strategize and support the aims of the RMPHEC. They developed 12 competencies to guide the work of the institutions and assist in the workforce development of future physicians. Each institution or grantee, in partnership with the community, worked toward innovative and sustainable incorporation of public, population, community health education. The grantees also developed and maintain a website to share their ideas and foster a support network. The ongoing communication and support are invaluable when working toward change of institutionalized or historic means of educating a given population. The changes witnessed by the RMPHEC grantees include the addition and/or integration of a broader array of health topics in the medical and resident curriculum. For example, the University of New Mexico added a policy that supports the requirement for a Certificate in Public Health. All students that matriculate in medical school beginning in 2010 will receive a certificate upon completion of medical school. Other changes include the incorporation of health promotion disease prevention content in the OSCE’s and other exams. Expanded public health course content and the addition of new content have been included in the medical and resident’s curriculum along with service learning requirements and evaluation or assessment techniques. Promotion of the holistic approach to curriculum development is communicated through the actions of the students, residents, faculty and staff. Other means of communication include written articles, publications, conferences, and word-of-mouth. While all the RMPHEC have had to deal with varying degrees of resistance or barriers, the seeds of change have been sowed. To date 29 institutions and their 14
community partners have begun the process of creating change among future physicians. We now await the outcomes, but with the work of many a new crop of personal/population professionals is now starting to emerge. Lily Dow Velarde, Ph.D. Email: livelarde@salud.unm.edu
Accreditation and Quality Assessment How to Encourage Doctors to Engage in Educational Continuing Professional Development: A Study of Doctors’ Perceptions Introduction Current trends in medical education have highlighted the need for skilled, competent delivery of teaching for undergraduate and postgraduate students. It is important for medical teachers to ensure what medical students learn, how they learn and when they learn is effective in preparing them as future medical practitioners. When medical teachers combine their discipline’s expertise with good pedagogical principles in teaching, medical students - and ultimately patients and the community - will be the beneficiaries of the quality education they provide. The term ‘Educational Continuing Professional Development’ (ECPD) is used to describe doctors’ professional development in their role as educators. There are many workshops operating around the world relating to teacher training for doctors. However, little is documented about doctors’ perceptions of continuing education in relation to developing their knowledge and abilities as teachers. This article summarizes how doctors teaching at the University of Western Australia (UWA) developed themselves in their teaching
International Health Professions Education Accreditation and Quality Assessment How to Encourage Doctors to Engage in Educational Continuing Professional Development: A Study of Doctors’ Perceptions roles and factors that facilitate or impede doctors to pursue ECPD. Who has responsibility for doctors’ educational continuing professional development? Many stakeholders have a significant interest in ECPD. These include the medical profession, whose responsibilities are maintaining its standards and competent training for the new generation; educationalists, who are keen to create effective training processes for trainees and teachers; and health planners, who have responsibility for providing cost-effective health services as well as policies in healthcare. These different key players yield various perspectives on how continuing health professional education should develop. This raises important questions for policy development in terms of where influence should lie between the politicians and professionals.
Poster presentation at Kathmandu Conference, 2010
to the formal structure of a postgraduate qualification. Driving factors that motivate doctors to spend time on ECPD The driving factors are consistent with the previous suggestion that doctors expressed a need for more direction in their ECPD from the University. Providing protected time for doctors to participate in ECPD was also the key theme emerging in previous studies. Also, this study revealed that better income for teaching is a driving factor for doctors to spend time pursuing a qualification. Neate et al.9 concluded that structured programs should occur at appropriate times and include topics that meet medical educators’ needs.
Motivating factors that motivate doctors to develop themselves as educators Factors that motivated doctors to teach included the intrinsic satisfaction of being involved in education, the enjoyment of having knowledge and skills in teaching and the feeling of a sense of responsibility to teach in medicine. In addition, the teaching role was perceived as enriching the general practitioner’s clinical role. This study suggests that the introduction of a mandatory requirement to possess an education qualification for appointment as an academic could be acceptable to some extent. Also, it is possible that doctors in WA may undertake a formal qualification if there is recognition of the Health Professional Education qualification within their School workload calculation system. This study found that the “interested in working within faculty development field” was less likely to be a motivating factor. Although significant numbers of doctors in this current study held management roles in their settings, half of them suggested they are not going to undertake an educational university qualification. It may be that the age of the respondents and their level of experience were related to the reluctance to undertake a qualification in education. Obstacles that impede doctors to ECPD The results build on previous research findings by Neate et al. suggesting that a lack of time represented the greatest barriers to continuing education for doctors in Australia. Other cited barriers to ECPD in this current study includes clinical commitment, a lack of recognition for teaching roles and lack of direction from the University. Pereira-Gray clearly stated doctors believe that time spent in teaching deserves additional remuneration. Moreover, the doctors felt that the lack of evidence for the value of education courses in ECPD lessen their intentions to commit to a formal training course in education. This may explain why the vast majority of respondents expressed interest in participating in ECPD with an informal structure such as attending a workshop, but were not willing to commit
Recommendation This research provides some suggestions that represent the key purpose of this investigation. It is expected that these suggestions, in conjunction with ongoing research in ECPD, will usefully inform those involved in faculty development. - Recognition and remuneration for teaching role should be improved - The accreditation requirement for teaching roles needs to be addressed. - ECPD should be delivered flexibly - There is a need to increase the relevance of ECPD - Formal training courses need to be marketed to make them more appealing. Marketing needs to communicate the value of engaging in ECPD. Conclusion The study demonstrated that doctors expect more direction and leadership from their employers. Making courses relevant and flexible and providing better payment for teaching roles is likely to encourage doctors to engage in formal training ECPD. Also, medical degrees that prepare medical students for a teaching role may be part of the solution for the future. Hoa Vo, S. Carr and S. Miller; University of Western Australia, Perth, Australia Email: lienhoa689@yahoo.com
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International Health Professions Education New Institutions and Programs Gezira\Sudan Family Medicine Program from Trial to Reality Since its establishment in 1975, Faculty Medicine University of Gezira (FMUG) has been community engaged; focusing on community health and development needs. The curriculum is Community Oriented Medical Education (COME), Community Based Education (CBE), and Problem Solving. The philosophy of Gezira University is to serve its community through education, research and service. One of the distinguishing features of Gezira University is the strong partnership with the government represented in the state coordination council. The council is headed by the State Governor and the members are deans and their counter parts are the State’s ministers. This council helps coordinate the school’s programmes with the health system and the health related sectors and the community.
Phase two: “Gezira Initiative of Family Medicine 2010” In 2010, with the help of their staff the Faculty was able to link with graduates who have been working abroad and together, they convinced the Governer of the State to adopt the Family Doctor program. The aim of the program is to promote the health of individuals, families, and community through training of doctors in the specialty of Family Medicine and the provision of comprehensive health care.
The process: The programme was conducted in two phases:
The role of the Ministry of Health:
Specific objectives were:
1. To graduate skilled family physicians 2. To rehabilitate the existing heath infrastructure 3. To strengthen the referral system Gezira state population is 4 million, administratively divided 4. To improve the health information system into seven localities with more than 2000 villages and camps. Strategies: The health facilities in the state are: 15 Specialized Hospitals 1. Partnership between the Ministry of Health, FMUG, 39 Rural Hospitals and the Health Insurance Directorate has been 167 Health Centers established 2. In-service training (4 years), 200 doctors per year for 5 There is a shortage of health workers and medical equipment years, targeting one Family Physician per 5000 in remote areas and most of the health centres need rehabili- population tation. 3. Provision of essential equipment and adequate number of staff in the training sites The objective was to demonstrate the process of introducing 4. Curriculum design a Family Medicine program in the health system and in the Fa- 5. Establishment of filing system (file for each family) culty of Medicine University of Gezira postgraduate program. 6. Provision of information technology devices
Phase one: Family Medicine Diploma In 2006, there was an initiative from Towards Unity for Health (TUFH) to establish a Family Medicine Training Program in the Gezira Faculty of Medicine. Accordingly FMUG, through the support of Primafamed, launched the Family Medicine diploma in 2008. It is a one year in-house training. Many workshops have been conducted to review Family Medicine curricula to adapt and adopt a suitable one to Gezira\Sudan. Training of the faculty and Ministry of Health (MOH) staff and revising the designed curriculum has been ensured. A total of 22 participants enrolled in the diploma (Two batches of 12&10 respectively).
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1. 2. 3. 4. 5. 6. 7.
Selection of the candidates Motivation of the selected candidates Budget for the training Rehabilitation of the selected health centres Supervision and monitoring Development of the file system Participation in the training
The role of Faculty Medicine University of Gezira: 1. Curriculum Design 2. Recruitment of the training staff (internal and external ) 3. Preparation of distant learning facilities
International Health Professions Education New Institutions and Programs Gezira\Sudan Family Medicine Program from Trial to Reality
In Gezira State there is a shortage of health workers and medical equipment in remote areas and most of the health centres need rehabilitation.
4. 5. 6. 7. 8. 9.
Electronic library Supervision Examination and evaluation of the students and the programme Links with other examination boards Award of the MD degree Participation in the selection of the candidates and the training sites
The State governor, Ministers of health and social affairs distributing the laptops provided by the Health Insurance Directorate
Gezira started a unique training with the following features:
1. 2. 3. 4.
In service training in the Health Centre has been applied Modern teaching technique (Groups, Tele- medicine) The trainers are tutors and supervisors Guided self learning has been applied
Finally Gezira adopted and adapted the WHO Principles for a Family Medicine Programme and also have their own principles:
The role of the Health Insurance Directorate: 1. 2. 3. 4. 5.
1. 2. 3. 4. 5.
Participation in the selection of the candidates Financial Support including training fees Avail the health insurance infrastructure for training of the candidates Contribution in rehabilitation of the health centres and equipment supplies Participation in supervision, monitoring, and evaluation
As a result 200 doctors were enrolled in the program. Each doctor has been provided a laptop, a free cell phone and free internet line for tele- communication.
Introduction of a new doctor role Triage process in Family Medicine (who needs urgent ac tion, who should be observed, who is not a patient for PHC, who should be referred to hospital) Application of Problem Based Training; Use of diagnostic flow charts, guidelines, clinical reaso ning and intuition, tactic knowledge The programme is politically supported and will help up grade and reform the health system
S. Elsanousi Hussein, Faculty of Medicine, University of Gezira, Sudan Email: salwasanousi@yahoo.com
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International Health Professions Education New Institutions and Programs Introducing the Women and Health Learning Package (WHLP) to Health Professionals’ Training Institutions in Uganda Context The Women and Health Learning Package (WHLP) was developed by members of the Women & Health Task Force of The Network-TUFH with the aim of equipping health providers and the community with Knowledge, Attitudes and Skills necessary to address critical gender related issues. In addition, the WHLP aims at building the capacity of current and future health professionals to address the needs of women and their families. The package consists of a series of learning modules, and is a free resource for use by Health Educators, health professional students as well as health workers. Uganda is characterized by poor reproductive health indices. The Maternal Mortality rate is still high at 434/100 live births, the total fertility rate is 6.7, and the contraceptive prevalence rate is just 24%, and 39% of women aged 15-49 years are illiterate. A number of social and cultural determinants contribute to the ill health of women. In spite of this, the training of health professionals regarding women’s health is mainly centered on reproductive health, and social determinants of health are not adequately addressed. To address this gap, we introduced the WHLP to tutors of Health Professional Institutions in Uganda. The two day workshop was conducted on August 4 – 5, 2010, Uganda. Workshop Objectives 1. To introduce the WHLP to tutors/facul ty of health professionals’ Institutions in Uganda. 2. To improve the knowledge of tutors/fa culty of health professionals’ Institu tions in Uganda in Women and Health Issues. 3. To discuss how the WHLP can be imple mented during the pre-service training of health professionals in Uganda. The workshop The two day workshop was held at the College of Health Sciences, Makerere University, Uganda. The workshop was attended by 22 participants from 14 health professional training institutions in Uganda, as well as the Uganda Nursing and Midwifery Council (UNMC) which is a Nursing Profession Registration Body.
Participants after the workshop
Methodology The workshop was participatory in nature, with a few plenary sessions to introduce the objectives of the workshop, and the WHLP. Other activities were small group discussions, followed by plenary presentations. Participants had a session where access to the electronic copy of the WHLP was demonstrated. They were also guided on how the modules could be downloaded. Workshop Outcome At the end of the two day workshop, participants unanimously agreed: • That some of the topics addressed by the WHLP are not adequately addressed in pre-service training. • That all the modules in the WHLP were important for their students. • To improve the current training by ad dressing the topics in the WHLP. • To put priority on the modules that had the biggest gaps in the current training. • To put in place activities to promote the health of female academic and non-aca demic staff, as well as women in the communities. • To mentor students in conducting WHLP practical skills. • Recommended a number of learning and assessment methods to introduce the WHLP to students, and the roles of the faculty (Table 1) • To form a task force to ensure adequate planning, implementation, monitoring and evaluation of the priority activities to implement the WHLP in institutions. • To have another taskforce meeting after one year to share experiences of the in stitutions in implementing the WHLP.
Learning methods
Assessment methods
Social models
Peer evaluation
Clubs
Observational
Debates
Portfolio
Music and Drama
Reflective journals
Case studies
Cases
Films shows
Mentor/ community evaluation
Community mentors Supervisors feedback Group discussions
OSCE/OSPE
The proposed role of faculty in the implementation of the WHLP: 1. Role models 2. Provision of enabling environment for learning/work place 3. Advocacy/promotion of women’s health 4. Social health clubs 5. Community outreach for WHLP promo tion practices 6. Identify Community preceptors to men tor students delivering WHLP practical skills 7. Continued monitoring and evaluation Conclusion The introduction of WHLP was highly welcomed by leaders of several health professional institutions in Uganda. Innovative teaching/learning and assessment methods were proposed to implement the training.
S. Kiguli 1, E. Nshimye I, M. Kabanga2 1College of Health Sciences, Makerere University, Uganda. 2Tutors College, Makerere University, Table 1: Recommended learning and asUganda sessment methods for WHLP Email: millykabanga@yahoo.com 18
International Health Professions Education Problem-based Learning and Community-based Education Straight Internship Program in Family and Community Medicine: a Responsive Curriculum to Attaining Health for All In the Philippines, a large part of medical training is set within urban tertiary care facilities under a biomedically-intensive, hospital-based and specialist-oriented curriculum. In the University of the Philippines-College of Medicine (UPCM), students spend only 10-18.7% of the total hours in each learning unit for biopsychosocial dimensions of health and illness, population medicine, family and community medicine, epidemiology and research. Most of the faculty with whom students interact and get role models from, are specialists in their respective fields. Current medical education and training largely shapes the preference of graduates to work in secondary and tertiary care facilities, go into specialization, and adopt a private practice within urban areas or even overseas. Specialists outnumber generalists in a ratio of more than 1. 70% of Filipino health professionals work in the private sector, mostly in the National Capital Region and the Southern Tagalog Region, serving a third of the population. The remaining third of the workforce is employed by the government catering to the needs of most Filipinos. More unfortunate is most government doctors and municipal health officers, after serving a certain number of years, heed the demand for health professionals in developed countries and leave the country. In 2007, the Secretary of Health estimated that 1 doctor looks after the health care needs of 28,000 Filipinos, far from the WHO ideal of 1:600. Inadequacies in health human resources aggravate the prevailing poor access to quality health care services. 7 out of 10 Filipinos die without seeing a doctor; 4 out of 10 livebirths are not attended to by a health professional. Declines in infant mortality rate and maternal mortality ratio in the past decade are also not encouraging. Disparities in health status between the high and
low-income regions of the country continue to grow. Unless medical schools take on their role in reducing these inequities through graduates capable of responding to the health problems of Filipinos in places and settings needed, the vicious cycle is bound to continue. Van Jerwin Mercado
In response to this challenge, the UPCM opened a 52-week straight internship track in Family and Community Medicine consisting of a 2 week-rotation at the ambulatory care and family medicine clinics of the Philippine General Hospital, 5 months each of rural and urban community rotation, and 2 months of elective courses. The program aims to provide the knowledge, skills and attitudes for a patient-centered, family-oriented and community-based generalist community practice. Guided by the primary health care approach, development of core competencies of a doctor-counselor, educator, researcher, health manager and social mobilizer through a varied array of teaching-learning strategies widens career opportunities, promotes lifelong learning and provides greater handles for dealing with health problems. Immersion in rural and urban communities, while rendering service in a public primary care facility allows a better grasp of the biopsychosocial factors which shape the health not only of individuals but also families and population groups. Involvement in curative, preventive, rehabilitative and promotive care highlights the value of interdisciplinary and multidisciplinary approaches. A look into the interplay of building blocks of the health system and the social determinants of health fosters a systems-based approach in tackling health problems. Areas for improvement remain in the program’s third year of implementation. Due to the limited breadth of cases at the primary care setting, more clinical case conferences and rotations within
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district hospitals will help augment the clinical experience of trainees. Didactics and skills development sessions on health management (policy development and financing), social work (community organizing) and research (epidemiology and biostatistics), will enable interns to respond with systems-level, populationbased interventions. Talks from speakers outside the discipline of Medicine will further strengthen the thrust towards the needed interdisciplinary, multi-sectoral response to health problems. With the emergence of health concerns which transcend geopolitical boundaries and require transnational efforts, inclusion of discussions on global health issues will properly contextualize the future practice of trainees. Collaborations with non-government organizations and the Department of Health are seen to continually enhance the alignment of the program to the ever evolving health needs of communities. With a curriculum that provides equal emphasis on social determinants to health, community-based learning and contact with community medicine practitioners, the dream of attaining health for all is never far from reach. Mercado, Van Jerwin P. Romelyn April P. Imperio. Jacqueline Frances F. Momville. Elizabeth R. Paterno, MD. Doris Mariebelle D. Camagay, MD. Portia F. Marcelo, MD. UNIVERSITY OF THE PHILIPPINES-COLLEGE OF MEDICINE Email: joseph053@yahoo.com
International Health Professions Education Leadership Column Within The Network: TUFH there is an increased attention for the role of leaders in educational innovations. Studies in this field demonstrate that leadership is not only an inherent characteristic of certain gifted people but can be learned as well. For that purpose some successful leaders share their experiences as a ‘change agent’ with the Network: TUFH membership-at-large. For this edition we did an interview with Dr.Olayinka Ayankogbe from Nigeria. He is a senior lecturer and the head of the Family Medicine Unit of The University of Lagos.
1. What change processes have you been part of/been leader of in the past? Who were the stakeholders in these change projects? The major change process I have been part of is the introduction, establishment and creation of a new specialty and unit of Family Medicine in the College of Medicine of my university, the University of Lagos, Lagos, Nigeria. Stakeholders include undergraduate medical students (especially final year students), the Colleges of Medicine authorities, the University of Lagos authorities, the other major specialties of Medicine, the Faculty of the Department of Community Health & Primary Care of the College and the leadership of the Department. 2. What is the first step towards a successful change processes? The level of conviction of the change agent about the change he wants to introduce: does he have a deep understanding of the change he desires? Is he passionate about the change? 3. What else is essential for change to succeed, what are the essential conditions? The change must benefit the majority of end users that the change agent is targeting. It must be SMART (i.e simple, measurable, achievable, result oriented and time-bound. There must be a defined measurable goal. The change must be affordable and cost effective. 4. What is required of a leader in change? What assets does (s) he need/ what model of leadership is required in producing change?
The change agent must have a clear, well developed and well articulated theoretical concept of the change he is advocating for; the change agent must be willing to defend every question raised against the change by stakeholders. He must be willing to go the whole hog and not chicken out until the change is affected. He must have extensive advocacy and networking skills, recognizing and aligning with colleagues that share his passion for the change he is advocating for. He must be persistent, assertive and persuasive. He should align himself with powerful outside local, national and international agents that support the change he desires and use them as a pressure group. He must recognize opportunities to play some little politics. He must be humble and very knowledgeable about the change he is advocating for. He must have the patience of Job and never give up until the change is effective. Finally, he must be able and willing to support, sustain and develop the change once it is implemented. No particular model is advised. Change agent must use the model that fits the environment in which he is operating. He should use any model that would most likely lead to success of the change he is advocating for. 5. Every change process knows its successes and failures/ could you tell us about your most important successes and failure? Like I said earlier, you must have well-defined goals that are achievable right from the onset. Among my major successes is the establishment of a unit of Family Medicine in the college department of Community Health & Primary Care of the University. Minor successes are the ability to convince the College and University authorities of the need for academic training of undergraduate and post-graduate students in the knowledge, skills, and attitudes of the specialty of Family Medicine and the relevance of research for the development of the specialty. 6. How do you gain the needed power/influence to achieve your vision? First, you live the vision. Train to have the skills needed as the end product of the change and become that change. Then you showcase the end result of the change in small projects that provide you with documented 20
evidence of the results of the change you are asking for. Then do advocacy to powerful and influential policy makers with your evidence and convince them using persuasive communication skills which you must learn how to do. Most importantly, learn to recognize and utilize small political openings to push your agenda, making it a campaign issue and politically campaign subtly and vote for the Provost (or the people seeking elective posts) that support your change. 7. What role do you give other stakeholders? The role you give other stakeholders depends on your perception of the degree of their influence in the change process. This depends on each change agent’s unique environment. But attempt to involve all stakeholders however little they can do to contribute to the change. 8. How do you make change sustainable, secure continuity? By training and capacity building of the younger generation of teachers. You seek them out and indoctrinate them with your desired change and the process of displaying the change outcome and teaching it to undergraduate and post-graduate students. This is the stage that I am involved in now and we have started the process: Training courses in Post-graduate Diplomas, Masters Programs and post-graduate professional Fellowships programs in Family Medicine. 9. Are there any more tricks you used to get things going? Read research especially of the literature relating to the change you are advocating. Attend gatherings, both national and international, of practitioners of the change you are advocating for, so you can get inspiration and support to continue your fight. You need it. 10. Any more advice for our readers? No change agent sets out to be a change agent. (S)he is just convinced that his/her idea can make society a better place for us all and (s)he pursues that idea doggedly and relentlessly and with God and providence on his/her side, (s)he will win. Dr.Olayinka O. Ayankogbe, University of Lagos, Nigeria Email: yinayanks@yahoo.com
International Health Professions Education Yellow Pages Between those outstanding publications that were already published in leading journals, and some preliminary notes scribbled on the last page of an agenda, there are also papers or reports that belong to the in-between (‘grey area’) category. Papers that, for whatever reason, have not been published before. Within this ocean of ‘grey’ papers, there are some which by content are most relevant to the Network: TUFH’s mission and aims. We will pick those pieces of gold from the ‘grey’ ocean, change their status to ‘yellow’ (because we can’t print in gold) and publish these in this section.
Climbing the Ladder of Integration – from Harmonisation to Multidisciplinary Curriculum Integrated curriculum cuts across subject-matter lines, bringing together various aspects of the curriculum into a meaningful association to focus upon broad areas of study (Shoemaker, 1989). In the context of medical schools it helps graduates to put together the learned facts so as to get the whole picture and adopt a holistic approach while treating patients or managing and preventing outbreaks. In the SPICES model for educational strategies, integration is represented as a continuum with full integration at one end, discipline-based teaching at the other and with intermediate steps between the two bookends (Harden, Sowden & Dunn, 1984). Faculty of Medicine, Universiti Teknologi MARA, Malaysia, went through a massive exercise of integrating its pre-clinical curriculum. The newly integrated curriculum was implemented in the academic year of 2009/10. In this paper we share our experiences of enhancing the curricular integration from harmonisation to multidisciplinary level (Harden, 2000). • Commitment Integrating an existing curriculum or preparing a new integrated curriculum is an enormous exercise and needs full commitment of the authorities as well as the academic staff members in terms of time, energy and resources. • Training of staff members Some form of staff development will almost certainly be needed to: (a) familiarise the staff with the objectives of an integrated programme and allow them to explore its advantages (b) identify the local barriers to integration and address them effectively (c) explain to staff members how the integrated curriculum will be delivered and their individual roles and responsibilities. • Scope of integration To start with, the scope of integration may be limited to only a module or a Phase. This will help to adapt to a change gradually, would be less stressful, and will provide an opportunity to learn from the experience. • Level of integration The aims of the curriculum, the organisational structure, staff, resources and assessment methods need to be considered before deciding the level of integration. However, the most appropriate level of integration may differ in different parts of the curriculum. • Vertical and horizontal integration Involving clinicians in preparation of basic medical science modules and vice versa is vital to develop both horizontal and vertical integration. • Working groups and their responsibilities Setting up of different working groups and defining their respon-
sibilities is crucial. The membership of the working teams would depend upon the module to be integrated. A medical educationalist must be included in the team. • Learning Outcomes Learning outcomes will specify what is to be achieved at the end of a module, guide the identification of the curriculum content, teaching learning methodologies and assessment methods. • Contents (knowledge, skills and attitude) Each discipline needs to map their curriculum content i.e. list down, in the sequence, the topics to be covered, skills to be learned and attitudes to be developed. The appropriate teaching/ learning methods must also be indentified. • Themes Focusing on “themes” (e.g. theme of the week) enables teachers to meaningfully link different disciplines so that students will see the “big” picture and appreciate the relevance of learning to their future practice. • Timetable Prepare a timetable that provides all the relevant information comprehensively, leaving 20 to 30% of the scheduled time for self-study. • Assessment methods Plan the assessment at the same time while preparing the integrated modules and integrate assessment to reflect integrated curriculum. • Communication with students and staff At the beginning of each module, give a briefing to the students about the structure and learning outcomes of the module. Regular communication between faculty and students allays fears and stop inaccurate rumours circulating. • Re-evaluation and revision Draw a plan for re-evaluation of the curriculum and design a mechanism to institute changes if required. Dr Alem Sher Malik, Professor of Paediatrics, Faculty of Medicine, University Teknologi Mara (UiTM), Malaysia Email: alamshermalik@hotmail.com
Dr. Rukhsana Hussain Malik and Dr. Alam Sher Malik 21
The Like-Minded Working Together Like-Minded Institutions Interview with Meenakshi Menon, the Brand New Executive Director of GHETS (Global Health through Education, Training and Service)
I think that GHETS and the Network: TUFH share many common goals, particularly in the realms of health systems strengthening and support to primary care and family medicine.
Meenakshi Menon
community-driven projects. It’s just a matter of increasing accessibility to funds and assisting our program partners to successfully implement their projects.
1. Can you present yourself? What is your background. Hello! I’m Meenakshi, the Executive Director of GHETS. My background is in anthropology and public health with interests in development and human rights. My previous work centered on research in the countries of mainland Southeast Asia, particularly Cambodia, and the accessibility of health services to populations in border provinces.
4. Why is it important that GHETS and The Network:TUFH work together? I think that GHETS and the Network: TUFH share many common goals, particularly in the realms of health systems strengthening and support to primary care and family medicine. This was evident in our collaboration with 15by2015. Both of our networks continue to grow, and I think that our long lasting partnership can only stand to benefit if we continue collaborating in our work.
2. Why did you come work for GHETS? How did you get in contact with them? I found GHETS through a website used in the U.S. called Idealist. I was interested in the work that GHETS was doing and applied for a job posting they had listed on the website.
5. Finally, can you give us your impression on your first conference? My first conference was exciting! I found Graz to be beautiful and thought that our hosts worked hard to accommodate us as best they could. I also thoroughly enjoyed meeting so many different health professionals who are as passionate now about their work as they were when they first began. We’re truly an impressive network of professionals. I look forward to Thunder Bay in 2012!
3. What are your ideals? What are your future plans for GHETS? Having worked on “big three” initiatives in the past, I know a bit about what the climate is surrounding global health and development work. While diseases like malaria, TB, and HIV/ AIDS are important, there is so much work to be done on creating and implementing effective health systems that directly address primary health care concerns. Both GHETS and the Network: TUFH are actively engaged in trying to capture the international community’s attention on this matter, and I would like to bring GHETS to new levels in this area. I would also like to see the GHETS mini-grant model expanded so that more partners have access to them. From our nearly ten years of service, we at GHETS know that small grants work and create sustainable,
Meenakshi Menon; Executive Director; GHETS Email: meenakshi@ghets.org
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The Like-Minded Working Together Like-Minded Institutions Karolinska Institute, Sweden: Leading for Change in Health Professional Education What, where and how we train tomorrow’s health professional are questions that are constantly debated. Health professional education has to be relevant for serving society’s health care needs. It is therefore critical to constantly review our mission and to keep adapting. This is important for the social contract between our professions and society in general. To match educational offerings and current needs of the health care system is quite challenging and requires skills in both education and leadership. A well-trained and professional educational leadership is required. The Lancet-commission talked about the need of transformative leadership in international health professional education. The purpose of this article is to present a leadership program that was developed at Karolinska Institutet, Sweden, in collaboration with the British Medical Journal aiming at strengthening educational leadership in health professional education.
Karolinska Institute
The need for change There are different drivers of change. Some of those intend to align the content of the curriculum with the needs of society. A perfect alignment has perhaps not always been the case, and many current curricula reflect other interests than serving society. Other drivers relates to modernizing and upgrading the educational methods. Even other drivers have a stronger focus on the organization of the curriculum, i.e higher degrees of integration between basic sciences and clinical sciences. Most of this applies to health professional education around the world, in various degrees (WHO). However, for low-income countries, in addition, there are a number of significant obstacles: financial, faculty, facilities, equipment, and learning materials for the student.
pants have now setup local leadership courses in Uganda, Ethiopia, Guatemala, United Arab Emirates and in Malaysia. These national or regional programs provide access for many more educational leaders to educational leadership training. The next course will be held on November 12-16 2012 at Karolinska Institutet, Sweden. The program is a partnership between Karolinska Institutet, BMJ and the Royal College of Physicians and Surgeons of Canada. Associated partners are the Karolinska University Hospital, the Academy of Medical Educators. There is also an ongoing discussion about having TUFH to join as an associated partner. Course directors are Dr Jonas Nordquist, Karolinska Institutet / Karolinska University Hospital, Sweden and Dr Fiona Godlee, Editor-in-Chief, BMJ, UK. Ultimately, our vision is to further improve the quality and methods of training future health professionals. Another part of our vision is to provide access for participants from low and middle-income countries in this program, side by side with participants from high-income countries. Currently we have very few scholarships available, but with a strong partnership in the future, we aim at increasing access to our offerings, and create a truly global community of educational leaders. We have to meet tomorrow’s needs in the area of international health professional education with the highest possible level of quality, relevance and authenticity. A professional educational leadership is required as one component to make this possible in high, middle and low-income countries. Health, health care for the ill and prevention of disease are indeed human rights and something truly global.
Leading for Change The program we have created intends to further improve the leadership skills of current educational leaders, and focuses on the senior levels of leadership and the mid-management in health professional education. Our understanding is that many leadership programs around the world have a strong focus on the business administration literature. As an alternative approach we have selected a socio-political perspective with an emphasis on culture in organizations. Areas of primary concern are education and implementation of sustainable change. Leading for Change is an intensive 5-day program at Karolinska Institutet in Sweden and is run by an international faculty. Over the three years the program has existed, about 80 participants from 22 countries, representing all continents, have participated. In order to give access to participants from Low and Middle Income Countries, a special scholarship system was created and there have been a few scholarships every year. The long-term effects for the participants are yet to be evaluated but as an immediate result we can see that former partici-
Jonas Nordquist, Karolinska Institutet, Director Medical Case Centre, Karolinska Institute, Stockholm, Sweden Email: Jonas.Nordquist@ki.se 23
Student’s Column Students’ Speaker Corner Rooms to the Mountains services, culture, and disunity. Hearing their stories and seeing their behaviors, it can easily be said that they have grown tired of broken promises of progress and failed attempts for reform.
At our last conference in Graz, Austria, Sharmie gave an inspiring student keynote speech. Enjoy her story! “Young as you are, you can change the world!” This may seem a grandiose thought but this phrase never ceases to invigorate my spirit and preoccupy my mind with an impression that I am capable of transforming the world. Being a young soul, I always seek adventure and open doors to merge my idealistic desire with reality. When I started pursuing my aspiration of being a doctor, I only had one vision as I searched for my place in medical school – to serve. Our institution, the University of the Philippines College of Medicine banners excellence in medical education directed to the underserved. Through its Regionalization Program, a program that recruits students coming from the different regions of the Philippines who pledge to serve the country and the underserved communities for five years, I found a niche that sheltered my desire. As we are required by the program to do annual summer immersions aiming to identify the health needs of the chosen community and help them address their problems, I discovered an experience that soon widened my horizon and understanding of service. My first summer immersion began last 2009 – the first time to set my feet away from the solitary confinement in academic institutions to face what lies outside. Rather than an escape from the dreaded hours of arduous medical lectures, this gave a feeling of adventure and thrill. Together with our team composed of five medical students, we literally climbed the mountains to live with our new teachers – the Indigenous Aytas of Bataan. The community of Indigenous Aytas lies in the mountains of Orion Bataan, Philippines. They live hours away from the lowland community with no potable water supply and electricity. Their hard life forces them to work for hours on the field just to bring any food to partake for their family meals. Analyzing their health, diarrhea and malnutrition are the primary disease burdens. But more than that, their health status persistently struggles with the interplay of poverty, low educational status, inaccessibility to health workers and 24
Though it is difficult to permeate a community which already has a prejudice to anyone showing the intent to help, a vision keeps everything altogether. Despite the deterrence of our first encounter, our desire to serve led us to a realization that to understand and serve them means to see their lives through their eyes. With this sprung a new and meaningful perspective on their condition. We recognized that if we are to change the world, we need to know how to live with the world that needs to be changed. And also, more than our voice, the Aytas have a bigger and more important voice to be heard. As we created altogether a health program that will address their identified needs, we ensured that they are part of all the doings. They are not just recipients of reform, they are part of it and they are relevant. Thus, we listen. A philosopher once said that a servant is a learner. Indeed, it is true. Even on top of the mountains, we remained students. In our immersions, we shared our knowledge and skills to Aytas and humbled ourselves to acquire wisdom from them. Though they are not experts of science, they are teachers adept with the life we are to serve. By eating, talking and living with the Indigenous Aytas, we saw a part of reality. And though we still have limited capacity to change their situation as much as we wanted to and as we accept the truth that more still needs to be done, we could say with a smile on our face that we have initiated a difference. Indeed, we are young and we could change the world! Though we know that changing this world is a continuous process, we are now walking towards it. Anna Sharmie Caraan Quezon, University of the Philippines Manila Email: annaquezon@gmail.com
Student’s Column Students’ Interview How do students from all over the world perceive the educational programme at their Faculty, or the educational system in their country? How do they see the future, for their nation and for themselves? And what changes would they make, if they had the chance? We wanted to know. Therefore, we will ask one student five questions for the December issue of the Newsletter..
The Big Five This interview was conducted with Daniela Klobassa, last year’s student at the University of Graz, Austria. 1. Why did you choose to study Medicine? I chose to study Medicine because of interest. I was always interested in how the human body is functioning, what is happening in our body in order to understand and be able to help people. Before that I studied Psychology and was a little unsatisfied because so many questions were not known and unanswered and the therapeutic options were limited in this field. However, in Medicine many processes of the body are already understood and many things are known, therefore there are many possibilities to really help people, to prevent, intervene and treat.
many effective teaching methods, but not used sufficiently at the university or hospital. Second, I would implement more bedside teaching, more practical trainings. Third, I would introduce more oral exams. Over the last few years oral exams decreased and multiple-choice-exams increased. In my opinion oral exams have many advantages for the students; we can get feedback and learn during the exam. In multiplechoice exams it would be reasonable to display at the end the wrong answers and the answers which would have been correct, so that students can learn from their wrong answers. Fourth, more English spoken classes should be held. On a national level I would facilitate international collaborations by making it easier for students and graduates to study and work abroad and on the other side make it easier for foreign students and graduates to study and work here in Austria. The regulations are quite strict and make it not so easy for foreign doctors to work here and also if Austrians work outside of Europe it is not so easy to get experiences credited here.
2. What is your opinion about innovative educational formats like problem-based learning (or the education format that your own faculty uses)? I think problem-based learning is very effective and the knowledge from it is long lasting if done properly. I would wish to have a more intensive form of problem-based learning in my faculty and throughout the whole study. Overall a more active form in learning has to be implemented. We had many passive forms of learning (lectures) and from that you can never take as much with you as from active learning forums. So there is still room for lots of improvement at my faculty.
5. Imagine if you were to choose: a practice in town or in a rural area. What would you choose and why? I am not sure about this question yet. Definitely I want to specialize in a field, because I think with specialization we can help more specifically, effectively and implement new ideas/improvements more easily. The higher our education level, the higher our experience the easier we reach the boards where our suggestions and future improvements for the community will be heard. Once specialized, I can imagine both working in a town and in a rural area. Personally I prefer living in a rural area and for patients it would be beneficial also to have specialized doctors in the field, not only in the city. I think everything is about prevention and early diagnosis not only for the patients, but also regarding the cost factor. If it is possible to have a practice later in my life I would go to a rural area, but most of the time we are dependent on hospitals, especially during our post graduate education and hospitals are most of the time in the cities.
3. What part of your study was the most educational for you, what was the best learning experience in your studies (e.g. internships, research or being ill yourself)? I remember some good lecturers who told stories that I can remember forever, but the best learning experience was definitely during internships. If you have a face, a person behind the symptoms and pathologies, you will remember forever, but not when just reading the information in a book. Bedside teaching is very important and there cannot be too much, it should be increased as much as possible. Observing pathologic changes in my own body is definitely very memorable, but it just happened a very few times. 4. What would you change if you were Dean of your Faculty? Or on a national level if you were Minister of Education in your country? First, I would put emphasis in teaching the teachers. Usually doctors don’t have any didactic background. I think it would make sense to provide teaching workshops to lecturers about effective teaching methods. Time is getting more valuable and it is thought that we students should learn as much as possible in the shortest time, but then we also need the correct methods for it. There are
Daniela Klobassa, Student, Medical Universtiy of Graz, Austria Email: daniela_k@gmx.at Daniela Klobassa 25
Member and Organisational News Taskforces
Student’s Column
Integrating Public Health and Medicine
Out of the SNO Pen
At first glance, public health and medicine may seem incompatible partners. Public Health deals with the health of populations; medicine traditionally deals with diseases in individuals. However, Public Health also deals with organisation of health services to ensure access to health care, while Public Health measures prevent disease and reduce its impact – we need only think of the tremendous reduction of disease due to proper sanitation and housing legislation or the impact of vaccination programmes. Meanwhile, the clinical professions, particularly in primary care, provide preventive care for individuals and progress in medical interventions has contributed to the health of populations including vaccination, lifestyle counselling and screening. The integration and collaboration of the two domains will likely have a far greater effect than that which can be achieved by the two continuing to work in relative isolation. Furthermore, integration is essential for both Public Health and medicine to act in a socially responsible way and respect their underlying values of quality, equity, relevance and cost-effectiveness.1
SNO @ Rendez-Vous is Well Underway! Almost immediately following the excellent conference in Graz, students at the Northern Ontario School of Medicine (NOSM) have been preparing for the student portion of next year’s conference in Thunder Bay, Canada. We are very much looking forward to hosting members of the SNO and have a number of exciting events planned to give a good sense of what Canada has to offer! Specifically we are working in three areas: Pre-Conference Workshop, SNO Site Visit and Social Activities. For the Pre-Conference Workshop, we will be highlighting some of the ways that health care is delivered in Canada and will be delving into other systems of health care delivery worldwide. There will also be a number of interactive workshops including clinical skills sessions using standardized patients. We hope to utilize the Pre-Conference Workshop as an opportunity to allow delegates to get to know each other on a more casual level through various ‘ice breaker’ (or ‘get to know you’) activities.
The integration of Public Health and medicine faces a number of problems. In most health systems they are administratively distinct, reflecting their often vastly differing fields of action. In many instances, they are academically distinct. Although schools of Public Health are often affiliated to mainstream academia, they are usually separate institutes. This reflects the interdisciplinary nature of Public Health that draws expertise from a wide range of knowledge areas, from physics to sociology and everything in between. Although medicine also includes a number of different disciplines, these disciplines focus on different aspects of the same knowledge area; that of disease prevention and management. Students and practitioners of the clinical professions find it difficult to see the relevance of the wider focus of Public Health. Similarly, many Public Health professionals find the interests of clinical medicine so far removed from their own that communication between the two is difficult.
The SNO Site Visit will be based around the theme of Wilderness Medicine and we are hoping to run this event at the beautiful Sleeping Giant provincial park just outside of Thunder Bay. This will be an all-day event where we hope to include workshops on search and rescue, splitting injuries and wilderness survival. There will also be an opportunity to hike in the park and get a flavor of Northern Ontario’s rich landscape! The Social Committee has many exciting events in the works. These may include a ‘Bear Crawl’ games night and a good ol’hockey game! It is a NOSM tradition called the Strasser Cup. This is sure to be a wonderful and inspiring conference! We are thrilled to host the SNO!
The Network :TUFH Task Force on Integrating Public Health and Medicine is interested in finding solutions to these problems in order to find ways of integrating the two. This is not easy; even defining Public Health and medicine is complicated by their scope being dictated by national and local health systems. Nonetheless, the group agrees that integrating Public Health and medicine is essential to ensure the social accountability of medical and health professional training,
If you have any suggestions, questions, etc. please email: rvsoc2012@gmail.com Emily Robinson, Student, Northern Ontario School of Medicine
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Member and Organisational News Taskforces Integrating Public Health and Medicine research and service. Moreover, integrating Public Health into medicine should ensure that health professionals have a population perspective which should increase their: • awareness of their health-improvement within the system to improve health • ability to contribute effectively and ensure that their interventions increase the health of the population • awareness of their role in environmental and other public health programs • awareness of the impact of the social determinants of health on their patients, thus leading to better patient management. The overall result should be an improvement in the quality of care offered as well as in health gained. The members of the Task Force report provided examples of interesting initiatives that are underway around the world: • In Europe, Catalunya has experience with a programme that trains primary care and Public Health professionals together in order to promote the development of networks in which the two work together. The research unit of the Ministry of Health in the Basque Country has a new strategy focusing on the role of information technology and organisation of services in the management of chronic disease. The results will be translated into primary care practice. • African countries are bringing together multiple stakeholders to collaborate in countering HIV infection and its consequences. In Nigeria, partnership with the private sector has resulted in a health maintenance organisation which integrates Public Health with patient care. • Also in Africa, in order to reduce the multidimensional problem of trafficking in persons, many countries around the world integrate approaches and interventions summarized in the four “P”: Prevention (campaigns); Protection (shelters, healthcare, social and legal services); Prosecution and Partnership. • North America was host to a joint conference of the Centres for Disease Control and the Association of American Medical Colleges on “Patients and Populations: Public Health in Medical Education”. Papers from the conference are available in a special issue of the American Journal of Preventive Medicine.2 A number of medical schools in North America are developing programs that integrate Public Health and medicine, including Nebraska which now has a Community Oriented Primary Care (COPC) Programme supported by a recently published book on COPC co-authored by the Task
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Force Chair Jaime Gofin3 and New Mexico where public health has been integrated into all four years of the medical curriculum. All Canadian medical schools already teach public health to medical students. To support this teaching and as part of its social accountability initiative, the Association of Faculties of Medicine of Canada has convened the Public Health Educators’ Network which, with representation from all 17 Canadian schools, has succeeded in several projects including the development of population health objectives that are included in the National Qualifying Examination and the production of an interactive online textbook4 designed for medical students that aims to show the relevance of population health concepts in the clinical setting. • Many Australian medical schools have developed ways of integrating public health in the medical curriculum, for instance, the University of New South Wales includes public health aspects in all its theoretical teaching scenarios. Preliminary evaluation of this strategy indicates an increase in the proportion of students choosing social and cultural topics in their independent learning projects.5 The Integrating Public Health and Medicine Task Force is planning to meet at the 2012 Network:TUFH conference. If you are interested, the Task Force encourages you to submit a poster or a workshop on what you are doing around integration and join us in Thunder Bay. Denise Donovan Denise.Donovan@USherbrooke.ca Boelen C. Vers l’unité pour la santé: Défis et opportunités des partenariats pour le développement de la santé. Genève: Organization mondiale de la Santé; 2001. 2 American Journal of Preventive Medicine. October 2011; 41(4) Supplement 3 3 Gofin J and Gofin R. Essentials of Global Community Health. Jones and Bartlett Learning, and APHA, 2011 4 Donovan D. McDowell I. eds. AFMC Primer on Population Health : a virtual textbook on Public Health concepts for clinicians. 2011 available at http://phprimer.afmc.ca/ index 5 Whelan A & Black D (2007) Integrating public health and medicine: first steps in a new curriculum. Education for Health 20(3): November 2007 available at http://www. educationforhealth.net/articles/defaultnew.asp?IssueID=3 1
Member and Organisational News Taskforces Position Paper for the Interprofessional Education Task Force (IPE)
Updates from the Women and Health Taskforce
Preamble At its 2000 Bahrain meeting, the Executive Committee (EC) of The Network decided to undertake the writing of a series of “position papers” on issues intimately related to its aims and objectives. This initiative was inspired by information shared at Network conferences showing the various approaches to education, health service and research, and the adaptability to meet different needs at different places on the globe. The papers should be seen as starting points for discussion, rather than be interpreted as static “Network Declarations”. Three position papers for the IPE task force have been developed since this time. This paper follows the publication of the WHO (2010) Framework for Interprofessional Education and Collaborative Practice as the task force would like to support the implementation of this framework. This document should therefore be read in conjunction with the WHO (2010) Framework http://www2.rgu.ac.uk/ipe/WHO_report_Interprofessional%20Ed%20Sep2509.pdf Mission of IPE Taskforce To enhance the quality of interprofessional education, learning and practice by drawing together experience(s) from the international community oriented context. Objectives 1. To aid the implementation of the WHO (2010) Framework for Interprofessional Education and Collaborative Practice 2. To encourage the sharing of resources and good practice in Interprofessional Education Internationally 3. To encourage evaluation of Interprofessional Education and Practice 4. To encourage research and publication in peer reviewed journals particularly the community based work associated with developing countries 5. To support the Journal of Education and Health by encouraging authors to see this as a vehicle for publication of Interprofessional Education and Practice articles 6. To enable collaborative ventures with other TUFH Taskforces and with other IPE and IPP interested organizations e.g. joint meetings and conferences 7. To promote interprofessional learning and practice based on the needs of service users and careers 8. To maintain the position paper on IPE through reviews and updates via IPE taskforce member and network member feedback
Building upon the momentum gained in Nepal, the Women and Health Taskforce convened once again in Graz, Austria to discuss and work towards improving maternal health worldwide. With support from GHETS, thirty GHETS fellows and members of the Women and Health Taskforce convened for a pre-conference workshop and thematic poster sessions. Members of the taskforce also conducted two workshops, one on the topic of violence against women and the other on teaching women’s health through literature and film. These workshops resulted in fruitful discussion and generated significant interest in the topic of women’s health from members of the Network outside of the taskforce. During this meeting, the WHTF was also able to convene to discuss the third revision of the Women and Health Learning Package (WHLP). The WHLP is a free e-learning resource for use by educators, health providers, and health sciences students (particularly medical and nursing students). The collaborative curriculum, authored by WHTF members from around the globe, seeks to improve the accessibility, availability, and quality of healthcare for women and girls. The creation, distribution and implementation of the WHLP is part of a broader effort to encourage open dialogue about important gender-related health issues, such as contraception, unwanted pregnancy, unsafe abortion, and violence against women. To date, the WHLP has been downloaded in over 100 countries worldwide. Currently, the taskforce is busy planning for the upcoming Network Conference in Thunder Bay, Canada. This year, the taskforce looks forward to completing the revision of the third edition of the WHLP and electing new members of the WHTF Management Committee. Taskforce members will also continue the work that they are conducting on community-based mini-grant projects, as well as conduct taskforce strategic planning and grant proposal-writing exercises. For more information about the taskforce, WHLP, and mini-grant projects, or to join the listserv, please contact WHTF@ghets.org. We look forward to seeing you in Thunder Bay in October! Ms Nighat Huda, Chairperson WHTF, Pakistan Email: nighathuda@gmail.com
Professor Dawn Foreman, Chair of the taskforce IPE Email: dawn@ilmd.biz
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Member and Organisational News Taskforces Social Accountability and Accreditation Since our meeting in Graz last year the TFSAA and its members have been very active in a range of geographical and topical areas. Much of the focus has been on the animation and application of the Global Consensus for the Social Accountability of Medical Schools (GCSA: www.healthsocialaccountability.org). The remarkably positive manner in which the ideas and principles have been received and are being acted upon around the world is a testament to the robustness and relevance of our joint work. In addition, a number of relevant parallel activities are having their own impacts. Ongoing communications and joint efforts promise continuing synergies towards positive change at the international, national and sub-national levels. A number of these are explicitly mentioned in the following table. Table 1 GCSA Collaborations: • World Federation for Medical Education • Assn for Medical Education In Europe (ASPIRE) • The NETWORK-TUFH • TheNET • Association of Francophone Deans • FAIMER Fellows SA • SEARAME • Global Independent Commission on Health Professionals for the 21st Century • SIDMEF On several of these there is explicit cross representation with members of the GCSA and TFSAA. Ongoing requests for presentations, panels and workshops are being honored where feasible and the organization of committees by the Global Task Force promises to streamline this for greater efficiency and impact. A very partial list of major presentations is represented in Table 2: Table 2 Partial List of Major Presentation/Workshop Locations on behalf of GCSA and TFSAA: • Spain • Tunisia • Saudi Arabia • France • Brazil • SEARO • EMRO • Indonesia • Italy (AMSE) • Bangladesh • Nepal • South Africa • India • Sweden (WFME) • Canada • USA • Austria (Network TUFH) • Thailand (GHWA) • International Webinar (AMEE) Details many of these activities can be found on the website www.healthsocialaccountability.org where the various translations of the consensus document can also be reviewed. At present the GCSA is organized by the Global Task Force (GTF) called for at the Global Consensus Conference and established in Yvoire at a follow-up Strategic Planning Meeting. The TFSAA will be meeting again in Thunder Bay at the Network TUFH Conference which this year is being held in conjunction with a number of major global organizations with a shared interest in enhancing the relevance of medical and other health professional schools to the health of populations. Active planning for joint efforts in the realms of research, evaluation, accreditation and policy development promise to make this a pivotal meeting in advancing the work of the TFSAA and the Network TUFH. Your presence and participation in this is requested. We always appreciate hearing from you and hope that after you review this report, you will find a willingness to contribute to the activities of the TFSAA and the GCSA and/or our collaborators so that our collective vision can be realized. It is our hope that you will continue on our shared journey towards increasingly relevant health education dedicated to fostering equity, effectiveness, and high quality service to all. Bob Woollard and Charles Boelen, Co-Chairs Email: woollard@familymed.ubd.ca/boelen.charles@wanadoo.fr 29
Member and Organisational News Education and Research The Wall of Fame In this new section we want to pay more respect to all those active members, publishing valuable articles. Hereunder you can find a summary of relevant articles for our network.
Blumenthal DS. Is Community-Based Participatory Research Possible? American Journal of Preventive Medicine 2011;40:386-9 McNeal MS, Blumenthal DS. Innovative Ways of Integrating Public Health Into the Medical School Curriculum. American Journal of Preventive Medicine 2011;41(3):S309-S311
Joshi A. Mountain Discourse on SPACE research. Mountain Medicine Society of Nepal 2011;8:18-19 Geppert C., Arndell C., Clithero A., Dow-Velarde L., Eldredge J., Kalishman S.,Kaufman A., McGrew M., Snyder T., Solan B., Timm C., Tollestrup K., Wagner L., Wiese W., Wiggins C. and Cosgrove E. Reuniting Public Health and Medicine; the University of New Mexico School of Medicine Public Health Certificate. American Journal of Preventive Medicine 2011 Oct;41(4 Suppl 3):S214-9 Bachofer S., Velarde L., Clithero A. Laying the Foundation: A Residency Curriculum that Advocacy by Family Physicians. American Journal of Preventive Medicine 2011 Oct;41(4Suppl3):S312–S313 Lorant V., Geerts C., Duchesnes C., Goedhuys J., Ryssaert L., Remmen R., et al. Attracting and retaining GPs : a stakeholder survey of priorities. The British journal of general practice 2011;61(588):411-18
Remmen R., Philips H., van Bergen J. Cost containment using primary care cooperatives is unlikely in open access health systems. Annals of internal medicine / American College of Physicians 2011;155(2):108 Shroff FM. Conceptualizing holism in international interdisciplinary critical perspective: Toward a framework for understanding holistic health. Social Theory & Health 2011 Aug;9:244-255 Baker HH, Pathman DE, Nemitz JW, Boisvert CS, Schwartz RJ, Ridpath LC. Which U.S. medical schools are providing physicians for Appalachian Region of the United States? Academic Medicine 2012;87(4):498-505.
Pathman DE, Teal R. Use of data by hospitals in North Carolina to identify disparities in the care and outcomes of minority patients. North Carolina Medical Journal 2011;72(3):177-182. Arinze-Onyia SU., Onwasigwe CN., Uzochukwu BSC. and Nwobodo E. The Effects of Health Education on Knowledge and Attitudes to Emergency Contraception by Female Students of a Tertiary Educational Institution in Enugu, South East Nigeria. Nig. J. Physiol. Sci. 2010 Dec;25:165 – 171 Oguoma, Nnaji LI, Nwobodo E. The challenges of budgeting in a newly introduced district health system: a case study. Glob Public Health 5 1, [pmid: 19946811 - added 2009-12-1]
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Member and Organisational News Education and Research The Wall of Fame
Mammen M. Using Mentee’s Feedback to improve a Mentoring Program in a South African Medical School. Anthropologist 2012; 14(1): 1-8 Khodakarami N, Naji H, Dashti MG, Yazdjerdi M. Woman abuse and pregnancy outcome among women in Khoram Abad, Islamic Republic of Iran. East Mediterr Health J. 2009 May-Jun;15(3):622-8
Magourilos FG, MPS, CPS, ICPS. Prevention and Wellness Practices in a 21st Century Environment: What We Have and What We Need. Corporate Wellness Magazine 2012 Apr
Ezeala CC, Swami N, Lal N, Hussain S. Admission scores as a predictor of academic success in the Fiji School of Medicine. Journal of Higher Education Policy and Management 2012 Jan;34(1):61-66 Ezeala CC. Skilling up medical laboratory technologists for higher roles in biomedical sciences: a needs analysis. African Journal of Health Professions Education 2011 Dec;3(2):3-5
Williams B, Warren S, McKim R, Janzen W. Caller self care decisions following teletriage advice. Journal of Clinical Nursing 2012 Jan;27 Williams B, Spiers J, Fisk A, Richards L, Gibson B, Kabotoff W, McIlwraith D, Sculley A. The influence of an undergraduate problem/context based learning program on evolving professional nursing graduate practice. Nurse Education Today 2011 Mar Redwood-Campbell et al. Developing a curriculum framework for global health in; family medicine: emerging principles,competencies, and educational approaches. BMC Medical Education 2011;11:46 Vadiee M. The UK ‘‘Expert Patient Program’’ and self-care in chronic disease management: An analysis. Eur Geriatr Med 2012; doi:10.1016/j.eurger.2012.02.003
Vadiee M. The quest for multi-sectoral HIV/AIDS prevention in Central and Eastern Europe and why it matters. HIV & AIDS 2011;10: 99–104 Akram A., Parimalakrishnan S., Patel I., Praveen Kumar T, Balkrishnan R., Mohanta GP. Evaluation of Self Medication Antibiotics Use among patients attending Community Pharmacies in Rural Area, Uttar Pradesh, India. Journal of Pharmacy Research 2012 Feb;5(2):765 –768.
Hester J. Cracking the nut of service-learning in nursing. African Journal of Health Professions Education 2011;1(3) De Maeseneer J, Roberts RG, Demarzo M, Heath I, Sewankambo N, Kidd MR, van Weel C, Egilman D, Boelen C, Willems S. Tackling NCDs: a different approach is needed. The Lancet 2012;379:1860-1
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Member and Organisational News Introducing Members New Members Our Network keeps on growing, this year we welcome the following new members:
Full Members Fundación Juan N. Corpas, School of Medicine, Bogota, Colombia
Shaul Sofer, Ben-Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel
Bahria University Medical and Dental College, Faculty of Medicine and Dental, Karachi, Pakistan
FAIMER We are happy to announce that once more The Foundation for Advancement of International Medical Education and Research (FAIMER) sponsored 105 of their fellows to become Individual Member of The Network: TUFH for the year 2012. With this collective membership, FAIMER and The Network: TUFH want to continue a strong collaboration and mutual assistance. We welcome all FAIMER fellows to the Network: TUFH and hope to meet many of them at the upcoming conferences of The Network: TUFH.
THEnet: Training for Health Equity, Belgium Ege University, Faculty of Medicine, Izmir, Turkey National University of Malaysia, Malaysia Princess of Naradhiwas University, Faculty of Medicine, Bangkok, Thailand Shifa College of Medicine, Faculty of Health Sciences, Islamabad, Pakistan
Student Members
Individual Members
From this year on, it’s possible for students to become a free member of The Network: TUFH. 15 students are already a member. Don’t hesitate to follow their example.
Mrs. Fiona MacVane Phipps, School of Health Studies, University of Bradford, Bradford, West Yorkshire, United Kingdom Dr. Olayinka Olufunmi Ayankogbe, College of Medicine, University of Lagos, Lagos, Nigeria
Newsletter Volume 30/no. 1/July 2012 ISSN 1571-9308 Editor: Julie Vanden Bulcke, Kaat De Backer Language editor: Amy Clithero The Network: Towards Unity for Health Publications UGent University Hospital, 1K3 De Pintelaan 185 B-9000 Ghent Belgium Tel: (32) (0)9 332 1234 Fax: (32) (0)9 332 49 67 Email: secretariat-network@ugent.be Internet: www.the-networktufh.org Lay Out: Marijke Deweerdt, Sofie De Backere Print: Drukkerij Focusprint
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