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Orientation Activity Facilitator Guide

Ande Jones, MD, Kristin Van Genderen, MD, Chelsea Schaack, & Mike Pitt, MD

sugarprep.org

Summary of Activity: This Orientation Activity is an interactive introductory experience intended to orient/familiarize learners with the basic/fundamental principles necessary to prepare for global health rotations. Learners will partake in a crash course on global health electives via team based-learning, engage in icebreaker activities, and take time to reflect on their personal goals for participating in global health electives.

Learning Objectives: 1. Utilize team-based learning for a “Global Health 101” crash course for electives: GH

definition, global epidemiology, terminology, and stakeholders. 2. Define medical (or “poverty”) tourism, sustainability, and partnerships. 3. Explore personal motivations and goals for participating in a global health elective. 4. Identify strategies for aligning personal goals with elective site/host goals.

Activities in this Module: This interactive orientation session includes large group didactics, self-assessment, team-based learning, self-reflection, and small group work.

Preparation Time: 20 minutes to modify the PowerPoint slides ahead of time and gather the necessary supplies.

Expected Duration of Activity: 60 minutes

Ideal Group Size: A large group is ideal for the overall orientation session. This large group will split into smaller teams of 4-6 learners to complete the team-based learning activity. Individual time for self-assessment and self-reflection will also take place during the large group orientation session.

Number of Facilitators Needed: 1 facilitator

Supplies Needed: Facilitator Materials

This Global Health Orientation Activity Facilitator Guide

Pens/pencils

Lined writing paper

Blank, letter sized envelopes

Whiteboard & Dry-erase marker

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Orientation & Global Health 101 Facilitator PPT (with notes embedded in pertinent slides)

Projector (or another way to display PowerPoint presentation)

A, B, C, D placards for the “Global Health 101” Activity [included below]

Post-it notes in 3 different colors (one post-it note pad for each learner)

Optional: folders, clipboards or another hard surface to write on Learner Materials *Print one for each learner:

Global Health 101 Learner Multiple Choice Quiz (handout)

Global Health 101 Reference Materials (handout)

Big Picture Timeline/Workflow: 1. Welcome & Introductions (5 min) 2. Learning Objectives for the Session/Day (5 min) 3. Global Health 101 Activity (20 min) 4. Icebreakers—Map Activity & Visual Likert Scale (20 min) 5. Self-Reflection Exercise (5 min) 6. Post-it Note Activity (5 min)

Facilitator Instructions: 1. Facilitator Preparation

a. Prior to this session, spend some time modifying the included PowerPoint Orientation Slides by removing/updating certain slides. Each slide with a yellow box should be modified. There are notes embedded in the power point slides to help guide you to which slides correlate to each of the sections detailed below.

b. Print the handouts and compile the supplies you will need [listed above]. c. Print A, B, C, D placards located at the end of this document; each team should

have a set of letters (A, B, C, D). 2. Session Details

*Utilize the included Orientation PowerPoint Slides for all Orientation Activities. a. Welcome everyone as they arrive and take time for brief introductions. b. Introduce yourself and then ask each person to say their name, number of years

they have been involved in global health, and their favorite______ (fill in the blank) i.e. food, animal, place to visit, etc.

c. Learning Objectives o Take 5-10 minutes to solicit learning objectives for the session/day o What areas would the learners like to make sure we address today about

their upcoming work in a resource-limited setting in global health? o Write each learning objective on a white board or easel for everyone to see. o If we know what the learners are hoping to get out of the session, we can:

Point some of the existing content back to these objectives Modify some content in real time

d. Overview for the session o Briefly review the schedule for the day (remember to modify this schedule to

reflect your agenda ahead of time).

DELETE THIS SLIDE

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e. Team-Based Learning *Refer to the included “Global Health 101” Activity Facilitator Guide below o In order to leverage peer teaching and lead to longer retention, we have

divided this quiz up into several activities: 1) Individual self-assessment (complete test solo) 2) Small groups (come to an agreement between peers) 3) Large group (overall consensus)

o Review the questions by using the slides to briefly discuss each answer, paying more attention to those where several groups missed the correct answer.

o Hand out the “Global Health 101 Reference Sheet” following this activity, for future reference.

f. Ice Breakers *No handouts/additional materials needed for ice breaker activities. o Map Activity

Use the floor space as a map of the world to demonstrate this activity. “Imagine this is a map of the world. I’m standing in North America now

(walk across the room), here is Europe, here is Asia, etc.” “Go stand in the place you last participated in a global health

experience. If you haven’t traveled yet in this capacity, go to the last place you went on vacation.”

As people settle, ask a few people to share where they were and when they were there.

Next, ask people to travel to the place they will be going on their upcoming GH experience.

After they have re-settled, check-in with them again. Select a handful of people to answer a few questions, like: “Where will you be going? Why did you choose this location? What do you hope to gain by going there?”

o Visual Likert Scale Ask attendees to form a line based on the number of weeks spent

working abroad in GH context over the course of one’s career (the least amount of time on one side of the room and the most of amount of time on the other side).

Select a few participants from each end of the spectrum. Ask them to say their name, where they have traveled, and the number of years they have been involved with global health work.

Now ask attendees to form a line based on their degree of certainty active engagement in GH work will be a part of their career (from the most unlikely on the left side to the most certain on the right side).

Ask if a few participants wouldn’t mind sharing with the group why they feel this way—one or two from each side is ideal.

g. Self-reflection Exercise o “Now we are going to do some time travel and ask you to communicate with

your future self.” o Handout envelopes, lined paper, and pens/pencils (one for each learner).

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o Encourage learners to write a letter to themselves to be opened upon return from their GH elective.

o Start with the prompt, “This global health experience will have been successful if…”

o Ask each learner to seal this letter in an envelope; include their name, address, and return date on the outside of the envelope.

o Have each learner hand in this envelope to be sent by their program once their GH experience has been completed.

h. Post-it Note Activity o Explain that we will be exploring common hopes and fears surrounding work

in GH over the course of today’s session. o In order to do this, we want to think about this question: “What about global

health work in a resource-limited country sets the stage for common challenges?”

o Ask the participants to count-off by three (1, 2, 3, 1, 2, 3, etc.) and remember their number. Based on these numbers, give the groups 3 different colors of post-it notes. Each post-it note represents the following: Different Country (blue) Different Healthcare System (pink) Different Clinical Context (yellow)

o Have each participants jot down what they believe the different aspects of working abroad are that could pose a challenge in global health.

o For example, if a learner has a blue post-it note, they could write down “language barrier” as a potential challenge when working in a different country.

o Write each topic (Country, Healthcare System, and Clinical Context) on a whiteboard or easel with space below each topic.

o Once everyone has completed 1-3 post-it notes, ask them to bring these to the front of the room.

o Add each post-it note to the topics listed on the board. o Reveal the PowerPoint slides that work through some possible answers; note

the areas of overlap. o The purpose of this activity is to establish what common challenges are set-

up by this sort of work, with the goal that over the course of the SUGAR-PACK Curriculum, strategies to address many of these challenges will be revealed.

3. Wrap up a. Overview for the rest of the session

o Briefly review the schedule for the day (remember to modify this schedule to reflect your agenda ahead of time).

b. Reminders and next steps

Learner Considerations: Utilize targeted and engaging questions to ensure all learners are contributing to the discussions.

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Learner Assessment: Learners can independently compare answers from their solo tests with their group tests, similar to a pre- and post-test.

Global Health 101 Activity Facilitator Guide

sugarprep.org

This is a team-based learning activity. You should budget 20 minutes to complete this activity as

part of your 1-hour orientation session.

1) Divide learners into small groups of 4-6 each and hand out the A, B, C, D placards (one

set for each group).

2) Hand out the Global Health 101 Learner Multiple Choice Quiz about topics and key

players in Global Health. Each individual should have their own copy.

3) Allow 5 minutes for learners to go through the questions individually.

4) Allow an additional 5 minutes for small groups to discuss the questions. The goal is for

the group to come to a consensus on the correct answer.

5) At the 10-minute mark, the large group moderator then discusses each question using

the power point. After each question, the groups display their answer choice on a

placard (A, B, C, D).

*For matching and definition write-in, have groups shout out the answers.

6) For a question where about 80% of the groups got the answer correct, it is deduced that

a majority of them understand the concept and no further discussion is needed.

7) For a question with greater answer disparity among the groups, a detailed discussion

should follow (see explanations in the following section).

8) Following the activity, each individual is handed the Global Health 101 Reference

Materials, for future reference.

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Global Health 101 Activity Multiple Choice Quiz with Answers

(for facilitators) sugarprep.org

1) There are a number of terms individuals use to refer to areas where groups may target

global health efforts. Which of the following is the most appropriate term?

A. Third world country B. Developing country C. Resource limited setting D. Poor country

Answer: C Explanation: The etymology of “Third World” dates back to the Cold War. During this time, “First World” referred to the United States, Western Europe, and their allies. “Second World” referred to the Soviet Union, China, and their allies. The remainder of countries in the world were given the designation of “Third World.” Because many of the countries included under this label were also resource limited, the term became synonymous with any country who had limited resources and lower socioeconomic status. This is problematic. Many countries that fall into the historical definition of “Third World” may not necessarily qualify as resource limited. Similarly, this term excludes countries (or parts of countries) that may in fact be resource limited, but otherwise fall within the “First World” or “Second World”. As this term was initially political in origin and does not accurately describe resource limited settings, it is no longer preferred.

The terms “developing” and “poor” may also be problematic. These are general descriptors, but do not give any additional information regarding an individual country’s access to resources, needs, etc. Furthermore, it again assumes that “developed” and “wealthy” countries do not need assistance. These countries may have regions within them that are resource limited. There is also the question of definitions. What is “developed”? Is being “developed” the goal for all areas? What is “wealth”? Does “wealth” always translate into well-being?

For example, in 2016, the Gross Domestic Product (GDP) of the United States was $18.5 trillion, and our infant mortality rate was 5.6/1000. In comparison, Slovenia’s GDP was significantly less at $43.9 billion, but their infant mortality rate was only 1.6/1000. Kenya, whose GDP of $70.5 billion was more than Slovenia’s, had an infant mortality rate of 35.6/1000. Thus, wealth does not always simply correlate with improved health statistics.

While there are many possible terms to designate areas in need of global health efforts, the term “resource limited setting” is the most appropriate. It does not confine the definition to

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political borders and it allows for flexibility in interpretation of what is meant by both resources and limited.

2) Part of working in global health is interacting with other cultures. There are many terms

that address aspects of these interactions, including culture shock, reverse culture shock, cultural humility, and cultural competence. Please match the terms listed on the left with their correct definitions.

1. Culture Shock

2. Reverse Culture Shock

3. Cultural Humility

4. Cultural Competence

A. When encountering a new culture, the process of being open to learning and to new experiences, recognizing personal biases, having awareness of one’s verbal and nonverbal reactions and the effect of those reactions on others, and having understanding and acceptance that one cannot ever master another culture.

B. The initial adaptation phase of integrating into a different culture, which

typically occurs over 4-5 days, and after which individuals feel comfortable and confident in their interactions with the new culture.

C. The ability to effectively communicate, interact, empathize, and integrate into another culture after achieving a mastery of that culture. This concept is now less favored, as one cannot truly master another culture.

D. The feeling of anxiety and uncertainty that comes with entering a new culture. This may manifest as a five-stage process, including the honeymoon phase, rejection, regression, acceptance/negotiation, and reverse culture shock.

E. The act of avoiding adaptation or integration into a new culture to prevent actions or phrases that may unintentionally insult others.

F. The psychological process and adjustment one goes through when re-entering their own culture.

G. The feeling of shame at aspects of one’s own culture after experiencing another culture, prompting individuals to change their own culture.

Answers:

1. Culture Shock: D The feeling of anxiety and uncertainty that comes with entering a new culture. This may manifest as a five-stage process, including the honeymoon phase, rejection, regression, acceptance/negotiation, and reverse culture shock.

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2. Reverse Culture Shock: F The psychological process and adjustment one goes through when re-entering their own culture.

3. Cultural Humility: A

When encountering a new culture, the process of being open to learning and to new experiences, recognizing your own biases, having awareness of your own verbal and nonverbal reactions and how those reactions may affect others, and having understanding and acceptance that one cannot ever completely master another culture.

4. Cultural Competence: C

The ability to effectively communicate, interact, empathize, and integrate into another culture after achieving a mastery of that culture. This concept is now less favored, as one cannot truly master another culture. The concept of cultural humility is more appropriate.

Explanation: The terms “culture shock” and “reverse culture shock” relate to a given individual’s personal experience when interacting, integrating, and re-integrating with a culture. These terms do not incorporate the community’s experience interacting with an individual of another culture. Furthermore, these terms encompass psychosocial changes and adjustment an individual experiences, but do not explicitly imply a desire or attempt to change a culture. While the stages of culture shock are recognized, they are not uniformly experienced in a specific timeline.

3) While the terms equality and equity may sound similar, there is a difference in their

meaning. Which of the following best illustrates health equity versus equality?

Dr. Walton wants to promote cholesterol screening in his practice

A. To promote equality, he openly advertises cholesterol screening to all patients. To promote equity, he charges everyone the same price for testing.

B. To promote equality, he openly advertises cholesterol screening to all patients. To

promote equity, he charges for the lab based on a sliding scale, thus reducing the economic barrier to screening completion.

C. To promote equality, he blinds himself when reviewing cholesterol levels to avoid bias in

his interpretation. To promote equity, he offers nutritional consultation to all patients regardless of results.

D. To promote equality, he tells every patient that they need testing. To promote equity,

he decides to charge a consultation fee for any patient with abnormal results, thus increasing his take-home pay.

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Answer: B Explanation: The World Health Organization defines equity as, “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.” Reducing health inequities will over time help to reduce health inequalities. Efforts to ameliorate health inequities typically target systemic change. In this context, equity has a different meaning than in financial planning, investments and personal wealth.

For example, two houses are both situated one mile from a clinic. In this sense, they are equal. If the clinic provides financial support for transportation to the clinic, it may divide its resources 50/50 between the two houses. Let’s say, however, that the path from one house is a paved road and the path from the other house requires crossing a river that does not have a bridge. To promote equity, the clinic may then distribute 10% of its financial support to help maintain the paved road, and 90% of its financial support to build a bridge over the river.

4) Please match the following terms on the left to their correct definition:

Credit: United Nations refugee agency and the World Health Organization

1. Displaced person

2. Refugee

3. Immigrant

4. Asylum seeker

5. Stateless person

6. Internally displaced person

7. Vulnerable groups

A. Individuals who are unable to anticipate, cope with, resist, or recover from the impacts of disasters.

B. People who have had to leave their homes due to natural,

political, economic, technical, or deliberate events. C. An individual who has been forced to flee their home, but

who has not cross an international boundary. D. Someone who is not a citizen of any country. E. Someone who chooses to resettle in a foreign country. F. Someone who has fled their own country and is now seeking

sanctuary in another country. G. Someone who has been forced to flee his or her country

because of persecution, war, or violence, which may be for reasons of race, religion, nationality, political opinion, or membership in a social group.

Answers:

1. Displaced person: B

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People who have had to leave their homes due to natural, political, economic, technical, or deliberate events.

2. Refugee: G Someone who has been forced to flee his or her country because of persecution, war, or violence, which may be for reasons of race, religion, nationality, political opinion, or membership in a social group.

3. Immigrant: E Someone who chooses to resettle in a foreign country.

4. Asylum Seeker: F Someone who has fled their own country and is now seeking sanctuary in another country.

5. Stateless person: D

Someone who is not a citizen of any country.

6. Internally displaced person: C An individual who has been forced to flee their home, but who has not crossed an international boundary.

7. Vulnerable groups: A Individuals who are unable to anticipate, cope with, resist, or recover from the impacts of disasters.

5) You may hear different not-for-profit organizations, political initiatives, or even

individuals discuss their global health efforts in relation to helping achieve a sustainable development goal. To what are they referring? A. Promotion of community development in ways that utilize sustainable resources and

have a limited impact on the environment.

B. A United Nations mandate that each country must establish individual health promotion and poverty reduction goals along with plans to achieve those goals. Countries must update these goals every 10 years.

C. A universally agreed upon principle that global health efforts should focus on projects

and initiatives that are sustainable in the communities they serve. This is in efforts to avoid brief solutions to long-term problems, one week mission trips, and transient clinical care

D. A coordinated effort through the United Nations and multiple countries, which adopted

goals to end poverty, protect the planet, and ensure prosperity for all, and with the mission to achieve specific targets over the next 15 years.

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Answer: D Explanation: In September of 2015, 193 countries of the UN General Assembly established the 2030 Agenda for Sustainable Development, describing 17 Sustainable Development Goals. These build on the success of the prior Millennium Development Goals, and call for action by all countries. Countries are expected to take ownership to help achieve the goals, and each goal contains targets to be met over the next 15 years. The term “sustainability” specifically highlights the idea that we should address the needs of the present without compromising future generations. Goals include:

1. Poverty 2. Zero Hunger 3. Good Health and Well-Being 4. Quality Education 5. Gender Equality 6. Clean Water and Sanitation 7. Affordable and Clean Energy 8. Decent Work and Economic Growth 9. Industry, Innovation, and Infrastructure

10. Reduced Inequalities 11. Sustainable Cities and Communities 12. Responsible Consumption and

Production 13. Climate Action 14. Life Below Water 15. Life on Land 16. Peace, Justice, and Strong Institutions 17. Partnerships for the Goals

6) In many areas, you might find that community health workers are pivotal players in healthcare. Which of the following best describes a community health worker? A. A licensed medical professional trained and supported by the United Nations to

supplement the healthcare workforce in areas where there is a shortage of doctors and nurses.

B. An umbrella term to encompass a wide variety of individuals who originate from the

community which they serve, who are trained to provide one or many aspects of healthcare, and who may promote social change. These individuals have not completed advanced degrees in healthcare.

C. A member of the community who is trained solely in health promotion so that they can

educate their community on preventive health topics, thereby reducing development of disease.

D. An individual who is trained to promote the overall health of the community by

engaging in environmental education, gender equality, clean water utilization, and vaccination initiatives. They do not care for individuals one-on-one.

Answer: B

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Explanation: Community health workers (CHWs) have long provided basic health needs to a community, notably in areas where there is a shortage of healthcare workers. This is a generalized term, and the roles and responsibilities of CHWs may vary from location to location. In general, they originate from the community in which they serve and provide healthcare in some fashion. While they generally have received training in one or more aspects of healthcare, they are not doctors, nurses, or other licensed medical professionals who have received a more formalized education.

Examples of care provided by CHWs include (but are not limited to) home visits, TB or HIV/AIDS care, treatment of acute infections, communicable disease control, nutrition counseling, surveillance, and data collection/record keeping. While there might be debate regarding which tasks are appropriate for CHWs given their level of training, they are widely considered pivotal players in healthcare delivery.

7) Tyler recently returned from working in an ED in Botswana. He had anticipated that he

would predominantly care for patients affected by tuberculosis, malaria, and HIV. However, he was surprised to learn that road traffic accidents were a major cause of injury and death and often saw these patients in the ED. The death rate due to road safety is 23.6 per 100,000, and Tyler laments that this issue contributes highly to Botswana’s overall burden of disease. What does he mean by “Burden of Disease”? A. The level of illness in a community, as measured by incidence and prevalence.

B. The impact of a health issue or problem on a community, often measured by disability

adjusted life years, quality adjusted life years, morbidity, mortality, or economic cost.

C. The overall economic cost attributed to a certain health condition, as measured by cost of services, tests, and therapies, time invested by the healthcare force, and loss of income by the patient.

D. The overall impact of acute conditions and infectious diseases on a community, thus

affecting resources that could otherwise be used for preventive healthcare and treatment of chronic diseases.

Answer: B Explanation: Burden of disease describes the impact of any healthcare condition, including acute, chronic, communicable, and non-communicable diseases and conditions. The burden is measured not simply by prevalence and incidence, but by determining the level to which a community is affected by that condition through DALYs, QALYs, morbidity, mortality, and economic cost. The World Health Organization initiated the Global Health Burden of Disease study in 1990 and continues to provide guidelines on data collection and measurement of disease burden. This data can be used to better target health initiatives.

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8) Sonja is planning to travel to Guatemala in her third year of residency. She is excited to

step out of the clinical realm and is partnering with a regional not-for-profit organization. This organization surveys various communities to collect data on health indicators. What exactly is a health indicator? A. A measurable piece of data obtained from a community that, when in conjunction with

other health indicators, gives a sense of the overall health of that community. Data can be collected on a wide variety of topics.

B. A series of measurements on a given community’s water sanitation, agricultural efforts,

average education level, and overall economic productivity that may influence the health of that community.

C. Statistics on the overall healthcare utilization of a community, as measured by number

of visits to a local doctor or nurse, number and productivity of community health workers, and income spent on healthcare.

D. Measurements pertaining to the overall health of the environment where a specific

community resides, which often predicts and correlates with the health of that community.

Answer: A Explanation: The World Health Organization identifies the top 100 core health indicators, which are measurements that can give a sense of the overall health of a community. Indicators span a wide range of topics, including health status, risk factors, service coverage, and health systems. Examples of these include infant mortality rate, hospital bed density, condom use, births attended by skilled healthcare professional, salt intake, and more.

9) Philippa has partnered with a tribal nation in her home state to promote health and well-

being among pregnant women. Instead of working in the perinatal clinic, she decides to reach out to community groups to target social determinants of health. What are social determinants of health? A. Initiatives and measures focused on psychological and mental health issues of a

community. This is an often ignored subject in Global Health.

B. Initiatives using the power of social media to reach communities, promote education, and effect change to better the health of that community.

C. An individual’s opinions or perspectives on their own health, which can influence their

decisions and lead to inequalities despite equal access to healthcare. This relates to an individual’s education.

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D. Conditions in which people are born, live, grow, work, and age. They encompass aspects

of an individual’s environment, socioeconomic status, political community, culture, etc. They are primarily responsible for health inequities.

Answer: D Explanation: The overall environment, setting, and place greatly influence health and well-being. These go beyond a basic understanding of disease, and instead focus on how all other conditions of an individual’s environment affect their experience with that disease. For example, an individual’s susceptibility to contract malaria is not simply the chance of suffering the bite of a mosquito infected with viable parasite, but also related to that individual’s nutritional status, housing situation, occupation, and personal education on mosquito avoidance.

10) Identify the following global-health-related key players and acronyms:

A. CDC B. WHO C. MSF D. NGO E. NPO F. LIC, LMIC, UMIC and HIC G. NCDs H. WTO I. SGD J. DALY

Answers:

A. CDC: Centers for Disease Control B. WHO: World Health Organization C. MSF: Médecins Sans Frontières, also known in English as Doctors Without Borders D. NGO: Non-governmental organization E. NPO: Not-for-profit organization F. LICs, LMICs, UMICs and HICs: Low income country, low-middle income country, upper-

middle income country, and high-income country G. NCDs: Non-communicable diseases H. WTO: World Trade Organization I. SGDs: Sustainable Development Goals J. DALY: Disability adjusted life years

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Global Health 101 Activity Reference Materials

(for facilitators & learners) sugarprep.org

Terminology: Third World v. Developing Country v. Resource Limited Setting The etymology of “Third World” dates back to the Cold War. During this time, “First World” referred to the United States, Western Europe, and their allies. “Second World” referred to the Soviet Union, China, and their allies. The remainder of countries in the world were given the designation of “Third World.” Because many of the countries included under this label were also resource limited, the term became synonymous with any country who had limited resources and lower socioeconomic status. This is problematic. Many countries that fall into the historical definition of “Third World” may not necessarily qualify as resource limited. Similarly, this term excludes countries (or parts of countries) that may in fact be resource limited, but otherwise fall within the “First World” or “Second World”. As this term was initially political in origin and does not accurately describe resource limited settings, it is no longer preferred.

The terms “developing” and “poor” may also be problematic. These are general descriptors, but do not give any additional information regarding an individual country’s access to resources, needs, etc. Furthermore, it again assumes that “developed” and “wealthy” countries do not need assistance. These countries may have regions within them that are resource limited. There is also the question of definitions. What is “developed”? Is being “developed” the goal for all areas? What is “wealth”? Does “wealth” always translate into well-being?

For example, in 2016, the Gross Domestic Product (GDP) of the United States was $18.5 trillion, and our infant mortality rate was 5.6/1000. In comparison, Slovenia’s GDP was significantly less at $43.9 billion, but their infant mortality rate was only 1.6/1000. Kenya, whose GDP of $70.5 billion was more than Slovenia’s, had an infant mortality rate of 35.6/1000. Thus, wealth does not always simply correlate with improved health statistics.

While there are many possible terms to designate areas in need of global health efforts, the term “resource limited setting” is the most appropriate. It does not confine the definition to political borders and it allows for flexibility in interpretation of what is meant by both resources and limited. “Culture” Terminology and Definitions The terms “culture shock” and “reverse culture shock” relate to a given individual’s personal experience when interacting, integrating, and re-integrating with a culture. These terms do not incorporate the community’s experience interacting with an individual of another culture. Furthermore, these terms encompass psychosocial changes and adjustment an individual experiences, but do not explicitly imply a desire or attempt to change a culture. While the

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stages of culture shock are recognized, they are not uniformly experienced in a specific timeline. Specific definitions are as follows:

Culture Shock: The feeling of anxiety and uncertainty that comes with entering a new culture. This may manifest as a five-stage process, including the honeymoon phase, rejection, regression, acceptance/negotiation, and reverse culture shock.

Reverse Culture Shock: The psychological process and adjustment one goes through when re-entering their own culture.

Cultural Humility: When encountering a new culture, the process of being open to learning and to new experiences, recognizing your own biases, having awareness of your own verbal and nonverbal reactions and how those reactions may affect others, and having understanding and acceptance that one cannot ever completely master another culture.

Cultural Competence: The ability to effectively communicate, interact, empathize, and integrate into another culture after achieving a mastery of that culture. This concept is now less favored, as one cannot truly master another culture. The concept of cultural humility is more appropriate.

Equity versus Equality The World Health Organization defines equity as, “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.” Reducing health inequities will over time help to reduce health inequalities. Efforts to ameliorate health inequities typically target systemic change. In this context, equity has a different meaning than in financial planning, investments and personal wealth.

For example, two houses are both situated one mile from a clinic. In this sense, they are equal. If the clinic provides financial support for transportation to the clinic, it may divide its resources 50/50 between the two houses. Let’s say, however, that the path from one house is a paved road and the path from the other house requires crossing a river that does not have a bridge. To promote equity, the clinic may then distribute 10% of its financial support to help maintain the paved road, and 90% of its financial support to build a bridge over the river. Terminology relating to Displaced Persons and Groups in Conflict

Asylum Seeker: Someone who has fled their own country and is now seeking sanctuary in another country.

Displaced person: People who have had to leave their homes due to natural, political, economic, technical, or deliberate events.

Immigrant: Someone who chooses to resettle in a foreign country.

Internally displaced person: An individual who has been forced to flee their home, but who has not crossed an international boundary.

Refugee: Someone who has been forced to flee his or her country because of persecution, war, or violence, which may be for reasons of race, religion, nationality, political opinion, or membership in a social group.

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Stateless person: Someone who is not a citizen of any country.

Vulnerable groups: Individuals who are unable to anticipate, cope with, resist, or recover from the impacts of disasters.

Sustainable Development Goals, Overview In September of 2015, 193 countries of the UN General Assembly established the 2030 Agenda for Sustainable Development, describing 17 Sustainable Development Goals. These build on the success of the prior Millennium Development Goals, and call for action by all countries. Countries are expected to take ownership to help achieve the goals, and each goal contains targets to be met over the next 15 years. The term “sustainability” specifically highlights the idea that we should address the needs of the present without compromising future generations. Goals include:

1. Poverty 2. Zero Hunger 3. Good Health and Well-Being 4. Quality Education 5. Gender Equality 6. Clean Water and Sanitation 7. Affordable and Clean Energy 8. Decent Work and Economic Growth 9. Industry, Innovation, and Infrastructure

10. Reduced Inequalities 11. Sustainable Cities and Communities 12. Responsible Consumption and

Production 13. Climate Action 14. Life Below Water 15. Life on Land 16. Peace, Justice, and Strong Institutions 17. Partnerships for the Goals

Community Health Workers Community health workers (CHWs) have long provided basic health needs to a community, notably in areas where there is a shortage of healthcare workers. This is a generalized term, and the roles and responsibilities of CHWs may vary from location to location. In general, they originate from the community in which they serve and provide healthcare in some fashion. While they generally have received training in one or more aspects of healthcare, they are not doctors, nurses, or other licensed medical professionals who have received a more formalized education.

Examples of care provided by CHWs include (but are not limited to) home visits, TB or HIV/AIDS care, treatment of acute infections, communicable disease control, nutrition counseling, surveillance, and data collection/record keeping. While there might be debate regarding which tasks are appropriate for CHWs given their level of training, they are widely considered pivotal players in healthcare delivery. Burden of Disease Burden of disease describes the impact of any healthcare condition, including acute, chronic, communicable, and non-communicable diseases and conditions. The burden is measured not simply by prevalence and incidence, but by determining the level to which a community is

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affected by that condition through DALYs, QALYs, morbidity, mortality, and economic cost. The World Health Organization initiated the Global Health Burden of Disease study in 1990 and continues to provide guidelines on data collection and measurement of disease burden. This data can be used to better target health initiatives. Health Indicators The World Health Organization identifies the top 100 core health indicators, which are measurements that can give a sense of the overall health of a community. Indicators span a wide range of topics, including health status, risk factors, service coverage, and health systems. Examples of these include infant mortality rate, hospital bed density, condom use, births attended by skilled healthcare professional, salt intake, and more. Social Determinants of Health The overall environment, setting, and place greatly influence health and well-being. These go beyond a basic understanding of disease, and instead focus on how all other conditions of an individual’s environment affect their experience with that disease. For example, an individual’s susceptibility to contract malaria is not simply the chance of suffering the bite of a mosquito infected with viable parasite, but also related to that individual’s nutritional status, housing situation, occupation, and personal education on mosquito avoidance. Key Players and Common Acronyms

CDC: Centers for Disease Control

DALY: Disability adjusted life years

LICs, LMICs, UMICs and HICs: Low income country, low-middle income country, upper-middle income country, and high-income country

MSF: Médecins Sans Frontières, also known in English as Doctors Without Borders

NCDs: Non-communicable diseases

NGO: Non-governmental organization

NPO: Not-for-profit organization

SGDs: Sustainable Development Goals

WHO: World Health Organization

WTO: World Trade Organization

For more definitions, see: http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf

A B

C D