Elective Portfolio - Awarded the Vandervall Elective Prize

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Elective Portfolio Felicity Jones

A Functional Adult Literacy group, learning applied basic language and numeracy skills – Courtesy of Afrinspire

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Contents Page Diary and Personal Reflections (Word Count =1,027)

3-4

Career Research and Reflections (Word Count =1,043)

5–8

Global Health Essay (Word Count =1,017)

9 - 11

Personal Safety, Health and Wellbeing (Word Count =1,030)

12– 16

Final Aims and Objectives (Word Count =193)

17

Account of Elective plans (Word Count = 807)

16 - 21

A group of workers of all ages who have teamed together in rural Uganda to form a labour force.

– Courtesy of Afrinspire

N.B. All reference lists and tables containing fewer than 200 words have not been included in the word counts, as per research article standards.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 1: Diary and Personal Reflections

“The world is a book, and those who don’t travel read only one page” – St Augustine Initial Decision-Making My elective has been an aspect of the medical curriculum that I have looked forward to with great anticipation. Even before coming to medical school I had highlighted the placement as an experience that would allow me to grow as an individual as well as a future doctor, and an opportunity to explore another culture and healthcare system, which excited me as I love travelling and learning about new places and people.

My enthusiasm for the elective was largely shaped by awareness that my interests in medicine are unusual. Throughout medical school I have been intrigued by the societal influences on health, and challenged by the health inequities that exist both within and between countries. I have also engaged with medical leadership, advocacy and education.

Therefore I saw the elective as providing a unique opportunity to explore these areas further.

One of the main challenges in my initial decision-making was to determine which of these areas I should focus upon. As someone with a keen interest in global health, I was initially determined to maximise the opportunity to spend time overseas.

However, I was unsure how to divide my time between clinical and non-clinical opportunities. I am fortunate enough to have already undertaken a month’s internship in an A&E in Sangolqui, Ecuador in my second year, and have taken advantage of the opportunity to carry out my Obstetrics and Gynaecology peripheral overseas, in Cape Town, South Africa, so would have already gained a significant amount of overseas clinical experience by the time I went on my Getting close to local wildlife after elective. a day at the hospital (Ecuador) As a past member of the National Global Health Education Project, I was also concerned about the ethical issues surrounding clinical work overseas, in particular the burden the visiting student places upon the host healthcare system. I was determined to try to make a positive impact through offering something in addition to ‘hands on’ assistance, such as teaching or research support.

Researching and Developing my Ideas After these initial considerations I decided to research the possibilities available to me. I utilised my contacts working in global health to consider a range of possibilities, and through discussions, became increasingly convinced that I would like to conduct some global health research. I asked the CEO of Afrinspire, a development charity of which I am a trustee, whether I could travel with them on their annual month-long public health research tour of Uganda and conduct some research on an aspect of healthcare provision of my choice, under their supervision.

As I had already been highly involved in the charity without the opportunity to see their projects in action, I thought this would provide an excellent opportunity to combine capacitybuilding of the charity with some meaningful research, and then spend a month in a local hospital on a clinical placement.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

I explored the options by reading about and speaking to students who had done research on the tour in the past to gain a more thorough understanding of what it would be like to be in Uganda for both the tour, and for four weeks afterwards. After listening to their experiences and those of others who had spent their elective in Uganda, through events such as the Medical Physical Society’s Elective evening, and reading accounts through books such as ‘Overseas Clinical Elective’ I became increasingly concerned about the idea of spending the second half of my elective attached to a hospital in Uganda without any western colleagues. I learned that many other students had experienced significant difficulties in this situation, and felt unsupported, miserable and lonely, and I was not so naïve to think I would be immune.

Celebrating the end of the global health conference with the national team. I’m still wearing my uniform from the weekend!

Having organised a National Global Health Conference in Cambridge (GHC11: ‘The Mad and the Bad – the diseases that noone talks about’) I had been fortunate enough to learn about the lack of sustainability associated with student electives. I therefore conducted further research into ethical challenges of clinical electives, through methods including attending the ethical electives symposium at the KCL global health day, and participating in a ‘Working Overseas Ethically as a Student’ workshop in New York, and this only strengthened my conviction that I did not wish to undertake more clinical work overseas.

An Evolving Plan Therefore, I decided to re-evaluate my aims for my elective. Within clinical medicine, I have found my interests gravitating towards the needs of our ageing population, and the huge health policy issues surrounding this area. I thoroughly enjoyed my geriatrics placement, but found it very short, and was interested in the community provision of care, which we had relatively little opportunity to experience.

Less obviously ‘exciting’ though such a placement would be, I realised that undertaking a community geriatrics placement in the UK would not only offer more relevant experience in helping me to pursue my career options, but also prove personally and financially beneficial, as the research tour would be expensive (over £3,000) and exhausting. Therefore I asked a number of geriatricians and geriatric services if I could undertake a placement with them, and whilst many fell through I eventually found a Christian charity which provides a unique combination of community-based care for the elderly where I could primarily be based.

Personal Reflections Organising my elective has given me the opportunity to reflect on my aspirations for the future and how best to improve my understanding of different career pathways before I graduate. It has required effective time-management and organisation skills, and a lot of perseverance when following up with grant applications or placement requests, which has at times been challenging, particularly on top of other commitments. In addition to enhancing these skills, I have already learnt a lot about health care provision in Uganda, and different models of geriatric care provision through training days and background research. I have also begun to develop new research skills and techniques, learning about methods such as how to design semi-structured interviews. These are skills and areas of knowledge I will develop and build upon throughout my elective.

Reference: Adomat, R. (1997) Overseas Clinical Elective: A Survival Guide for Healthcare Workers. Oxford: Blackwell Science.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 2: Career Research and Reflections “If I don’t know where I am going, how will I know when I get there?”

- Anon Introduction I am a planner, someone who likes to be in control of herself and her future, and therefore I have comprehensively explored a range of career options. Through medical school I have learnt a lot more about myself and my interests, and my elective will provide me with a valuable opportunity to develop these further.

My Journey through Medical School: Learning more about Myself Motivations for entering Medical School I, like many medical school applicants, could have summed up my reasons for applying almost as simply as saying ‘I want to help people, and science is interesting’. Voluntary experience had only confirmed to me how rewarding such a career could be. But of course, we rapidly realised we had to reshape these motivations into an admission-tutor-friendly package!

Finding myself in the fortunate possession of four offers, I had to question my motivations and what it was that I wanted out of medicine, and a medical school. I knew I would struggle with the research-orientated, traditional course at Cambridge, but hoped that it would offer some academic weight if I pursued an interest in medical education, and that the small-group supervisions and the interesting contemporaries I would meet would outweigh any disadvantages of studying there.

My Time at Cambridge As I had anticipated, I did struggle with the heavy science, particularly when it didn’t seem relevant to my future career as a medic. For example, I found myself poorly motivated to learn about drugs which had never been used clinically, even if their mechanism of action was novel. I began to realise that it is when science is applied to improving quality of life that it most interests me,; I enjoy it much less in the abstract.

I found that I was much more interested in the ‘arts’ of medicine than my course-mates. I enjoyed the sociology course that many derided, was disappointed that there wasn’t more focus on communication, ethics, and ‘softer skills’, and pursued a multitude of extracurricular, non-scientific interests in global health, social justice, and the welfare of students.

In comparison to my contemporaries, I found that I am interested in the big picture and less so in specific details. I am quick to extract key messages and to relate broad concepts to one another, and enjoy designing high-level strategies and managing teams. This ‘big picture’ focus explains my interest in the patient over the molecule, and in society over the patient.

Thus my time at Cambridge helped me to learn more about myself and appreciate my strengths and weaknesses. These are all key findings when thinking about future careers.

They suggest I would be suited to a broad specialty that relates closely to society and policy issues. They suggest I might enjoy service design and medical leadership and management more than many of my contemporaries.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

My Time at King’s My time at King’s has been challenging for a whole new set of reasons. I found the hospital environment chaotic, and felt unable to anticipate or prepare myself for the demands that might be made of me – a lack of control which unnerved me.

I longed for the opportunity to make proper relationships with clinicians and patients; throughout my time at my small school and Cambridge I was personally known to many of the staff, and reflecting on why I didn’t like moving around between firms, I realised I missed the security of working with those who I understood, and who understood me. Being quite shy, I found constantly having to approach patients and doctors to ask for their time and assistance difficult; as someone who went into medicine to lighten other’s burdens, being a burden myself seemed ironic, and didn’t come easily, particularly outside of the context of an ongoing relationship.

I also came across many clinicians who were poor role models, who didn’t seem compassionate about their patients, didn’t want to teach and didn’t understand my motivations for medicine.

However, as I continue through the course, I am gaining confidence and understanding of clinical environment, which helps me to prepare and understand what is expected of me. I feel I now have a foundation upon which I can draw when asked unexpected questions, and some rudimentary skills I can offer a foundation doctor in return for teaching, so I can work to build mutually-beneficial relationships.

Through confronting my difficulties in the hospital I have appreciated my need for structure and support in chaotic environments, and thus realised that I would be better suited to a largely outpatient or community-based specialty. Additionally I would enjoy working in a multi-disciplinary team with patients with chronic conditions, so I can build the long-term relationships I relish.

Researching Careers: After reflecting on my medical school experience and the challenges I have faced I drew on my past experiences (see tables below) to consider how they might shape my career choices going forward. I also considered which careers my personality (below) might be suited to, and researched a range of career choices (see reference list).

I discussed career options with a consultant I admire who balances a clinical and global health career, and engages in policy, research and medical education, which was very helpful in exploring less conventional routes through medicine.

Assessing and Understanding my Personal Qualities and Characteristics Method Sci 59 Developing my CV and Portfolio Feedback from Clinicians Personal Discussions

Details A personality and assessment test available to BMA members.

Required to apply for my elective and for grants.

Helped me more accurately assess my own performance.

Talked to junior doctors with similar interests, and members of the British Geriatric Society.

Learning Points I developed a greater understanding of the work environment and challenges that might suit me in the future.

This helped me to review my interests and strengths and weaknesses.

Feedback encouraged me that I consistently underestimate my ability.

I understood to what extent they share my frustrations with medicine and how this has informed their career choice. Helps me to consider whether I have similar aspirations.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Voluntary Additional Medical Experiences that Have Shaped My Career Choices Experience

Details

Learning Points

Disabled Children Volunteer Belarusian Hospice Stroke Work Experience Volunteer on a Geriatrics Ward A & E Volunteer in Ecuador Kerala Palliative Care

3 years voluntary work in the UK prior to medical school.

2 three week volunteer trips in 2007 and 2009.

1 week shadowing in Chichester Hospital.

Weekly for a year at Worthing Hospital.

1 month in second year.

Mostly menial tasks.

3 days shadowing a community team.

I enjoy working with individuals with chronic conditions. I was challenged by not understanding the children’s conditions.

I enjoy caring for those in this important stage of their lives in a multi-disciplinary team.

I relished the close interactions with the patients and seeing them improve over the week.

A multi-disciplinary, holistic approach is key in this population, who often have co-morbidities.

I was struck by differences in our health systems which sparked my interest in global health.

India has community-outreach teams for those with chronic conditions which we can learn from.

Extracurricular Experiences that Have Shaped My Career Choices Experience

Details

Learning Points

Medsin National President Advocacy & Leadership Coordinator British Geriatric Society Junior Representative Health Links Literature Review AMEE Conference Team Member

1 year leading a student global health network.

Ran a 4 day conference for 75 international medical students.

Representing students and junior doctors on the trainees council.

Conducted a systematic review and prepared it for publication.

Helped run the Medical Education Conference.

Attended sessions.

I enjoy leading and managing organisations. I developed my interest in health policy.

I enjoy designing curricula and training. I developed my facilitating and presenting skills and learnt about other cultures.

I learnt a lot about training pathways within geriatric medicine and the possible introduction of community-based training options.

I developed research skills in finding and analysing both quantitative and qualitative data.

I found I don’t particularly enjoy research.

I enjoyed learning about curriculum-planning and novel teaching methods for ‘soft skills’. This confirmed my passion for medical education.

Conclusion & Future Plans My career thoughts have developed significantly over time. To me now, medicine is about more than just helping the individual patient, my initial aim when I entered medical school.

I now believe that there is a need for doctors to engage in advocating for the needs of the most vulnerable, to conduct further research into the social determinants of health, and to work with other disciplines to develop comprehensive, equitable and evidence-based health and social care policy. I now know that these are areas I would like to engage in, and whilst I haven’t worked out exactly how this will combine with my interest in geriatrics, I am excited by the possibilities the future holds.

I will also be using future experiences to help me refine and reshape this vision, by finding an independent GP placement that will foster these interests, by taking the opportunity to understand better South Africa’s healthcare system through my peripheral placement, and by utilising my elective to explore community-based models of care, and the future of geriatrics.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Reference List of Resources Consulted Events

Academic Foundation Programme Events (October, KCL MSA Event) RSM Careers Fair (November, RSM, London) GKT Careers Day (January, KCL Medical School Event) Books Richards, P. Living Medicine: Planning a Career, Choosing a Specialty. (1990). Cambridge: Cambridge University Press. So you want to be a brain surgeon? 3rd Edition. Oxford: OUP. Hastie, A., Stephenson, A. Choosing General Practice: Your Career Guide. (2008). Oxford: Blackwell Publishing.

Hill, E. So you want to be a medical Mum? (2008). Oxford: OUP.

Websites www.medicalcareers.nhs.uk www.mmc.nhs.uk www.gprecruitment.org.uk www.support4doctors.org BMA & BMJ online careers resources

A group of the Batwa, a rural tribe in Uganda, after a community healthcare and sustainable agriculture training programme - Courtesy of Afrinspire

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 3: Global Health Essay “To What Extent is Uganda prepared to face the challenges of an ageing population?”

Background: Uganda’s Health System In 2006, Uganda’s healthcare expenditure amounted to $25 per capita. This tiny sum amounts to 8.2% of Gross Domestic Product (GDP). Despite increasing expenditure, Uganda’s healthcare performance is still ranked as one of the worst in the world by the WHO (186th out of 191 nations in 2009). In a country with such limited healthcare funding, how can healthcare be provided to a growing and ageing population?

The Ugandan healthcare sector is a complex set of public-private partnerships, with key players including the ministries of health and finance, PEPFAR funders (the U.S. President's Emergency Plan for AIDS Relief) and CHAI (The Clinton Health Access Initiative). Funding comes from three primary sources: out-of-pocket expenses (37.9%), governmental spending (33.6%), and external sources (28.5%).

Healthcare is coordinated by The Ministry of Health, a government body mandated to develop research, form policy and provide quality assurance and monitoring and evaluation, and is delivered at seven levels. The highest level is the National Referral Hospitals, which provide comprehensive specialty care, research, education and training to a population of 27 million.

Regional referral hospitals provide some specialty care and outreach to approximately 2 million, and below these health centres (level I to IV) provide services ranging from prevention and health education (I) to emergency and treatment services (IV).

Healthcare Access and Inequities In a country in which many live under the poverty line, it is perhaps unsurprising that the eradication of user-fees at governmental health facilities in 2001 resulted in an 80% increase in visits to health-services. However, health access and health inequity across regions and different populations remain significant challenges. For example, life expectancy in some districts exceeds 60 years, whereas in others it is less than 30.

This is in part due to geographical location of healthcare facilities, which are strongly centred around the capital, Kampala. For example, 16 of the 80 districts in Uganda have no hospital, whilst there are 8 in Kampala. In Kampala there is a facility per 5,295 people, whilst the national average is 1 per 8,785 people and in some rural districts there is less than 1 facility per 20,000 of the population.

The inequitable distribution of healthcare infrastructure is mirrored by other civil infrastructure such as roads, and exacerbated by the failure to seek care in some regions, particularly the central and east areas. This is thought to be partially due to lack of healthcare education, and partially due to insufficient medication supply in state facilities, forcing patients to purchase medication from private pharmacies at unaffordable expense.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Key Public Health Challenges Facing Uganda

Like many developing countries, Uganda is plagued by a significant communicable disease burden, including HIV, TB, and the neglected tropical diseases. HIV in particular presents significant healthcare challenges. Services for prevention and treatment of HIV are limited despite the high prevalence rate of 6.4%, with only a third of health facilities able to test for the condition. However the strong political leadership in this arena established a national AIDS Control Programme (ACP) in 1986 with a mass education ABC program to reduce HIV prevalence and free antiviral drugs since 1994. The Uganda AIDS Commission (UAC) was set up in 1992 to further develop and implement policy and guidelines, and coordinate provision.

Maternal and infant mortality also presents a significant issue. Despite reductions in the Infant Mortality Rate (IMR) from 88 to 63 per 1,000 from 2000 to 2010 many children continue to die from preventable conditions such as childhood infections, and maternal mortality and morbidity rates remain high as a result of a failure to address physical, sociocultural, and financial obstacles to reproductive health services.

Donor support of the Ugandan healthcare system has focused on the infectious diseases. This has failed to address the growing burdens of conditions such as cancer, diabetes and heart disease. Uganda NCD Alliance (UNCDA was founded in 2010 to provide a strong and coordinated effort to tackle these conditions through advocacy and patient empowerment.

Thus, despite a range of external and in-country responses, both communicable and noncommunicable diseases present significant threats to the Ugandan population. The healthcare system, particularly in rural areas, is insufficiently equipped to respond to these challenges.

Current Elderly Care Uganda’s elderly suffer from a wide range of conditions, including stroke, cancer, dementia, and chronic respiratory and orthopaedic conditions. Sense impairment through cataracts and other visual and hearing problems is also common.

Despite poor health, the elderly frequently receive limited support from their relatives and communities, particularly those ravaged by HIV, and often face neglect, isolation and chronic poverty. They are also poorly served by the healthcare system due to poor mobility making facilities inaccessible, lack of geriatric expertise and negative attitudes towards the elderly.

These problems are exacerbated by limited regular income as assets are usually sold in younger life and social pensions are only available for those who have worked for the government, by exclusion from development and micro-financing programmes and a lack of political representation: the elderly are still not recognised as a marginalised group by article 32 of the constitutions and thus are not represented in Parliament.

Thus poor health is exacerbated by Ugandan socio-cultural values and political systems.

Combined with the wider healthcare inequities of geographical distribution, 85% of those older persons in rural areas live in absolute chronic poverty.

Conclusion Uganda’s healthcare system is weak and there is insufficient funding to deliver adequate health services to the current population. Uganda faces significant public health challenges; the growing double burden of disease, a weak and poorly-coordinated healthcare system and inequitable structural coverage for rural areas. The rapidly growing and aging population, a result of Uganda’s low contraceptive prevalence and high fertility (6.1 per woman), is only likely to increase these challenges.

The elderly population is currently marginalised due to cultural attitudes, poor health and lack of social support and political representation. The creation of the Aged Family Uganda (TAFU), a national non-government organisation that aims to advocate for and support older peoples in Uganda provides significant hope for this vulnerable group.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

References Briggs, P. 2010 Uganda Bradt Travel Series United Nations Population Division. World Population Report 2009. Accessed 18/03/13.

Available at www.unpopulation.org.

Uganda Population Census Report 2002. Kampala: Uganda Bureau of Statistics, 2002.

Uganda Demographic and Health Survey (UDHS). The Uganda Demographic and Health Survey Report 2006. Kampala: Uganda Bureau of Statistics, 2006.

Chronic Poverty Research Centre in Uganda, Targeting and protecting the chronically poor in Uganda: A case for the elderly, Policy Brief No 3/2006 Development Research & Training (2008). Ministry of Health; Report of the Mid-term review of the Health Sector Strategic Plan 2005/05 – 2009/10;. Kampala, Uganda: Ministry of Health.

Okwero, P., Tandon, A., Sparkes, S., McLaughlin, J., & Hoogeveen, J. G. (March 2010).Fiscal Space for Health in Uganda – World Bank Working Paper No. 186. Washington, D.C.: The International Bank for Reconstruction and Development / The World Bank.

Health Facilities Inventory. (2006). Kampala, Uganda: Ministry of Health.

The Elimination of User Fees in Uganda: Impact on Utilization and Catastrophic Health Expenditures. (2005). Geneva, Switzerland: World Health Organization.

Uganda Reach the Aged Association, Age Demands Action. Statement to H.E. President Yoweri Kaguta Museveni on the plight of older persons in Uganda on the occasion of the International Day for Older Persons on 1 October 2007 with support from Help Age International.

Uganda Chronic Poverty Report (2005). Available through the World Health Organisation.

UNFPA, State of Uganda Population Report (2005). Available through the World Health Organisation.

Orphans, who lost their parents to AIDS - Courtesy of Afrinspire

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 4: Personal Health, Safety and Wellbeing “A desire to be in charge of our own lives, a need for control, is born in each of us. It is essential to our mental and physical health, and our success, that we take control.”- Robert Bennett Introduction It is essential to undertake a thorough review of health and safety risks that travelling overseas or staying in an unfamiliar part of London might pose, in order to prepare for and reduce the risk where possible. Therefore I have visited my GP, spoken to students who have visited Uganda and lived in similar areas of London, and revised online advice.

General Health Precautions (I will undertake these in both Uganda and London)

      

Take a medical information sheet with all relevant information to pass on to local medical services in case of illness or emergencies Bring personal first aid supplies Carry a mobile phone with telephone numbers for local medical facilities Take basic hygiene precautions such as washing hands frequently and carrying antibacterial hand sanitizer Only consume water and food from trusted sources (in Uganda this means only utilising boiled or bottled water and avoiding ice in drinks.)

Stay away from all animals and go to hospital immediately if bitten.

Drink plenty of water, wear sun cream and a hat to reduce risk of sun stroke.

Additional Major Health Concerns in Uganda The FCO advises that there are a number of additional significant health and safety risks in Uganda. I have discussed safety concerns in a later section.

Most of the health risks are presented by infectious diseases, and therefore it is important to try to prevent exposure to pathogens and vaccinate against these conditions where possible. However, not all conditions can be protected against, and indeed last year outbreaks of Ebola haemorrhagic fever prevented many KCL students from completing their Ugandan elective. Therefore I will ensure that I check the FCO Website for advice up to and during my elective.

Health Issue 1: Vaccinations The travel websites, medical resources and my GP advise that vaccine preventable risks are: yellow fever, cholera, diphtheria, hepatitis A &B, TB, meningococcal meningitis, polio, rabies, tetanus and typhoid. I will therefore arrange to have all boosters and vaccines at least 8 weeks before departure, and ensure I have my yellow fever certificate. All vaccinations can be given by my GP or local travel clinics.

Health Issue 2: HIV HIV prevalence is estimated at around 6.5% (approximately 1,000,000 adults aged 15 or over) in Uganda by the FCO. As I am not undertaking any clinical work in Uganda I am unlikely to risk needlestick injury. However, I will take an emergency PEP kit and report any needle stick injury or similar incident.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Health Issue 3: Malaria Precautions that the group will take against malaria include wearing insect repellent, long sleeves and trousers at night, and using mosquito nets.

In addition it is essential to bring adequate anti-malarials for this trip; as shown on the map from ‘Fit to Travel’ below, travelling throughout the vast majority of Uganda leads to a high risk of contracting malaria.

Atovaquone/proguanil or doxycycline or mefloquine are recommended for Uganda, as chloroquine resistance is widespread.

Having discussed the options with my GP I have decided to purchase a full course of malarone to avoid the side effect profile associated with the other drugs. I will also take several spare tablets and store these separately, in the unlikely instance of losing some of my tablets.

If I develop a fever of 38°C or higher more than one week after the trip I will seek immediate medical care.

Health Issue 4: Other Viral and Parasitic Diseases Dengue Fever is not currently reported in Uganda but remains a risk. Therefore I will take mosquito bite avoidance measures.

Schistosomiasis (a parasitic flatworm infection) is present in many fresh water rivers, streams or lakes. The larvae penetrate intact skin; I will therefore avoid wading, swimming or bathing in fresh water.

Hookworms are also present in many areas of Uganda. They can burrow through feet if no protection is worn on contaminated soils. Therefore I will always wear shoes.

If I am concerned that I have been exposed to any of these conditions I will seek medical assessment.

Health Issue 5: Culture Shock Culture shock is a common issue for those travelling overseas. I will prepare myself for the mental dimensions of travel to Uganda by attending training and reading about the culture of Uganda, and make provisions for culture shock upon return to the UK.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Personal Safety Risk Assessment What hazards may arise?

What risks are associated with these hazards?

What is the risk in Uganda?

What is the risk in London?

I commit to the following measures to avoid or reduce the risk:

Terrorism

Being injured

Medium-High (Precautionar y measures reduce this.)

MediumHigh (Precautiona ry measures reduce this.)



 

Dark Streets

Being attacked

Medium-High

Low Medium

Unsafe Roads

Being injured in a road traffic accident

MediumHigh

Low-Medium

Carrying of valuable items

Theft with the potential of the use of violence

Medium

Medium

I will:

 

        

Review FCO travel advice and email alerts before and during my elective Register my details with the British Embassy in Kampala Be vigilant in public areas and avoid large gatherings e.g. political rallies.

Not travel alone at night.

Carry a rape alarm and a torch in case of a black-out in my accommodation Stay in safe accommodation (below).

Only use roads during daylight hours.

Travel measures (see below) Always wear a seat-belt.

Avoid dangerous routes Not take unnecessary valuables.

Keep valuables and cash out of sight; on my person, in a locked room or a locked vehicle Distribute cash in several locations Keep paper photocopies of key documents

Travel and Accommodation Measures I have no travel concerns about the UK part of elective.

FCO advises against all but essential travel to the North-Eastern parts of Uganda. The tour will never go anywhere near this region, and will only travel through areas which have been visited by the charity on several previous occasions.

The FCO also reports that in Uganda “Travelling on the roads can be hazardous, particularly outside the main cities. Driving standards are poor, vehicles are often poorly maintained and the accident rate is high.”

Therefore I will travel with an escorted group on the public health tour at all times. This includes travel in a privately-hired vehicle with a fully-qualified and experienced driver, and being accompanied by Ian, who has undertaken ten such tours and is very experienced in travelling safely in Africa. Transport has been arranged to and from Entebbe Airport.

All accommodation will be booked in advance. I will visit my accommodation in London to ensure it has appropriate safety measures such as working locks before I book it. All accommodation in Uganda has been utilised by the charity on previous occasions. All are accustomed to hosting international visitors and have appropriate safety measures such as a security wall. I will always share a room with other female tour members.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Emergency Contingency Planning I will carry a comprehensive first aid kit. Whilst in the UK I will be based entirely at medical units so would receive adequate medical care if required, and in Uganda I am travelling with a group with medical knowledge and knowledge of the local medical facilities. I would refuse all but essential blood transfusions. I will purchase Wesleyan travel insurance so that should I need PEP at any point whilst in Uganda it can be couriered to me. I will give my details to the British Embassy upon arrival in order that I may be alerted of any emergencies and able to withdraw rapidly if required.

Emergency Contact Details for Uganda Ian Sanderson - Director of Afrinspire and Leader of the Trip Email: iansand12@gmail.com Phone:07411931961 (UK) 00 256 785 634 544 (Ugandan Mobile) Nkamuhebwa Willy -Manager of the Development Studies Centre Email: aidts2005@yahoo.co.uk Phone: 00 256 48 520 853 (centre) 00 256 772 665 458 (mobile) British High Commission (4 Windsor Loop, P.O Box 7070, Kampala) Phone: (256)(31)2312000

Personal Health Promotion I enjoyed the opportunity to reflect on my health, risk factors and health related behaviour. I am generally fit and well, with no long-term medical conditions. I lead an active lifestyle and eat healthily. However over the last year my sleep patterns have been very erratic. Therefore I decided to use the process taught in the KCL health promotion symposium to consider how best to improve my sleep hygiene.

Step of Process

Details

Identify Health Issue Consider what needs to be addressed: - risk behaviour?

- potential/actual problem?

- protection/prophylaxis?

- disease detection/screening?

Set achievable goal Learn from previous experiences

Erratic Sleep Patterns Going to sleep very late on occasion Getting up very late at weekends and napping due to not getting enough sleep during the week Difficulties with getting to sleep due to anxiety and irregular sleep patterns Nightmares when trying to sleep due to stress Try to sleep between 7 and 9 hours every night I usually fail to sleep for this amount if: - I leave assignments to the last minute - Am very anxious - Have late night phone/ skype conversations I will tell my family friends and housemates about my plan and ask them to help me.

I will not phone friends after 9.30pm.

I will reduce my commitments next year to reduce my anxiety and stress I will mark my assignments in my diary so I don’t leave them to the last minute I will try to relax for 30mins before going to bed I shall use my elective period in the UK as a pilot to put my plan into action throughout fifth year.

Devise action plan and identify goal support (how, where, who, skills, resources)

Implement Action Plan

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

References Briggs, P. 2010 Uganda Bradt Travel Series Foreign and Commonwealth Office website. Accessed on 21/03/2013. Accessible at http://www.fco.gov.uk/en/travel-and-living-abroad/travel-advice-by-country/subsaharan-africa/uganda Masta Travel Health. Accessed on 21/03/2013. Accessible at http://www.masta-travelhealth.com/ MD Travel Health. Accessed on 21/03/2013. Accessible at http://www.mdtravelhealth.com/ National Travel Health Network and Centre website. Accessed 21/03/2013. Accessible at http://www.nathnac.org/ds/c_pages/country_page_ug.htm#non_vpr NHS Fit For Travel website. Accessed on 25/03/2012. Accessed 21/03/2013. Accessible at http://www.fitfortravel.nhs.uk/destinations/africa/uganda.aspx Ugandan High Commission, London. Accessed 21/03/2013. Accessible at, http://www.ugandahighcommission.co.uk/MenuSections/GeneralInfo.aspx

A group of Ugandan Women – Courtesy of Afrinspire

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 5: Final Plans My aims and objectives are: 1. To gain an overview of the public health needs and models of development in Uganda. I will achieve this through the research tour and questioning other tour members and those we meet.

2. To learn about and compare the needs and presentations in the elderly and their typical outcomes, between the UK and Uganda. I will do this is by engaging with elderly people and their carers in both countries.

3. To learn about different models of care provision for the elderly in the UK, particularly focusing on community provision, by visiting and asking about different methods of healthcare policy. I will then reflect and consider possible future models of healthcare provision, and implications for health policy.

4. To develop my research skills, by designing and conduct a study of communitybased healthcare provision for the elderly in Uganda, 5. To explore the role of the community geriatrician and to what extent this career pathway might suit me. I will ask those I work with about their daily routine, the variety of activities they may engage in and the training pathways through which they have reached this position.

A group of disabled adults and carers which I will be visiting - Courtesy of Afrinspire

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Section 6: Final Elective Plans Demographic and Public Health Data Public Health Data for Uganda Total Population Annual Population Growth Rate Median Population Age Life Expectancy Male Female Percentage of Population over 60 IMR (Per 1,000 Live Births) Physician Density (Per 10,000 Population) Health Care Expenditure as a % of GDP

33,425,000 3.2% 16 Years 48 Years 57 Years 4 63 1.2 8.2%

Public Health Data for England Total Population Annual Population Growth Rate Median Population Age Life Expectancy Male Female Percentage of Population over 60 IMR (Per 1,000 Live Births) Physician Density (Per 10,000 Population) Health Care Expenditure as a % of GDP

62,036,000 0.6% 40 Years 78 Years 82 Years 23 5 27.4 9.8%

Local Health Issues Key issues in Mbarara include HIV, the infant and maternal mortality rates (which at 435 deaths per 100,000 live births is one of the worst in Africa) and challenges of lack of health equity and access for all individuals, especially those in rural areas.

In comparison, London is challenged by a rise of non-communicable diseases and mental illness, a multi-ethnic population, social isolation and increasing inequity within the city.

Local Population Differences As can be seen in the data shown above, the demography of the English and Ugandan populations is vastly different, and it will be interesting to explore how this impacts upon health policy and planning for population change in the future. The Ugandan population is much more rapidly expanding, which partially explains the young median population age. The life expectancy is a whole 30 years greater for males in the UK. Therefore it will be interesting to learn about what age Ugandans perceive as ‘elderly’ and the health of the elderly in Uganda and the UK differ.

Ugandan Tour Placement and Description

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Dates: 16th July – 13th August (Travel days not included in the itinerary below) I will be travelling with a research group from the African grassroots development charity, Afrinspire.

The group will comprise the CEO of Afrinspire (Ian Sanderson), other researchers and students from the UK, and three local development experts.

The Development Studies Centre, Mbarara, where we will be based for much of the tour (please see the itinerary) During the tour I hope to learn about three key areas: 1) The Afrinspire model of grassroots development 2) Public health challenges affecting Uganda today, and the health systems and health policy changes needed to address these 3) The health needs and health services available to the elderly in Uganda 1) I am looking forward to learning from the group about Afrinspire’s unusual model of development which is community-led and sustainable, aiming to catalyse local projects.

The charity has expanded greatly in the 10 years since its inception and has been selected by the Foundation for Social Improvement (FSI) as an exceptional small charity for its affiliates programme. Therefore I look forward to learn more about its approach.

2) I will personally witness many of the health challenges faced by Ugandans today.

Visiting the water development services and community health projects will provide me with an understanding of the rural situations, and visits to tertiary health centres will show me some of the most advanced technology available in Uganda. I will try to learn from those who I meet and travel with about the current issues and limitations in health service provisions, and what their hopes and recommendations are for the future.

3) I will be supported by Ian and the other team members, with advice from several Ugandan gerontologists, in carrying out a mixed methods research study into community healthcare provision for the elderly in Southern rural Uganda. This will comprise a survey, focus groups with four sets of elderly individuals, and in-depth interviews with care providers and elderly individuals. Through this I hope to learn more about the needs of the elderly, the variation in healthcare provision in different areas and the different community programmes available.

Please see the draft itinerary on the following page. This may be subject to amendment.

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Date

Draft Research Tour Itinerary Fieldwork During Day Travel

Wednesday 17th July

Day field visit to Bugaya with Ugandan Development Services

First operational day with team

Thursday 18th July

Visit to the Joint Childcare Support Association (morning)

Travel to Mbale

Friday 19th July Saturday 20th July Sunday 21st July Monday 22nd July Tuesday 23rd July Wednesday 24th July Thursday 25th July Friday 26th July Saturday 27th July Sunday 28th July Monday 29th July Tuesday 30th July Wednesday 31st July Thursday 1st July Friday 2nd July Saturday 3rd July Sunday 4th July Monday 5th July Tuesday 6th July Wednesday 7th July Thursday 8th July Friday 9th July Saturday 10th July Sunday 11th

Visits to school, Bumunea Community health, MIDPRO Water harvesting.

Visit to Women’s Literacy and Community empowerment Programme Visit to Mbale Hospital (morning)

Travel to Kampala

Visit Community Health Programme

Travel to Mbarara

Hotel

West End Inn, Mbale West End Inn, Mbale West End Inn, Mbale Kolping Guest House DSC, Mbarara

Rest Day

DSC, Mbarara

Afrinspire Young Leaders Conference  sharing health inequity challenges Afrinspire Young Leaders Conference

DSC, Mbarara

Visit to Hornby High School for the Blind (afternoon) Visit the Foundation for People with Disabilities and Jaipur Limb Workshop Visit church outreach groups (health promotion, elderly, orphans) Day with Anne discussing/ visiting rural groups with disabilities Visit Shuuku Vocational Secondary School

DSC, Mbarara To Kabale

To Mbarara

Victoria Inn, Kabale Victoria Inn, Kabale Victoria Inn, Kabale Victoria Inn, Kabale DSC, Mbarara

Rest Day

DSC, Mbarara

Visit to Mbarara Hospital (1)

DSC, Mbarara

Visit to Mbarara Hospital (2)

DSC, Mbarara

Visit to two elderly people groups

DSC, Mbarara

Rest Day

DSC, Mbarara

Visit to public health department (afternoon) Visit to sustainable agriculture project

To Kaharo

Kaharo Hotel

Visit to Community health promotion team Morning with Zadok (gerontologist) discussing needs of the elderly Day with mobile hospice team

Kaharo Hotel

Kaharo Hotel To Mbarara

DSC, Mbarara DSC, Mbarara

Day with mobile hospice team

DSC, Mbarara

Rest Day

DSC, Mbarara

UK Placement and Description

Felicity Jones MBBS4 Student, King’s College London Elective Portfolio

Dates: 2nd -29th September I will be working with a number of different geriatric organisations and shadowing those working in both acute and community settings.

I have managed to set up a number of placements through my contacts at the British Geriatric Society but hope to be largely based around Morden College in South London.

Morden College, an independent charity supporting the elderly through an unusual range of services, in Blackheath, South London

I will also be processing and analysing the results of my research in Uganda for presentation.

During my UK placement I hope to learn about three key areas: 1) To better understand the needs of elderly individuals in the UK 2) To explore different methods of community care for this population 3) To understand the role of community geriatricians in this care provision and further consider this possible career choice 1) I hope to learn about the health needs of the elderly by interviewing and taking detailed case histories from a number of clients and exploring the role of the multidisciplinary team in meeting these.

2) I will learn about different models of care provision for the elderly in the UK, particularly through studying the unusual model provided by Morden College, a Christian charity which provides a range of services through both a residential centre and community outreach. I will engage in a range of therapeutic activities and will ask about the impact of the NHS reforms of care provision in the future.

3) I will shadow a number of geriatricians and ask them about their education and training history and current role. I will also ask for careers advice. In addition I will attend a conference in Newcastle called ‘Geriatrics for Juniors’ on the 21 st of September, which provides advice on the future possibilities of a career in geriatrics.

References: WHO Global Health Observatory Data Repository. Accessed 20/03/13. Accessible at http://apps.who.int/ghodata/?vid=20800&theme=country World Health Statistics 2012. World Health Organisation. Accessed 20/03/13. Accessible: http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf