Effective Strategies for Global Health Research, Training and Clinical Care: A Narrative Review

The purpose of this narrative review was to synthesize the evidence on effective strategies for global health research, training and clinical care in order to identify common structures that have been used to guide program development. A Medline search from 2001 to 2011 produced 951 articles, which were reviewed and categorized. Thirty articles met criteria to be included in this review. Eleven articles discussed recommendations for research, 8 discussed training and 11 discussed clinical care. Global health program development should be completed within the framework of a larger institutional commitment or partnership. Support from leadership in the university or NGO, and an engaged local community are both integral to success and sustainability of efforts. It is also important for program development to engage local partners from the onset, jointly exploring issues and developing goals and objectives. Evaluation is a recommended way to determine if goals are being met, and should include considerations of sustainability, partnership building, and capacity. Global health research programs should consider details regarding the research process, context of research, partnerships, and community relationships. Training for global health should involve mentorship, pre-departure preparation of students, and elements developed to increase impact. Clinical care programs should focus on collaboration, sustainability, meeting local needs, and appropriate process considerations.

in resource-constrained settings differs dramatically from resource-rich settings (Furin et al., 2006). While there is a great deal of published literature on ethics, guidelines and models for global health, no systematic review on effective strategies exists. Disease specific reviews are more common than reviews on effective strategies for research, training and clinical care across diseases and cultures.
The purpose of this systematic review is to synthesize the evidence on effective strategies for global health research, training and clinical care in order to provide common structures that have been used to guide program development. Articles included in this review focused on ethics, guidelines and models for global health as defined by the Institute of Medicine where "health problems, issues, and concerns that transcend national boundaries, may best be addressed by cooperative actions" (Institute of Medicine, 1997). Public and private efforts, theoretical and practical frameworks, and existing and new programs were also included.

Materials and Methods
Medline was searched for articles published from January 2001 through December 2011 using a reproducible strategy. Three broad searches were conducted, the first using the term global health, the second using the terms global health and training, and the third using the terms global health and academic medicine. Duplicates were removed, producing 951 citations. Titles and abstracts were reviewed to determine whether articles were obviously ineligible, for instance focused on a review of global health efforts on a specific disease. Abstracts were also reviewed to determine whether articles addressed training, education, medical care, or collaboration in global health. This produced 204 articles for full review.
Full articles were read by two reviewers and categorized into project guidelines/ethics (103 articles), program models (57 articles), and training projects (44 articles). Eligibility of articles was determined by two reviewers and categorized into one of three overarching categories of recommendations: research (11 articles), training (8 articles) and clinical care (11 articles). This produced 30 articles for inclusion in the manuscript.
The context of each article and recommendations made by the authors were summarized. A table was compiled for recommendations from each of the main overarching categories: research, training and clinical care. After all articles in a category were read and summarized, recommendations were reviewed for themes within the three overarching categories. Two reviewers categorized each recommendation into a theme and compiled implications for each category and overall. Six tables were produced to display summarized recommendations and themes present in each article.
Eight articles were reviewed regarding effective strategies for training (Table 3). One article focused on training within the host country (Leonard, 2002), four articles were based on lessons learned from multi-institutional experiences (Rojas et al., 2007;Spiegal et al., 2011;Elit et al., 2011;Provenzano et al., 2010)., and three articles were based on development of new training programs or guidelines for development of programs (Furin et al., 2006;Redwood-Campbell et al., 2011;Crump & Sugarman, 2010). Six of the eight articles gave recommendations for preparation of students, four commented on the importance of long term commitments, four noted aspects used to increase impact, and three stated the need for mentorship (Table 4).
Eleven articles were reviewed regarding effective strategies for clinical care (Table 5). Five articles were based on academic-national partnerships (Babich, Bicknell, Culpepper, & Jack, 2008;Quinn, 2008;Curioso et al., 2010;Crump & Sugarman, 2008;Suchdev et al., 2007), four were based on NGO-national partnerships (Pfeiffer, 2003;Van den Broucke et al., 2009), and two were based on a local service location ( Green et al., 2009;Cheah et al., 2010;Vidyasager, 2009;Sarriot et al., 2004). Nine of the eleven articles commented on collaborations/partnerships, seven commented on sustainability/capacity, seven commented on the meeting local needs, and five commented on process details such as training, evaluation or providing resources (Table 6).

Effective Strategies for Research
Many of the articles reviewed focused on ethical considerations or frameworks for research, rather than on a specific global health research initiative, however, six of the eleven noted important process considerations when conducting research projects. First, the need for appropriate funding to allow for all phases of the research and capacity development in the host country was discussed (Treloar & Graham, 2003;Tugwell et al., 2006). Treloar and Graham (2003) noted the importance of standardization when conducting qualitative research due to the inexperience of most researchers with the methodology (Treloar & Graham, 2003). Lack of standardization, particularly when working with a multidisciplinary approach, can lead to inconsistency in implementation as well diminishing motivation in process utilization (Treloar &Graham, 2003). However, it was also noted that research projects need to allow for flexibility to ensure investigators can respond to needs and concerns, specifically of the community (Treloar & Graham, 2003;Simon et al., 2007). Simon et al. (2007) found that keeping a flexible design to allow for input and cooperation of the community can help address ethical concerns of conducting research on vulnerable populations (Simon et al., 2007). Providing appropriate amounts of information to ensure research goals are clear, and informed consent is truly informed is also important (Lavery et al., 2010;Macrae, 2007). Additionally, it was found that development of a community advisory board promotes more effective communication and enables dissemination of research goals while also addressing community needs (Simon et al., 2007). Lastly, Nishtar (2004) discussed the importance of transparency for appropriate development of policies and procedural frameworks based on the research (Nishtar, 2004), noting that third party accountability has a key role in the effective utilization of global policies and frameworks for effective research procedures (Nishtar, 2004).
The second recommendation for global health research was consideration of the social, political, and economic context. Mosavel et al. (2005) noted that the research context is important to consider in order to work alongside policy, rather than in opposition to it (Mosavel et al., 2005). It also assists in addressing the tension between research and service delivery that can lead to ethical challenges (Mosavel et al., 2005). Recognition of the complexity of the situation provides exploration of possible pathways to impact the research concern, rather than simply addressing one problem (Huynen et al., 2005). Additionally, providing for continued discussion when developing research plans, recognizes the importance of respect and collaboration with the community, and develops a research process, rather than a single project focus (Simon et al., 2007;Tugwell et al., 2006). This further enables cultivation of a collaborative forum wherein both researcher and host country are given a voice to shape real community needs while also generating knowledge to address health outcomes (Simon et al., 2007). Techniques such as dissemination into national or regional journals, rather than only international journals provides for more policy and practice impact in the host country, and integration of research into health programs develops capacity of the community and host institution (Costello & Zumla, 2000;Tugwell et al., 2006). Recognizing that the research should benefit society rather than the partners and posing minimal risk to vulnerable populations by taking into account expected therapeutic results are also important aspects of considering the context upfront to make the most impact (Nishtar, 2004;Macrae, 2007).
Capacity of the host country was continually mentioned in articles regarding effective global health research strategies, however, not all defined capacity in the same manner. A portion of the articles focused on capacity of the research partners in the host country, and the importance of collaboration and interdisciplinary work. Rojas et al. made a case for promoting development and sustainability of capacity by using available resources in the host nation, discussing designs and ethical issues, and assigning the bulk of funding to the resource-poor country (Rojas et al., 2007). Costello and Zumla (2000) also noted the importance of line management of funds in the local institution, as well as providing advice and technical support (Costello & Zumla, 2000). It was recommended to promote the collaborative process by assigning specific roles to each partner and holding regular meetings to gather feedback (Rojas et al., 2007;Nishtar, 2004). The necessity of drawing from multiple fields, such as medicine, epidemiology, sociology, political science, education and economics, was also suggested as a way to get the best research product, while also building partnerships with the host country (Huynen et al., 2005). Nurturing partnerships and building trust through shared decision making, joint priority setting, and developing national research networks was recommended (Costello & Zumla, 2000;Tan-Torres, 1999). strengthening relationships with stakeholders. Mosavel et al. (2005) recommended inviting local critique and feedback, and involving non-mainstream community members to accomplish this end Mosavel et al., 2005). Providing opportunities for community questions and training community members to help conduct the research were regular suggestions to build rapport and trust (Simon et al., 2007;Mosavel et al., 2005;Lavery et al., 2010;Tan-Torres, 1999). Additionally, engaging community members and utilizing collaborative processes unveiled underlying determinants of poor health while in turn empowering community members to further engage in health promotion (Simon et al., 2007). Strategic selection of sites, seeking to understand perceptions rather than just measure them, and working to respect dissenting opinions in the community were noted by Lavery et al. (2010) to both build capacity and establish relationships (Lavery et al., 2010). Lastly, increasing translation and impact through appropriate knowledge sharing, and packaging of results was necessary for developing capacity in low and middle income countries to develop equity research (Tugwell et al., 2006).

Effective Strategies for Training
Most articles categorized as addressing training were focused on the students and training program, with only one article focused on training within the host country. Using a comparison between NGOs and government health care systems, Leonard suggested systems should allow flexibility and invest in organizational quality (Leonard, 2002). Based on the recommendations, training of staff should result in increasing the reputation of the government health care system. The importance of completeness of examinations, appropriate use of laboratory tests, and attentiveness to the client and health education should be addressed in training for staff (Leonard, 2002).
The importance of institutional commitment and long-term partnerships were discussed in four of the articles (Scarlett et al., 2011;Spiegel et al., 2011;Provenzano et al., 2010;Crump & Sugarman, 2010). Institutional commitment was recommended as necessary for success and sustainability of initiatives, allowing for continuity and establishment of networks (Spiegel et al., 2011). It was also recommended to ensure experiences are meaningful, ethical, and relevant to the local community (Spiegel et al., 2011;Provenzano et al., 2010;Crump & Sugarman, 2010). Scarlet et al suggested using previous institutional relationships to build a mutually beneficial program (Scarlett et al., 2011). The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) recommends well-structured programs in order to delineate roles and responsibilities, ensure benefits are mutual, and promote transparency and safety (Crump & Sugarman, 2010). Recognition of true costs and fair and appropriate compensation are both noted as important to this process (Provenzano et al., 2010;Crump & Sugarman, 2010).
Four articles commented on specific aspects of the program used to increase impact. Two commented on the importance of a clear vision (Spiegel et al., 2011;Redwood-Campbell et al., 2011) and two noted the use of field experiences (Scarlett et al., 2011;Furin et al., 2006). Spiegel et al. (2011) emphasized the importance of a vision to keep the focus on application of knowledge and allow for evaluation of intended outcomes (Spiegel et al., 2011). Core values and principles can also be used as a background context for competencies when developing a curriculum (Redwood-Campbell et al., 2011). Furin et al. (2006 developed strategic field experiences to increase the impact of didactic teaching provided in a resident training program (Furin et al., 2006). Similarly, Scarlett et al. (2011) used a diversity of field visits and teamwork to teach team-based work and the importance of a cooperative learning environment (Scarlett et al., 2011).
Mentorship was noted as an important aspect in three articles. Furin et al. (2006) stated that mentorship was the most important program element (Furin et al., 2006). It was suggested to establish mentorship at both the university and local setting in order to balance or reverse the drain on local resources commonly seen in short term trips (Elit et al., 2011;Crump & Sugarman, 2008). Mentorship would also provide for structured debriefing and facilitate communication (Elit et al., 2011;Crump & Sugarman, 2008).
Preparation of students was the most commonly mentioned recommendation in the articles reviewed. Specific topics to include in pre-departure training varied, but some topics were consistent including ethics, cultural competency, and language fluency (Furin et al., 2006;Elit et al., 2011;Provenzano et al., 2010;Crump & Sugarman 2010). In addition to building a knowledge base, articles also noted the importance of teaching skills such as advocacy, operational management, critical thinking, and problem-solving (Scarlett et al., 2011;Furin et al., 2006;Redwood-Campbell et al., 2011). A number of articles also commented on the importance of selecting the best applicants by including consideration of a participant's performance, motivation, experience, personal character, and willingness to listen and learn (Furin et al., 2006;Elit et al., 2011;Provenzano et al., 2010;Crump & Sugarman, 2010).

Effective Strategies for Clinical Care
Articles categorized as addressing clinical care commented on four major topics: collaboration/partnerships, sustainability/capacity, meeting local needs, and process specific recommendations. The vast majority of the articles commented on the need for mutually beneficial partnerships involving commitment to collaboration and equitable relationships. Authors noted the importance of trusting and respectful professional relationships (Green et al., 2009;Pfeiffer, 2009), strong and sustained leadership (Green et al., 2009;Quinn, 2008;Curioso et al., 2010), and the need to ensure programs were beneficial to both institutions and stakeholders (Babich et al., 2008;Crump & Sugarman, 2008;Vidyasager, 2009). While each article noted recommendations to accomplish this in specific settings, most projects would benefit from improved communication (Babich et al., 2008;Quinn, 2008;Vidyasager, 2009), and development of partnerships across various levels ( Van den Broucke et al., 2009). When considering on-the-ground efforts, Babich et al. (2008) noted the importance of a visible and widespread presence through small initial interventions in order to build relationships (Babich et el., 2008). On the university side, Quinn noted the need for a central coordinating body to recognize synergies and establish new relationships (Quinn, 2008). Pfeiffer noted the need to add coordination as a core criterion for assessment of projects, rather than focusing on short-term output evaluation (Pfeiffer, 2003). Green commented on the importance of coordinating with local providers to acknowledge competence and improve continuity of care (Green et al., 2009). Suchdev et al. (2007 and Vidyasager (2009) noted the importance of partnership with the community (Suchdeve et al., 2007;Vidyasager, 2009). It was also noted that consideration of national impact and evaluation of mutually developed plans assist in developing partnerships (Vidyasager, 2009).
A second major theme noted in the articles focused on clinical care was the need for a focus on sustainability of the project through capacity building at the local level. Sustainability recommendations ranged from up-front project considerations such as assessing resources that are actually available (Babich et al., 2008), to end-of-the-project considerations such as exit strategies (Van den Broucke, 2009). A number of different types of capacity building activities were noted such as educational programs, symposia, and on-the-job training (Quinn, 2008;Pfeiffer, 2003). Pfeiffer (2003) pointed out the importance of building capacity through development of productive, long-term relationships and a transfer of skills, rather than simply providing workshops that may take workers away from their crucial duties (Pfeiffer, 2003). Vidyasagar (2009) also discussed the importance of sustainability when transferring skills and noted the importance of commitment both from high levels of authority and community stakeholders (Vidyasager, 2009). The use of existing infrastructure and focus on long-term impact were noted as promoting sustainability in projects (Babich et al., 2008;Pfeiffer, 2003;Van den Broucke et al., 2009;Vidyasager, 2009), and periodic evaluation was suggested to ensure programs are meeting outcomes and developing interventions appropriately (Suchdev et al., 2007;Sarriot et al., 2004). Sarriot et al. (2004) developed a framework to evaluate sustainability, including considerations of health outcomes, health services, organizational capacity and viability, community competence/capacity, and the larger environmental context (Sarriot et al., 2004).
The necessity of considering local needs was the third theme noted in the articles on clinical care. Exploring problems and needs of the community/country, accommodating local needs in the overarching project goals, and encouraging participation in all aspects of the project were noted as effective methods (Babich et  Finally, five of the articles gave recommendations specific to processes such as evaluation, training and providing resources. Quinn (2008) noted at the university level, the importance of providing resources such as access to existing programs and support through funding (Quinn, 2008). Pfeiffer (2003) suggested conducting re-evaluations 12 months after the project end to measure the long-term impact and encourage consideration of sustainability (Pfeiffer, 2003). Cheah et al. (2010) and Crump and Sugarman (2008) both noted the importance of training, both for local stakeholders and visiting clinicians, to ensure an appropriate knowledge base and appreciation of ethical considerations (Cheah et al., 2010;Crump & Sugarman, 2008). Limitation of team personnel, donation of equipment, and focus on populations most in need are also processes that can minimize the burden and maximize the impact of programs (Green et al., 2009

Conclusions
This review provides evidence on effective strategies in conducting global health research, training, and clinical care by identifying the common structures used in implementation of programs as well as the key elements that allowed for program success, and the common barriers experienced. In defining global health as the "health problems, issues, and concerns that transcend national boundaries and [that] may be addressed by cooperative actions" (Institute of Medicine, 1997), three main implications for the development of new global health programs can be seen in this review. The first is the need for new programs to be developed within the framework of formal long-term arrangements. A number of articles noted that better coordination resulted from long-term partnerships. Long-standing commitments also help ensure experiences are mutually beneficial, meaningful and ethical. Using small projects to build trust and develop relationships was suggested as an effective process. While formal partnerships can be time-consuming and require effort to develop, the commitment can increase impact and sustainability. The second main implication of this review is the necessity of engaging local partners from the onset of program development. Focusing on local needs and understanding of local political, social and cultural conditions leads to more ethical research, prepared trainees, and effective clinical care. Exploration of problems and needs through consultation with stakeholders assists in ensuring programs are truly accomplishing their mission and vision. The third is regular recommendations to evaluate programs in order to determine if goals are being met, programs are needs based and sustainable, and the best outcomes are being reached. Considerations of sustainability, partnership building, and organizational capacity were mentioned as part of evaluation topics, in addition to the more common endpoints of outcomes and access.
There are several limitations to this review. First selected articles were limited to publications in the English language between 2001 and 2011, which could have led to exclusion of important articles in other languages and prior to 2001. Second, since studies with positive results are more likely to be published, the studies in this review may represent successful programs with positive program evaluation results. Lastly, the difference in methodology used by each article limited the amount of comparison that could be made between articles. So a formal meta-analysis could not be performed and would not have been appropriate. Therefore, conclusions from this review are qualitative and meant to guide future program development.
Evidence from this review suggests that global health program development should be completed within the framework of a larger institutional commitment or partnership. Support from leadership in the university or NGO, and an engaged local community are both integral to success and sustainability of efforts. It is also important for program development to engage local partners from the onset, jointly exploring issues and developing goals and objectives. Evaluation is a recommended way to determine if these goals are being met, and should include considerations of sustainability, partnership building, and capacity. Global health research programs should consider details regarding the research process, the context of research, partnerships, and community relationships. Training for global health should involve mentorship, pre-departure preparation of students, and elements developed to increase impact. Clinical care programs should focus on collaboration, sustainability, meeting local needs, and appropriate process considerations.