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Exploring the Need for Social Emotional Learning Programs: A New Model for Mental Health and Wellness

by Karen M. Sarafian

 

Abstract

In their early years, children often experience a number of adverse childhood experiences (ACEs) including verbal, physical, and sexual abuse; violence; neglect; poverty; and parental divorce, incarceration, and addiction (Bjrkenstam et al., 2017; Dube et al., 2001; Fuller-Thomson et al., 2014; Sarafian, 2018a).  These ACEs place children at greater risk of developing academic and behavioral problems, as well as a number of mental health challenges in adolescence and adulthood (Chapman et al., 2007; Sarafian, 2018a).  Committed to providing mental health education and services to those impacted by ACEs, a number of organizations are addressing ACE-related challenges within the context of after-school expanded learning programs designed to teach social emotional learning skills (4-H, 2018; Boys and Girls Clubs of America, n.d.; Yale Center for Emotional Intelligence, 2018).  This paper provides a review of the literature regarding ACEs, their impact, and risks to adolescent and adult psychological health; as well as a brief description of several learning programs designed to combat these ACE-related risks by providing care, support, and instruction in social emotional competencies.  Specifically highlighted is the work of The Sarafian Foundation, a newly established 501(c)3 social enterprise dedicated to reducing ACE-related risks through explicit instruction in and development of the five social emotional competencies: self-awareness, social awareness, self-management, relationship skills, and responsible decision-making (CASEL, 2018). The foundation’s leadership, programs, partnerships, supports and challenges; and efforts to build capacity, scale, and sustainability are examined in relation to its mission of providing accessible and low or no-cost mental health and wellness instruction and resources to children and families (The Sarafian Foundation, 2018).

 

Review of Literature

Across the country administrators, teachers, and staff work tirelessly to teach elementary children the basics of reading, writing, and math.  However, their efforts are often countered by minimal engagement and inattention, anger and impulsive behavior, and low test scores.  Are the students of today unteachable?  Or must education take a new direction, offering more than the core academic curriculum?  With a focus on the whole child; including the attitudes, feelings, and life experiences that make up each individual; educators and community partnering agencies can combat the adverse childhood experiences these students face, and provide them with the social emotional skills necessary for mental health and wellness now and in the future.

Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) are a set of “non-specific” and “modifiable risk factors” responsible for “an array of mental health outcomes” (Chapman, Dube & Anda, 2007, p. 360).  According to the Center for Behavioral Health Statistics and Quality (CBHSQ) Report, approximately “1 in 8 children (8.7 million) aged 17 or younger” (Lipari & Van Horn, 2017, p. 5) reside with at least one recurrent substance-abusing parent.  Furthermore, these same children may be negatively impacted by parental divorce, violence, incarceration, verbal, physical, and sexual abuse, physical and emotional neglect, and residential instability (Bjrkenstam, et al., 2017; Dube et al., 2001; Fuller-Thomson, et al., 2014; Gonzalez et al., 2016; Overstreet & Matthews, 2011).  In addition, they are likely to grow up witnessing “criminality of household members, parental discord,” and mental illness (Dube et al., 2001, p. 1628).  Researchers suggest that these children are exposed to a greater number of ACEs, and are at greater risk of psychological and behavioral disorders in adolescence and adulthood (Anda et al., 2002; Dube et al., 2001; Chapman et al., 2007).

Psychological and behavioral disorders. 

ACEs can lead to a higher risk of behavioral and psychological disorders; and mental health problems such as depression, anxiety, and substance abuse in adolescence and adulthood (Chapman et al, 2004; Choi et al., 2017; Overstreet & Matthews, 2011).  Children of alcoholics are often sad, anxious, and depressed; and tend to experience low self-esteem, and “insecure-avoidant” attachment as they exhibit difficulty establishing and maintaining relationships (Peleg-Oren et al., 2008, p. 17).  These children are also apt to exhibit academic problems as well as behaviors that are disruptive, aggressive, impulsive, and oppositional (Burlew et al., 2013; Gonzalez et al., 2016; Overstreet et al., 2011; Schroeder et al., 2006).

These behavioral disorders affect high school completion rates, adolescent and young adult substance abuse, incarceration rates, unemployment, and poverty.  Research suggests that depressed teens are twice as likely to drop out of high school than peers who experience mental wellness or who have recovered from depression (Weinstock, 2018).  ACEs are also linked to early onset of drinking (Anda, 2018).  Furthermore, ACEs in childhood “raised the chances of juvenile arrest by 59%” (Bartos, 2016, para. 3).  Finally, researchers have noted that a cumulative effect of ACEs increases the likelihood of adult poverty.  Poverty, in turn, puts children at increased risk of continued poverty, fewer life opportunities, and “an intergenerational effect of these ACEs” (Metzler, et al., 2017, p. 146).

Depressive disorders.  Children who experience ACEs are also at greater risk of developing depressive disorders and attempting suicide later in life.  Researchers, examining the relationship between ACEs and recent onset as well as chronic depressive disorders, have found that ACEs increase vulnerability to depressive disorders “up to decades after their occurrence” (Chapman et al., 2004, p. 217).  Researchers have also noted that suicide attempts tend to be associated with ACE exposure, and the number of ACEs “had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood” (Choi et al., 2017, p. 253).

Social Emotional Learning

In response to the growing need to address these psychological and behavioral issues, there is greater societal and educational interest in making social emotional learning a priority for elementary, middle, and high school students within classrooms, schools, homes and communities.  According to the Collaborative for Academic and Social Emotional Learning (CASEL), social emotional learning (SEL) is defined as development of five key competencies: self-awareness, social awareness, self-management, relationship skills, and responsible decision-making (“What is sel?,” 2018).  These can be taught in a coordinated framework designed to reduce ACE-related risks.  Within schools, coordinated efforts take the form of stand-alone SEL curriculum, integration of SEL principles across the curriculum, school-wide policies, and implementation of Positive Behavior Interventions and Supports (PBIS, 2018).

Programs.  In 2018, the California Department of Education (CDE) introduced its Guiding Principles for Social Emotional Learning (CDE, 2018).  Publication of these principles provides a pathway for school-community partnerships in provision of mental health and wellness instruction and services in after-school expanded learning programs.  Programs offer leadership and team building activities, community service learning experiences, and wellness resources to children and families. Such partnerships include Boys and Girls Clubs of America (BCGA), 4-H, RULER, and Ayo! CONNECT.

BCGA offers programs from sports and education to the arts and wellness, and character and leadership.  BGCA participants are surrounded by supportive adults who explicitly teach social emotional skills such as responsible decision-making, relationship skills, and social awareness so children follow the “path to great futures” (Boys and Girls Clubs of America, n.d., p. 1).  Specific programs such as “Youth of the Year” and “Million Members, Million Hours of Service” utilize recognition and community service as vehicles for development of relationship and leadership skills (Boys and Girls Clubs of America, n.d., p. 1).

4-H is recognized worldwide in its efforts to develop leadership in young people.  With a focus on community service as well as hands-on experiential learning; 4-H members develop social emotional competencies such as compassion, decision-making, and communication.  In turn, these abilities lead to greater confidence and resilience, as well as other life skills. The 4-H model focuses on positive youth development to ensure long-term goals of greater societal contribution and decreased risk behavior in adolescence and adulthood (Institute for Applied Research in Youth Development, 2013, p. 2).

The Yale Center for Emotional Intelligence uses the evidence-based RULER approach to integrate SEL in schools by teaching students to “recognize, understand, label, express, and regulate emotion” (Yale Center for Emotional Intelligence, 2018, p. 1).  Found to lead to success in school and beyond, these skills are taught across the curriculum and in after-school settings. The program is available to pre-kindergarten through twelfth grade students and families in participating RULER schools and districts.

Case in Point

The Sarafian Foundation, a 501(c)3 social enterprise, has recently launched its inaugural Ayo! CONNECT and Ayo! CONNECTions family workshops in partnership with a local elementary school in the Elk Grove Unified School District in Sacramento County, California.  Ayo, meaning yes in the Armenian language, provides the theme for each twelve-week session.  Participants are taught to say “yes” to mental health and wellness as they learn social emotional skills within the context of an after-school expanded learning program.  Third through fifth grade students and families are encouraged to participate in this free program and learn SEL skills related to empathy, goal-setting, appropriate and productive risk-taking, the body’s reaction to anxiety, and tools for developing mindfulness.

While the foundation’s board of directors is optimistic about initial program success, there are several challenges that must be overcome.  To begin, the necessity to build capacity and expand leadership is critical.  The founders, in establishing the mission and vision for the organization, have the passion to drive the work forward.  But, program demand requires a larger and more diverse network.  The foundation, based on the work of the Sprout Fund’s Remake Learning Playbook (2015), developed its own leadership guide for scale and sustainability.  Utilizing playbook tools; the leadership will convene, catalyze, communicate, coordinate, and champion for mental health and wellness for children and families (Sarafian, 2018b).

The foundation’s leadership is also working to address challenges specific to implementation of its Ayo! CONNECT program.  For example, due to the partner school’s multi-track year-round calendar as well as the voluntary nature of the program, attendance has been inconsistent.  This leads to the potential for curricular gaps that may negatively impact program effectiveness.  Additionally, the program has not yet been piloted with other educational partners.  Differences in demographics, school calendars, and program facilitators may yield contrasting results.  It is therefore necessary to conduct an empirical study of program effectiveness.

Armed with research findings, future plans include program expansion to other schools in Sacramento County and beyond.  In addition to after-school expanded learning programs, the foundation strives to develop other community partnership programs, such as those outlined in the California Department of Education’s Guiding Principles for Social Emotional Learning (CDE, 2018).  Programs will address the lack of available and appropriate mental health services for children by providing low or no-cost opportunities such as weekend retreats and summer camps for children and families impacted by ACEs.

Conclusion

In examination of the literature regarding adverse childhood experiences, it is clear that there is great need for mental health education, programs, and resources for the children in today’s schools and communities.  It is time for children impacted by ACEs to say “no” to substance abuse, depression, incarceration, poverty, and suicide and say “ayo!” or “yes” to mental wellness and prosperity.  The California Department of Education’s Guiding Principles for Social Emotional Learning provide an avenue to development of school-community partnerships.  SEL programs such as The Sarafian Foundation’s Ayo! CONNECT may support reduction in mental health risks, positively impact academic and behavioral performance, and decrease the likelihood of mental disease in adolescence and adulthood.  By taking initial steps to fulfill its mission of providing low or no-cost mental health and wellness programs, The Sarafian Foundation is challenging the status quo of adverse childhood experiences and defining a new normal for children and families.


References

4-H. (n.d.)  Leadership. Retrieved from https://4-h.org/parents/benefits/

Anda, R., (2018).  The role of adverse childhood experiences in substance misuse and related behavioral health problems.  Retrieved from https://www.samhsa.gov/capt/sites/default/files/resources/aces-behavioral-health-problems.pdf

Bartos, L., (2016).  Pipeline to prison may start with childhood trauma.  Retrieved from http://www.calhealthreport.org/2016/01/06/pipeline-to-prison-may-start-with-childhood-trauma/

Bjrkenstam, E., Bjrkenstam, C., Jablonska, B., & Kosidou, K. (2017).  Cumulative exposure to childhood adversity, and treated attention deficit/hyperactivity disorder: A cohort study of 543 650 adolescents and young adults in Sweden.  Psychological Medicine. doi:10.1017/S0033291717001933

Boys and Girls Clubs of America. (n.d.)  Programs. Retrieved from https://www.bgca.org/programs

California Department of Education. (2018).  California’s social and emotional learning guiding principles.  Retrieved from https://www.cde.ca.gov/eo/in/documents/selguidingprincipleswb.pdf

Chapman, D. P., Dube, S. R., & Anda, R. F. (2007).  Adverse childhood events as risk factors for negative mental health outcomes.  Psychiatric Annals, 37(5), 359-364.  Retrieved from http://0-web.b.ebscohost.com.pacificatclassic.pacific.edu/ehost/pdfviewer/pdfviewer?vid=2&sid=4ab190da-b630-49b2-834f-d59d209aea74%40sessionmgr103

Collaborative for Academic and Social Emotional Learning. (2018).  What is sel?  Retrieved from https://casel.org/what-is-sel/

Dube, S. R., Anda, R. F., Croft, J. B., Edwards, V. J., Giles, W. H., & Felitti, V. J. (2001).  Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect, and household dysfunction.  Child Abuse & Neglect, 25(12), 1627-1640.  doi:10.1016/S0145-2134(01)00293-9

Fuller-Thomson, E., Mehta, R., & Valeo, A. (2014).  Establishing a link between attention deficit disorder/attention deficit hyperactivity disorder and childhood physical abuse.  Journal of Aggression, Maltreatment & Trauma, 23(2), 188-198.  doi:10.1080/10926771.2014.873510

Hurd, N, & Deutsh, N. (2017).  SEL focused after school programs, The Future of Children, 27(1).  Retrieved from https://files.eric.ed.gov/fulltext/EJ1145092.pdf

Institute for Applied Research in Youth Development, (2013).  The positive development of youth: Comprehensive findings from the 4-H study of positive youth development. Retrieved from https://4-h.org/wp-content/uploads/2016/02/4-H-Study-of-Positive-Youth-Development-Fact-Sheet.pdf

Metzler, M., Merrick, M., Klevins, J., Ports, K., & Ford, D. (2017).  Adverse childhood experiences and life opportunities.  Children and Youth Services Review, 72, 141-149. doi:10.1016/j.childyouth.2016.10.021

Positive Behavior Interventions and Supports. (2018).  PBIS.  Retrieved from https://www.pbis.org

Sarafian, K. (2018a).  Examination of an after-school social emotional learning program for elementary school students (Working Paper 092418V1).

Sarafian, K. (2018b).  The Sarafian Foundation playbook (Working Paper 120518V1).

The Sarafian Foundation. (2018).  About us.  Retrieved from https://www.thesarafianfoundation.org

The Sprout Fund. (2015).  Remake learning playbook.  Retrieved from https://playbook.remakelearning.org

Weinstock, C.P., 2017.  Depressed high school students more likely to drop out.  Retrieved from https://www.psychcongress.com/news/depressed-high-school-students-more-likely-drop-out

Yale Center for Emotional Intelligence. (2018).  RULER. Retrieved from http://ei.yale.edu/ruler/ruler-overview/

Addressing the Shame Imposed by Healthcare Providers on Individuals with HIV/AIDS – Using Change Models and the SPELIT Power Matrix to Provide Cultural Sensitivity Training to Physicians and Nurses in Belize

by Tabia Richardson

 

Abstract

According to the literature, “the United Nations Agency for International development and the World Health Organization estimated that 33.2 million people worldwide had HIV/AIDS in 2007 with an estimated 1.6 million living in Latin America” (Andrewin & Chien, 2008, p. 897) and the rates of prevalence and incidence were increasing worldwide. In Belize the contempt associated with HIV/AIDS is great because the “acquisition [of this disease] is perceived to be a result of immoral and voluntary actions, [due to] homosexual and promiscuous sex and the sharing of infected needles among injection drug users” (Andrewin et al., 2008, p.897). More specifically, the literature asserts that for these patients, their first experience with rejection comes from healthcare providers for whom diagnose and treated them (Andrewin et al., 2008).

This proposal is being submitted to the 4th Annual Conference of the International Center for Global Leadership in Placencia, Belize. This conference highlights different phenomenon for which global leaders offer their attention. HIV/AIDS has been on the radar for global health leaders because it not only affects health care providers, but a number of industries worldwide. This proposal highlights the phenomenon of contempt that is prevalent amongst healthcare leaders for whom serve HIV/AIDS patients worldwide, but more specifically in the country of Belize. It is hoped that through offering training, the issue of contempt may be addressed and eventually eradicated as it relates to individuals afflicted with HIV/AIDS no matter the vector of contraction.

Introduction

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS) is a debilitating disease that can be deadly, and for some, comes with a stigma. This is a disease that is said to be an equal opportunity disease that affects people of every gender, age, race; and nationality. It can be contracted from mother to newborn, from man to man, man to woman; and can be contracted through the inappropriate handling of medical procedures.

In many countries around the world, this disease has reached pandemic levels. Due to its severity and sometimes the shame associated with it, when some people are diagnosed with this disease, they may feel as if they have the proverbial scarlet letter embossed on their person for all to see.

According to the literature, HIV/AIDS is a global health issue that causes those diagnosed with the disease to sometimes want to hide from the diagnose rather than acknowledge and confront it (Andrewin et al., 2008). In fact, “in Central America, the fear of the negative consequences of disclosing one’s HIV status – a key step in building alliances amongst patients and empowering communities living with HIV – is based on concrete instances of rejection and discrimination” (Gonzalez & Colon, 2014, p. 11). Thus, HIV/AIDS is a global health issue that needs to be better addressed by healthcare organizations. Although this disease is a well-known global health issue, interestingly it  is infamous for the silence it evokes.

In 1987, “HIV was first diagnosed in Belize” (Pope, 2012, p. 1161). It is thought that the disease came to Belize from abroad from people who migrated to the country (Pope, 2012). However, once HIV/AIDS became prevalent in the country, and its effects were fully understood by the healthcare professionals, for cultural and religious reasons, its existence was somewhat ignored as well as the people who contracted the disease (Pope, 2012). Therefore, the purpose of this paper is to discuss ways to erase the disdain associated with an HIV/AIDS diagnose for Belizeans by training healthcare professionals to treat these patients with compassion rather than contempt as they fight this disease.

Literature Review

In the article written by Andrewin et al (2008), entitled “Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize”, the authors performed an observational study in 2007 of 230 healthcare providers who diagnosed and treated HIV/AIDS patients. The researchers found that the “stigmatization imposed on patients was greatest [due to] ‘attitudes of blame/judgment’ [that were] inflicted on those with the disease” (Andrewin et al., 2008, p. 900) by doctors and nurses. They also learned that, due to the healthcare professionals’ negative feelings toward the HIV/AIDS patients, the physicians and nurses who treated them were involved in such unethical practices as “sharing a patients HIV status with colleagues without the patients’ permission, testing patients for HIV/AIDS without the patients’ consent, treating patients with HIV/AIDS with disdain compared to other patients; and they found that female nurse healthcare professionals, who spend the most time with these patients, showed more differential treatment than their male physician counterparts” (Andrewin et al., 2008, p. 902). The researchers concluded that there was a need for healthcare professionals to receive training on how to better serve patients with HIV/AIDS and that future research should investigate this phenomenon.

In the article “Therapeutic imaginaries in the Caribbean: competing approaches to HIV/AIDs policy in Cuba and Belize” (2012), the author highlights the historical differences found in the care of HIV/AIDS patients in Cuba versus those in Belize (Pope, 2012). The researcher showed how initially Cuba stigmatized HIV/AIDS; however, overtime, its healthcare system decided to provide “education about sexually transmitted infections, access to primary care, and culturally appropriate disease control” (Pope, 2012) in order to reduce the incidence and prevalence of the disease. Pope stated that unlike Belize, and its handling of this disease, the Cuban constitution mandates that medical care be granted to all; thereby permitting that all “persons living with HIV are guaranteed adequate medical care” (Pope, 2012, p. 1159) and because of this mandate, Cuba “has reduced the stigma associated with HIV and therefore has reduced negative stereotypes associated with this disease” (Pope, 2012, p. 1160). Conversely, the article showed that unlike Cuba, Belize struggles with the stigma associated with this disease. According to Pope (2012), in Belize, HIV/AIDS is seen as a “moral disease that is a result of immoral acts and thus there is no education offered” (Pope, 2012, p. 1161) concerning prevention or maintenance of this disease.

SPELIT

A proposed way to address the matter of compassionate HIV/AIDS healthcare delivery in the Belizean healthcare system is through the SPELIT Power Matrix (Schmieder-Ramirez & Mallette, 2007). The premise of The SPELIT Power Matrix (Schmieder-Ramirez et al., 2007) is that it assists in analyzing the environment in which an organization exists before implementing change. The acronym SPELIT stands for S: Social Environment, P: Political Environment, E: Economic Environment, L: Legal Environment, I: Intercultural Environment; and T: Technological Environment. To assess the Belizean healthcare system with the proposed organizational change, evaluating the following tenets of the SPELIT is imperative:

S: Social Environment – Belize gained independence in 1981 from the United Kingdom. The population of Belize is 377, 968 people (“United Nations”, 2016). According to the United Nations Agency for International Development, there are “3,600 adults who are 15 years old or older reported to be living with HIV/AIDS: 1,700 women and 1,800 men” (“United Nations”, 2016). In Belize’s 2015 Ministry of Health report, it is documented that of those Belizeans diagnosed with HIV/AIDS, “30.8% of them have experienced discriminatory attitudes because of their disease” (“Ministry of Health”, 2015).

P: Political Environment – Belize has two major political parties: People’s United Party and the United Democratic Party. The country also is a member of such global organizations as the United Nations, the Association of Caribbean States, and the Organization of American States.

E: Economic Environment – Belize has an agricultural economy where the main crops are sugar and bananas. The countries it trades with most frequently include: United States, Mexico, Europe; and other Central American countries – all of whom have experienced the effects of HIV/AIDS (“United Nations”, 2016).

L: Legal Environment – Belize has its own Constitution and functions under the Common Law of England. It has three different branches of its judicial system: Magistrate Courts, Supreme Court, and a Court of Appeals. As of 2003, it also is a member of the Caribbean Court of Justice with other Caribbean Nations (“World Encyclopedia”, 2016). While the treatment of HIV/AIDS patients is a human rights issue, unlike Cuba, the Belizean Constitution does not include language on the expectations of treatment for these individuals (Pope, 2012).

I: Intercultural Environment – There are a number of cultural groups living in the country including Mestizos, Creoles, Mayans, Garinagus, Mennonites, East Indians and Chinese. The country’s main language is English, but Belizean Creole, Spanish, German, and other indigenous languages are spoken.

T: Technological Environment – In 2008, Belize instituted an electronic medical record system to keep track of diagnosed HIV/AIDS patients (“Ministry of Health”, 2016). The Ministry of Health introduced this system in order to “improve capacity to monitor patients and facilitate care of people with and getting tested for” (“Ministry of Health”, 2016) having this disease. Similarly, in 2010, the Ministry of Health implemented a computer-based system called the “2010 Care-Based Surveillance System” whose purpose was to gather and store demographic information on all known Belizeans who had been diagnosed with HIV/AIDS (“Ministry of Health”, 2016).

After evaluating the areas of the SPELIT (Schmieder-Ramirez et al., 2007) and the literature, perhaps Belize could benefit from an organizational change in how healthcare organizations there address the needs of HIV/AIDS patients.

Change Models

According to Andrewin and Chien (2008), “HIV/AIDS stigma discrimination compound the challenge of getting the pandemic under control” (Andrewin et al., 2008, p. 897). Surprisingly, “the healthcare setting has been identified as one of the major settings in which stigmatization urgently needs to be addressed” (Andrewin et al., 2008, p. 898) and the authors acknowledged that “little is known or documented about the attitudes and practices of healthcare workers in Belize regarding the treatment of HIV/AIDS patients” (Andrewin et al., 2008, p. 898). Therefore, because of the latter, this proposal suggests that Belize implements a community-based, health promotion intervention that can be conducted with healthcare professionals. The objective of this program would be to train physicians and nurses on how to offer competent and individualized care that would show compassion and understanding to patients who are diagnosed with HIV/AIDS — regardless of how they may have contracted the disease. This training program could also afford health care professionals a “safe place” to express and work through their biases regarding HIV/AIDS patients amongst their peers. The hope would be that, in such an environment, they would be able to acquire the tools to help to eliminate their biases. By learning new ways to render compassionate healthcare to these patients, the healthcare providers may become the non-judgmental entities these patients need to encourage and empower them to became self-efficacious as they manage their diagnosis.

When initiating organizational change in a healthcare system such as Belize, it is important to substantiate the changes by referencing theoretical change models. One change model that could be implemented to help destigmatize HIV/AIDS in Belizean medical facilities is Kurt Lewin’s Action Research Model. This model has four components to effect change: 1. Field Theory, 2. Group Dynamics, 3. Action Research; and 4. the 3-Step Model of Change (Burnes, 2004). Therefore, in keeping with Lewin’s change model, the concept of Field Theory depicts the “field” as the environment where the organizational change occurs. Thus, the field would be the Belizean medical facilities (Burnes, 2004). In endeavoring to change the perceptions physicians and nurses have toward HIV/AIDS patients, it would be necessary to also use Lewin’s Theory of Group Dynamics which states that “understanding the internal dynamics of a group is not sufficient by itself to bring about change, but that there is also the need to provide a process whereby the members could be engaged in and committed to changing their behaviour.” (Burnes, 2004, p. 983). Thus, it would be imperative that the feelings and perceptions of the Belizean physicians and nurses be regularly assessed so that the proposed organizational changes could properly take root in medical settings (Burnes, 2004). Also, to further assess the organization, an important aspect would be to determine to what extinct patients as well as healthcare professionals felt that the organizational change would benefit the organization. The latter is an example of Lewin’s principle of Action Research which “recognizes that successful action is based on analyzing the situation correctly, identifying all the possible alternative solutions and choosing the one most appropriate to the situation at hand” (Burnes, 2004, p. 983) by assessing the “felt-need” (Burnes, 2004, p. 983) of those involved is addressed. Thus, the “felt-need is an individual’s or group’s inner realization that change is necessary” (Burnes, 2004, pp. 983-984).  To summarize the literature states that “unfreezing or getting rid of the former organizational norms before wholeheartedly implementing the changes in an effort for the medical professionals to “unlearn” their old organizational behaviors” (Burnes, 2004, p. 985) is imperative and thus the main goal of change management. The literature also states that when implementing the second step of organizational change called “moving” (Burnes, 2004, p. 985), it is necessary to try not to “predict or identify a specific outcome from Planned change” (Burnes, 2004, p. 985), but instead to allow organizations to be open to whatever the results that are initiated by the change (Burnes, 2004, p. 985). Finally, the last of the three steps is “refreezing” (Burnes, 2004, p. 985), which would help the health professionals to maintain the organizational changes they make overtime (Burnes, 2004).

Another change model that could be used to help the Belize healthcare system deal with the proposed organizational changes is Woodard’s Leading and Coping with Change Model (Woodard & Hendry, 2004). According to the literature, Woodard and Hendry cautions that “when change processes require fundamental shifts in the way organizational members think and act, the consequences of change can test to the utmost the organization’s capabilities and resources” (Woodard et al., 2004, p. 156). Woodard and Hendry affirm that when implementing this theory, it is imperative to offer “support for employees to learn new competencies, through formal coaching, helps them to develop the skills to manage the new situations they are faced with” (Woodard et al., 2004, p. 168) because as the change unfolds, employees continue to evaluate what is going on, and apply various coping strategies thus the premise behind this paper.

Conclusion

HIV/AIDS is a serious global health phenomenon. It has a particularly harmful impact in countries where the disease is attached to negative societal perceptions – especially when these perceptions negatively impact the patients which is the case in Belize (Andrewin et al, 2008). Thus, in order to gain a true understanding of this phenomenon, it is imperative to research it further. The need to ascertain the true biases that some healthcare providers have toward this patient population are interesting as this is a profession that takes an oath to help all people and to do no harm while doing so. Therefore, to learn that there are some healthcare providers who contribute to the contempt that some in Belizean society may hold towards those diagnosed with HIV/AIDS is unfortunate. The objective of this proposal is to use the SPELIT Power Matrix (Schmieder-Ramirez et al., 2007) to help to identify ways that the healthcare system in Belize might implement organizational change by instituting training for its healthcare providers, as outlined in this proposal, in order to inject more compassion into the business of treating HIV/AIDS patients in Belize.

 


References

Andrewin, A., & Chien, L. (2008). Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize. AIDS Patient Care and STDs, 22(11), 897-906.

Burnes, B. (2004). Kurt Lewin and the planned approach to change: a re-appraisal.

Journal of Management Studies, 41(6), 977-1002. Gonzalez, M.A., & Colon, M. (2014). Black Central Americans in the struggle against AIDS.

NACLA Report on the Americas, 11-13.

Ministry of Health, Belize (2015). Annual HIV Statistical Report 2015. Retrieved on December 3,

2016 from http://www.health.gov.bz/www/publiations/hivaids/877-hiv-annual-report.2015

Pope, C. (2012). Therapeutic imaginaries in the Caribbean: competing approaches to HIV/AIDS policy in Cuba and Belize. Annals of the Association of American Geographers, 102(5), 1157-1164.

Schmieder-Ramirez, J., & Mallette, L.A. (2007). The SPELIT Power Matrix, Untangling the Organizational Environment with the SPELIT Leadership Tool. San Bernardino, CA: BookSurge, LLC.

United Nations Development Programme in Belize (2016). Retrieved on December 7, 2016 from

http://www.bz.undp.org/content/belize/en/home/countryinfo

Woodard, S., & Hendry C. (2004). Leading and coping with change. Journal of Change Management, 4(2), 155-183.

World Encyclopedia of Nations (2016). Retrieved on December 7, 2016 from  http://www.encyclopedia.com

Academic Integration Among College Students with Disabilities and the Effect of Time to Program Completion

by Toby Tomlinson Baker

 Abstract

It is the researcher’s working theory that three variables affect the academic integration of students with disabilities (SWD) and will predict how the variables contribute to the amount of time of the completion of SWDs to complete college programs. While there are other variables of academic integration, three have been determined to have the most effect on the time to complete college, including time to completion, disability status and academic integration (Clark, Middleton, Nguyen, & Zwick, 2014). It is noted that there are two important integration concepts: academic and social integration, which are associated, yet different. This study examines the relationship between academic integration, as created by Vincent Tinto (Clark et al., 2014) and time to completion among SWDs. While many SWDs complete undergraduate degree programs and go on to Masters and Doctoral level programs, including law school, which could justifiably take longer to complete, this study focuses solely on SWDs in undergraduate degree programs with a focus to earn Associate or Bachelor of Arts degrees. When the researcher examines secondary data, it is predicted that those who exhibit persistence, as described by Tinto, will complete their degrees in fewer years than those who did not meet the criteria for academic integration (Clark et al., 2014).

 

Introduction

Academic integration among college students with disabilities (SWD) is affected by significant factors, which include each student’s disability status and the effect of time to program completion. There are two types of integration; academic and social, which have been created and developed by Tinto (Chapman & Pascarella, 1983). Tinto points out that student integration into a college or institution can occur along two dimensions; the first, academic integration which occurs when students become attached to the intellectual life of the college, while social integration occurs when students create relationships and connections outside of the classroom (Chapman & Pascarella, 1983). These two concepts, though analytically distinct, interact with and enhance one another. Furthermore, while students must be immersed into the institution along both elements to increase their likelihood of persistence, they need not be equally integrated along the two (Chapman & Pascarella, 1983). Additionally. Tinto justifies that there are both formal and informal systems within institutions that can motivate integration and persistence.

The elements of academic integration greatly contribute to the overall academic success of college students with learning disabilities, as they directly impact the amount of time spent in an academic program of study (Brinckerhoff & And, 1992). A Specific Learning Disability (SLD) is defined as a condition giving rise to difficulties in acquiring knowledge and skills to the level expected of those of the same age, especially when not associated with a physical handicap (Department of Defense Education Activity, n.d.). Since learning disabilities are directly linked to cognitive ability and acquiring knowledge, students who have disabilities often demonstrate delays in academic processing (Wei, Christiano, Yu, Wagner, & Spiker, 2015). Moreover, growth trajectories among this population show that reaching academic goals takes a longer amount of time to achieve, interfering with the ability to become upwardly mobile in society (Wei et al., 2015).

Review of Relevant Literature

College SWDs who demonstrate academic integration by adamantly seeking and receiving accommodations and counseling, ultimately have a quicker completion rate in their academic programs (Lester & Nusbaum 2017). Furthermore, since SWDs may need additional time to complete academic tasks, it follows that their entire program may take a longer amount of time to complete. Colleges and universities should increase focus and attention to details of both academic and social programs, to ensure that the overall experience for the SWDs is merged (Korinek & Popp, 1997). Moreover, by finding a college or institution with characteristics that strengthen the student’s overall college experience with suitable programs, educators are better equipped to meet each student’s academic and social needs (Chapman & Pascarella, 1983). Based on Tinto’s model, by influencing each student’s experience with on-campus academic and social integration, the commitment level of these students to graduate from college is heightened (Chapman & Pascarella, 1983).

The academic commitment of SWD’s is needed throughout their time spent in a college program. Borglum and Kubala (2000) studied college SWD’s and found that more than half of them intended to spend up to four years at a college and spent 10 hours per week studying for their courses (Borglum & Kubala, 2000). These 10 hours are in addition to the variables which the researcher has targeted. Lester and Nusbaum (2017) confirm that SLD’s in higher education often exhibit greater levels of academic activity in order to overcome adversity, thus displaying intense fervor. Academic and social integration have been demonstrated to increase student’s satisfaction in college, academic growth and personal development (Stage, 1989).

Educational Training

Since there are academic barriers in college which hinder those with disabilities, it is pivotal to provide meaningful support, or scaffolding, in the critical areas of their academic needs (Jorgensen, Budd, Fichten, Nguyen & Havel, 2018). College students with disabilities need to recognize that there are challenges presented by the educational system; therefore, they need a plan to address these challenges and be proactive in overcoming such barriers (Pallisera, Fullana, Puyalto, & Vila, 2016). SWD’s are entering college and participating in higher education at a higher rate (Cawthon & Cole, 2010). These factors inhibit many college SWD’s’ ability to access the proper assistance which they need to succeed in college. Student advocacy and active engagement in receiving tutoring and accommodations should be monitored by adults assisting these students, but mainly by the students themselves. Educators, parents, and counselors share a responsibility to educate all students equally by law (Rein, 2018).

Tinto created the Academic and Social integration framework which has been utilized to measure student persistence in college (Mannan, 2007). It is affirmed that both academic and social integration should merge for SWDs to be successful and complete a college program. Yet, if one of these types of integration, academic or social, overpowers the other, it has been proven that the stronger type will compensate for the more fragile type of integration (Mannan, 2007). Since Tinto’s model has been implemented, colleges have increased student support services. These on-campus support services may be academic or social services, intentionally provided by these colleges to increase student persistence, with the intention of increasing student awareness and use. Questions arise regarding the structure and utility of these academic and social services, particularly if they lack demonstration of effectiveness among SWDs (Clark et al., 2014).

Academic Performance

As demonstrated in (Wagner, And, & SRI International 1993; West Chester University, 2018; Wilczenski & Gillespie-Silver, 1992), academic performance was examined between SWD’s who entered college programs compared with the performance and progress of their nondisabled peers. The link between the direct focus of each student’s academic subjects and additional support, including tutoring and teacher advisory, on each student’s specific area of academic need, results in evidence of student retention, higher tests scores, and a higher GPA (DuPaul, Pinho et al., 2017).  Certain SWDs may need an even greater amount of time during tutoring and advisory to exhibit retention of academic material; therefore, students with learning disabilities may extend beyond the designated minutes in this study. For example, perhaps a student with a learning disability needs six hours of tutoring, rather than a strict limit of three hours before they understand a topic or academic concept. There is a possibility that SWDs must forfeit time in other areas of their lives to maximize their own academic opportunity (DuPaul, Pinho et al., 2017). This concept is quite contrary to Tinto’s model, overall process and social development theory (Clark et al., 2014). Moreover, each SWD has his or her own trajectory and developmental path in order to reach the goal of graduation or completion of their program (DuPaul, Pinho et al., 2017).

Shaw and And (1989) and Shokoohi-Yekta and Kavale (1994) examined performance levels of SWD and their nondisabled peers, with a focus on math scores, particularly college entrance examinations such as the American College Testing exam, (ACT). SWD’s earned lower test scores in academic core subjects (Shokoohi-Yekta &Kavale, 1994). Jorgensen et al. (2003) and Lamberg (2012) focus their studies on the results and graduation rates of students with learning disabilities which were similar to those students without learning disabilities. Students who attended to academic tasks within their program and received appropriate assistance throughout their years in the program demonstrated as much success as their nondisabled peers (Jorgensen et al., 2003; Lamberg, 2012). Resulting from this type of academic integration is that college students with learning disabilities exhibit strict attention to academic tasks and are receptive and unwavering in receiving assistance and accommodations, in order to demonstrate their ability and progress toward graduation. These measures aid in reducing or even eliminating delayed graduation (Hakkarainen, Holopainen, & Savolainen, 2016).

In a study by DuPaul, Dahlstrom-Hakki et al., (2017), the academic progress of students with learning disabilities and ADHD was followed during a five-year period. It was found that of all of the SWD’s on campus who received academic support services, the final grades and GPA’s of students with ADHD actually surpassed those with other types of learning disabilities. By strategically targeting each student’s specific area of academic need, there is a significant probability that their academic goals will be met (DuPaul, Dahlstrom-Hakki et al., 2017).  It is noted that this study’s particular focus is not specifically targeted on the higher GPA of college students with learning disabilities, even though it may be an indirect result of the study.

During a transition to college, academic barriers can impede many students with learning disabilities’ capability to flourish, or even to perform. Brinckerhoff and And (1992) suggest transitioning skills and appropriate academic accommodations needed for SWDs and suggest approaches to gain access, acceptable college preparation and programs to assist and support these students. Cawthon and Cole (2010) have stressed the importance of checklists and accommodations during college testing, particularly prior to and during the transition to college. Without these academic supports, students may not fully master and demonstrate performance at their full capacity (Cawthon & Cole, 2010).

Challenges that Affect Academic Integration

There are additional aspects to consider when measuring time to completion in relation to SWDs. These students’ individual disabilities affect each of their academic needs, requiring more attention, assistance, and direct explicit instruction, which ultimately results in taking more time to complete (Hurks & van Loosbroek, 2014). This includes SWDs who may need to drop a class in order to have more time available to focus on the remaining three courses. The researcher takes into account that even though the level of academic material covered in each of the courses may be difficult for the SWDs, their level of academic integration is dependent on their ability to overcome adversity. It is acknowledged that SWDs can participate and make up dropped classes during off-track semester coursework terms, such as summer terms.

Current Statistics and Graduation Rate

Graduation is the ultimate goal of SWDs. A recent study compared two groups of college students with disabilities. The group of students who had just learning disabilities had more intent to graduate than the group with other disabilities (Jorgensen, Budd, Fichten, & Havel, 2018).  Jorgensen and her colleagues (2018) demonstrated how, even though the needs and accommodations of the students with learning disabilities vary, this population of students with learning disabilities demonstrated proactive measures towards graduating, such as choosing a major, enrolling in and for classes consistently, attending classes, advocating to professors and advisors, and actively registering for disability services (Jorgensen et al., 2018). These findings align with the researcher’s thesis and hypothesis since they demonstrate this population’s success in persevering toward completing college in a timely manner.

According to Troiano, Liefeld, and Trachtenberg (2010), 68% of those students who participated consistently in the services of the Learning Resource Center were more likely to graduate from the college when compared to those who did not. This evidence confirms how effective academic support and resource centers are in the success of SWDs. In this study based on attendance and graduation rates, it was predicted that SWDs who actively attended the academic support center had higher overall grade point averages and higher rates of graduation (Troiano et al., 2010). Even though there is evidence of betterment in this population, there are still factors regarding graduation which need to be addressed. Recommendations include minimizing the fear of stigmatization, engaging in stress-reducing activities and adopting a model where accommodations are based on students’ unique needs rather than their diagnoses (Jorgensen et al., 2018). The uncertainty of post-graduation inhibits students’ success and personal contribution to the world. College students with disabilities and their families expressed concern of their possible inability to be successful in future jobs and careers, to live independently, and to be able to contribute to society as a purposeful member (Pallisera et al., 2016). SWDs who obtain a college degree improve employment outcomes and overall quality of life (Mamiseishvili & Koch, 2011).

Social Integration

Gerdes & Mallinckrodt (1994) base their study on SWDs who leave college or exit college early, known as “Leavers” and compare their reasons for leaving with those who remain on college campuses, known as “Persisters.” These two groups represent SWDs who are successful or able to continue in their studies, versus those SWDs who choose to leave college and universities due to negative experiences or face internal or external factors. The college campus and university environment, particularly academic and social support services, governs the outcome of whether an SWD becomes a “leaver” or a “persister” (Gerdes & Mallinckrodt,1994). This affects the outcome of the amount of time SWDs show in relation to time to completion. Bers and Smith (1991) examine how the university environment contributes to the steady persistence of SWDs. Academic and social integration are strong motivators for SWDs to persist at a university. Concepts of academic and social integration suggest that a student’s decisions to stay or leave an institution are influenced by the level of connection that they have developed with the institution. When SWDs evaluate their reasons for leaving, they should revisit their initial connection to the university. Questions regarding the student’s level of intent to persist in the college program should be carefully considered. If SWDs are demonstrating academic and social success at a university, initial motivators should be reinforced to spark further interest in attendance (Bers & Smith, 1991).

Significance of the Study

The significance of this study is that it will add to the literature concerning effective measures to foster success at the college level for SWDs who have been left to drift in college. Moreover, SWDs must accept a certain amount of self-responsibility by utilizing the supports that are in place and taking advantage of them. The concept of academic integration greatly impacts SWDs through enhancement of their completion time of college programs. It is the researcher’s hope to positively influence SWDs to enroll and attend college, graduate and advance toward higher education (Cawthon & Cole, 2010).  The population of students should not be deterred from the prospect of academics, simply as a result of their disability (Cawthon & Cole, 2010). This study stimulates further research and contributes by determining the cumulative effect of academic integration or whether any of the factors of academic integration has more weight in the outcome of completing a college degree in a timely manner.

Areas of Further Research/Empirical Research Questions

Research in special education, particularly in the area of college SWDs, demands more attention. The scarcity of collected data corroborates the necessity for further study. The apparent gaps in professional literature regarding college students with learning disabilities signify how there are still questions unanswered. Further questions could be researched as individual topics. The following empirical research questions may be addressed:

  • Does medication contribute to success in college completion in relation to time?
  • Do students with disabilities demonstrate higher social integration as opposed to academic integration?
  • Does transferring from community college after two years of attendance to a four-school college affect the academic progress towards completion?
  • Does the award of scholarships (academic, sports, arts), in conjunction with time in a specific academic program influence academic progress towards completion of a four-year program for students with disabilities?

Research Methodology and Design

The Beginning Postsecondary Students (BPS) Longitudinal Study

The researcher will utilize available data from the National Center for Education Statistics (NCES, 2018) database to evaluate the academic progress of SWDs on a national level. Specifically, the researcher will utilize the Beginning Postsecondary Students (BPS) Longitudinal Study (NCES, n.d.). Moreover, BPS follows students who are enrolled in their first year of postsecondary education and collects data on the various activity of their programs, the transition to employment, demographic characteristics and student changes overtime (Hurst & Smerdon, 2000).

Academic Integration, which is tested, valid, and an already existing variable, and time to completion among SWD’s. The Dependent Variable (DV) is time to completion and this study aims to perform a correlation, and regression. Both of these statistical techniques require a linear, continuously measured dependent variable. The Independent variables are disability status and academic integration and there is an interaction between these two variables. Academic integration will be measured in a 4-items scale as a continuous variable (Mamiseishvili & Koch, 2011), and disability status is a categorical variable with six categories (learning, orthopedic, other, visual, hearing, and speech) (Hurst, 2000). The theoretical model is based on previous research which is explained in the literature review. For instance, DaDeppo (2009) investigated the academic integration impact on students with learning disabilities (DaDeppo, 2009). Moreover, the creator of Academic Integration, Tinto (Mannan, 2007) examines the two main types of integration: academic and social. As demonstrated by the emergence of intellectual growth and development, in conjunction with social relationships and bonds among collegiate groups, SWD’s experience academic and social integration (Mamiseishvili & Koch, 2011). Tinto’s created theory and model further explain how formal and informal methods of integration exist in the college arena.

Hypothesis

A Linear Regression model also called a regression, will be utilized to analyze the data (Privitera, 2017).  It is predicted that there is a positive correlation between a student’s academic integration, disability status, and time of completing school. After gathering data from the National Center for Education Statistics (NCES) to find the correlation coefficient of the linear regression. The prediction of the value of the outcome variable which is the time of completion will be determined by calculating the slope of the linear model. Further, the researcher will determine the possible correlation between outcome and predictor variables.  The researcher will compute the coefficient of the regression line (Privitera, 2017). The value of these variables is to be determined and known once the study is carried out. The number of predictors will be included in the linear model of this study must be verified. For one predictor variable, researchers intend to use a linear regression. Yet, for two or more predictor variables, the researcher intends to use multiple regression (Privitera, 2017). For this study, since there are two predictors the best statistical model is a multiple regression model.

The predicted multiple linear model for this study is as follows:

In this linear model, there are two predictors which are located on the right side of the equation. One is entitled “academic integration” and the other is entitled “disability status,” which is shown by “ ” in this equation. The outcome of this linear model is “months to complete,” which is measured by the amount of time it takes a student with disabilities to complete an academic college program.

The researcher will determine the slope of the linear model ( ,  ) through analysis of the regression model to predict the value of outcome variable ( ) after discovering the predictors (  and ). In other words, if the researcher finds a correlation between each of the predictors and the outcome, she will continue her analysis to determine the exact values of ,  to determine the unknown values in the linear model. This potential model can help school administrators to predict the year of completion for each student with learning disabilities through measuring their perseverance.

Multiple Linear Regression

Upon examining the collected data, the researcher will test the hypothesis of the research.  If this were the correlation between the three variables of this study, then the researcher will delve into the collected data to discover the Pearson Correlation coefficient of the regression line. Furthermore, the linear model explains the relationship between the dependent variable the independent variable for this research (Privitera, 2017). The researcher will utilize the multiple linear regression to find the linear relationship between predictors and outcome. Since the outcome is a continuous variable measured in months, and the predictors are categorical variables, the best statistical model to analyze the data will be in a linear regression analysis.

Data Analysis

Based on the researcher’s hypothesis, the data will be a Multiple linear regression which investigates the linear relationship between the three variables of the research. The Multiple linear regression model demonstrates how the time of completing college is related to academic integration and disability status.  These methods were chosen because the researcher is interested in predicting the dependent variable (the year of completion of a college program) with knowing the academic integration of each SWD.  Since this study hinges on simply three variables, it follows logic to employ the Multiple Linear Regression model. The researcher plans on examining data to test the hypothesis.

The first step after gathering data from NCES will be entering data into a spreadsheet to define the variables of the research, which will be calculated by adding up three independent variables: academic integration, time to completion, and each student’s disability status. The next step is to find the correlation between these two variables. Upon conducting the correlation analysis, the researcher will determine the correlation coefficient of the research variables. Upon discovering the positive or negative significant correlation between the variables, the data will be analyzed.  More analysis will be done to determine the multiple linear relationship between the three variables. Upon finding a protentional linear regression line, the researcher would estimate the coefficient, and recommendations will be made to school administrators and parents. This facilitates the path towards timely graduation for students with disabilities. Since the scope of this study is a correlational and a nonexperimental study, there are no participants needed to complete this research. The IRB regulations and intervention are immaterial, as are the experiences of participants and they are not manipulated. Secondary data will be examined and implemented for this study, without the primary intervention of the researcher. The researcher is observing and examining the past behavior of participants through the NCES database.

Conclusion

Although students with disabilities have cognitive processing delays (Wei et al., 2015), by incorporating academic integration based on Tinto’s model (Clark et al., 2014), this population can flourish in college and other academic and social settings, thus minimizing their time to completion and maximizing their academic growth and social development.

SWDs have difficulties with academic integration, particularly with academics, upon graduating from high school and entering a college setting, as the transition is taxing. Even taking into consideration their growth trajectories (longer period of time to complete academic tasks and plans), this specific population needs academic and social integration in order to achieve their academic goals successfully. As academic and social integration influence time of program completion, often with measures such as tutoring, university programs, additional assistance, guidance, and counseling, SWDs will be able to complete college programs in a timely manner. SWDs demonstrate a desire to adequately contribute to society and become upwardly mobile along-side their nondisabled peers (Wei et al., 2015). Academic and social integration aids in this process by reducing anxiety and fear, as it allows students with disabilities to demonstrate their abilities, complete competitive academic college programs, and allows them to have control over their future. While the actual analysis has yet to be performed, it is expected that SWDs who exhibited higher levels of academic integration, will have completed their postsecondary programs, more rapidly relative to their peers with lower levels of academic and social integration.

The academic integration examined throughout this study adds strength to the current research. SWDs need to have academic and social integration in order to endure these aspects of their college experience. Moreover, these students will complete the programs allowing them to enter the workforce and contribute to society within a satisfactory timeframe. Even though each SWDs have different trajectories and different academic and social needs, these SWDs may have the ability to finish college programs. In a society where having a college degree often measures success, SWDs will have the chance to demonstrate success in an equal manner as those without disabilities. This success will be comparable with their nondisabled peers, thus making SWDs competitive in the job market and in an equal position of power.

 

 


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Global Mindset and Mobile Health Education Exchange Initiative

by Marsha E. Nickerson

 

Abstract

The Global Mindset Mobile Health Education Exchange will be an empirical encounter between North American and Central American professional healthcare students implementing Mobile Health (mhealth) Tools in Belize Southern Regional District.  The initiative to bring US healthcare professional students to Placencia Belize to aid in the wellness, decreasing of chronic illness exacerbation, and disease prevention for Belizeans in the public health system. This endeavor would foster partnerships with worthy organizations and aid in bringing experienced faculty, senior-level student support, and telehealth capabilities to Belize.

Keywords: Global Mindset, Mobile Health, Chronic Illness, Education, Student Exchange

Introduction/Background

The Global Mindset Mobile Health Education Exchange is a proposal to bring US healthcare professional students armed with Mobile Health Technology to provide support to chronically ill Belizeans in the public health system. This endeavor would foster partnerships with Placencia Belize to aid in the wellness, decreasing of chronic illness exacerbation, and disease prevention and aid in bringing experienced faculty, senior-level students support, and telehealth capabilities to Belize.

The cultural exchange between Belizean healthcare patients, professionals, and students with US students will foster a global mindset among the participants involved. The proposal will also provide a means for Belizean students eligible for high school to get funding to continue their education, and to journey to the United States to participate in classes in the academic setting and gain clinical experiences in the US healthcare system.

It is hoped as an overall purpose to increase holistic improvement of the quality of care of Belizean patients and advance the cultural understanding and humility in healthcare learners. The project will educate Belizean nursing students and faculty on innovative technology and treatments used for rural and shut-in patients in need.

The partnership project will begin as a pilot and scale up to a full-fledged sustainable effort, (Kumaranayake, 2008), to have an ongoing interchange between healthcare workers and professionals in the US and Belize.  The proposal has multifactorial implications and the possibility of accommodation for all involved. The hope is for nursing student cultivation to cultural norms and mores that are integral to care, US students interfacing with an international healthcare system, gaining a global mindset and learning to provide congruent transcultural care to native Belizeans in acute, community, and home setting.

Another facet of this action would be, the University of Belize Department of Nursing, Allied Health, and Social Work partnering with Mount Saint Mary’s University (MSMU), Los Angeles Nursing Department to exchange students. And the integration of mobile health technology to boost healthcare in Belize, increase access to proper care, and provide 21st-century chronic illness management.

Scope of Problem

Healthcare services in Belize are limited for most native Belizeans due to an ineffective public siloed Ministry of Health system with ephemeral Cuban Brigade nurses and doctors rotating through the clinic and hospital settings, and conducting limited home visits to chronically ill patients, with a native skeleton staff. There is a high demand for more skilled professional personnel to aid in providing chronic illness care.

According to the World Health Organization (2018), Diabetes Mellitus and Hypertension are major chronic maladies striking Belizean individuals, monitoring of blood pressure and glucose levels and patient teaching on nutrition, exercise, and medication regimen are needed to aid in keeping chronic illness exacerbations at bay, (CDC, 2017: W.H.O., 2018).

As reported in the Central Intelligence Agency World Factbook: Belize, only 5.8% of the GDP is spent on the public healthcare system, (country comparison to the world is the 109th place).   The physician density is  0.77 physicians/1,000 population (2009), compared to 2.57 physicians/1,000 population (2014) in the US,  and the hospital bed density is 1.3 beds/1,000 population (2014) compared to 2.9 beds/1,000 population in the United States (CDC, 2017; CIA, 2017).

It is essential that US healthcare students engage in an international experience to understand the transcultural care context.  There is a need to increase access to chronic illness, holistic, mobile healthcare for Belizean patients interfacing with the public healthcare system in the acute, healthcare clinic, and home care settings.

Mount Saint Mary’s University, (MSMU), a liberal arts women’s academic center in Los Angeles has grant opportunities to pilot global clinical experiences with nursing students. There is the need to instill a global mindset in US health care students by employing them to provide mobile healthcare and interface with the health care system in a developing country.

The Objectives of the Initiative are to:

  1. Provide equal access to complete culturally congruent care to chronically ill Belizean patients as a hallmark of social justice
  2. Create a means to provide mobile health chronic illness monitoring and education for Belizean citizens.
  3. Aid students in developing a global mindset in professional clinical practice
  4. Develop a cultural, educational exchange for US and Belize healthcare students to confer and learn about health care outside of their domain.
  5. Build a technology investor climate in an emerging market.
  6. Establish an ongoing sustainable partnership by creating an international experience as a 1 unit capstone course at a university to be taken by senior-level healthcare students in the spring semester before graduation.

Context and Economic Policy Change Recommendations

Although Belize has the third highest per capita income in Central America, the average income figure masks a huge income disparity between rich and poor, and key government objectives remain to increase education, reducing poverty, and inequality with the help of international donors. High unemployment, a growing trade deficit, and a heavy foreign debt burden continue to be major concerns. Belize faces continued pressure from rising sovereign debt, and a growing trade imbalance (CIA, 2017).

The per capita per Belizean citizen is $8300.00  (2017), $8,400 (2016), and $8,700 (2015). The unemployment rate 10.1% (2017 est.), 11.1% (2016). The population below poverty line is a whopping 41% (2013). The cost for education per person is $50.00 at the elementary level, $1000.00 at the high school, and college costs average approximately $10,000.00 for a 4-year degree (CIA, 2017; WHO, 2018). The government’s expansionary monetary and fiscal policies, initiated in September 1998, led to GDP growth averaging nearly 4% in 1999-2007, but GDP, ($3.23 billion in 2017, $3.151 billion in 2016, $3.176 billion in 2015), growth has averaged only 2.1% from 2007-2016, and only 2.5% growth estimated for 2017 (CDC, 2017; CIA, 2017; WHO; 2018).

The economic picture in Belize reflects the need to increase healthcare expenditures for the health and welfare of Belizean citizens and the three following economic policies are warranted:

  1. Macroeconomic Stabilization Policy, which attempts to keep the money supply growing at a rate that does not result in excessive inflation and attempts to smooth out the business cycle (Mell & Walker, 2014; Rashid & Antonioni, 2016).  This policy can work in Belize by not increasing prices on goods and services for the citizens to stimulate a rise in the purchasing value of money to stabilize the economy.
  2. Revisit the Expansionary Monetary Policy, which allows the government to increase the money supply to lower interest rates. Lower interest rates to make loans for education, cars, homes, and investment goods cheaper, which means increased consumption spending by households and increased investment spending by businesses in technology and healthcare (Mell & Walker, 2014). This policy can work in Belize by aiding more citizens to pay for their high school and college education.
  3. Revisit Expansionary Fiscal Policy, which occurs when increasing government purchases of goods and healthcare services or decreasing taxes can stimulate the economy. Growing investments increases economic activity directly, giving businesses money to hire new workers or pay for increased orders from their suppliers. Decreasing taxes increases economic activity indirectly by leaving households with more after-tax dollars to spend (Mell & Walker, 2014). This policy can work in Belize by helping increase Belizeans ability to gain employment and have more money to save, live, and spent. It also can help achieve more expenditures for health care and technology infrastructure to aid in the utilization of telehealth capabilities for monitoring and education of chronically ill patients.

Alternatives to Project Proposed

A worthy alternative to the Global Mindset Educational Exchange initiative is to create a crowd raising campaign like Global Giving to generate funds to aid Belizean students to complete high school and financially sponsor Belizean high school graduates to attend university in the US with the stipulation the students return to Belize to engage in needed STEAM careers in the country.

Collaboration to Success             

A collaborative partnership between Nursing Education, Mobile Health Technology, and the Belizean Healthcare System will need to be established.  After definitive grant approval, I will partner with The Department of Nursing at Mount Saint Mary’s University (MSMU), The Department of Nursing Allied Health, and Social Work at the University of Belize, a Mobile Health Technology Company ( Apple Healthcare, TytoClinic or Dimagi),  and Pepperdine University Doctoral Student Scholars, Theresa Dawson, Judy Johnson, and Faculty Global Leadership Scholar, Dr. June Schmieder- Ramirez.

Upon the completion of grant documentation, MSMU has agreed to provide 25,000 dollars seed money via Margaret Mary Murphy Expendable Scholarships for Nurse’s Global Study to pilot an international capstone experience for senior level students about to graduate.  In the past, student nurses at MSMU have only had local faith community health, public health, and school camp nurse experiential courses and the Nursing Department is chomping at the bit to provide a global experience in a developing country.

At the University of Belize, there are BSN, Nurse-Midwifery, Nurse Practitioner, Pharmacy, and Social Work programs. We will conspire and create the education interchange between MSMU senior level nursing students who will rotate through government-run acute care, clinics, and home settings with Belizean healthcare professionals and students and also visit the University of Belize Nursing program for classroom conferring.  Students will utilize Mobile Healthcare technology in the provision of care and aid in teaching patients how M-Health tools can aid in gauging their chronic illness.

The students will receive preparatory Global Mindset educational content before the journey and learn to train others to use M-Health tools.  Then Belizean nursing students will be sponsored to come to the United States for an international experience and coursework.

We will partner with the Ministry of Health Head Office in Belmopan, Belize to coordinate clinical experiences.  The Ministry of Health has approved international clinical experiences for dental students from the United States in the past.

A  Pepperdine University partnership will enable us to write grants to branch out of nursing and provide participation for viable clinical experts to come to Belize for a transcultural healthcare engagement, e.g., Speech Pathology, Registered Dietitian, Occupational and Physical Therapy students, faculty, and consultants.  The specialty therapists would consult on interventions using Mobile Health technology to aid in the rehabilitation of patients with chronic illness.

Action Steps

  1. Complete grant funding process to gain funds to pilot, plan, and implement the proposal. The budget is complete and based on the $25,000. 00 quoted by MSMU Dean of Nursing.
  2. Create an application and interview process for students to be considered for the experiential learning experience. Interview students and choose number of candidates according to budget created.
  3. Plan for logistics for the budgeted number of students and faculty, e.g., hotel, meals, plane, etc.
  4. Begin exchange experience as a pilot with a small group of students and faculty from the US. The piloting the experience will allow for barriers to a broader effort to reveal themselves.  An analysis of short run to extended run data and what occurred in the pilot experience with m-health tools, WIFI, and bandwidth capability, and other revealed stimuli will enable reviewing, revamping and refining of the initiative.
  5. Develop a one unit sustainable international experiential course focused on Belize itself and on Healthcare Global Mindset, Roy Adaptation Nursing, SPELIT Power Matrix, Mobile Health Technology, and Transcultural Care Theory (Kim, 2005 ; Schmieder-Ramirez & Mallette; 2007; Roy, 2009; McPhee et al. 2013; Betancourt, 2015; Edmonson et al, 2017).
  6. Implement the global experiential course offering by bringing US students, mobile health technology to augment health services in Belize’s Healthcare system.
  7. After analysis of the pilot experience, write grants to replicate the experience for other specialty health professional students, e.g., speech pathology, social work, pharmacy.
  8. Petition for funds to sponsor Belizean elementary students to complete high school and provide funding opportunities for the University of Belize nursing students to travel and interface with the US healthcare and education system to broaden their cultural mindset.

 

Conclusion

Devising a plan that addressed health care and the use of technology in a developing country seemed daunting until the task forced me to focus and take action steps to bring the thing to life.  There is a great more to be considered but I do understand the importance of the social, political, economic, legal, intercultural, and technical drivers shaping the environment that can impact the result produced.  This endeavor opened my eyes to the possibilities regarding how to be an active participant in making a small difference in the world, which is quite meaningful, gratifying, and empowering.


Marsha E. Nickerson, RN, PHN, MSN is an Assistant Professor of Nursing at Mount Saint Mary’s University and is completing doctoral studies in Learning Technologies at Pepperdine University.

E-mail: marsha [dot] nickerson [at] pepperdine.edu

Websites:  http://menickerson.org

Acknowledgments:
Thank you to Theresa Dawson, Judy Jackson, and June Schmieder-Ramirez who helped tremendously with the development of this initiative.


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Edmondson, C. et al. (2017). Emerging Global Health Issues: A Nurse’s Role. The Online Journal of Issues in Nursing. Vol.22  Issue 1. doi

Kim, M. J. (2005). Developing a Global Mindset for Nursing Scholarship and Health Policy.  Australian Journal of Advanced Nursing, Vol. 22,No. 3, pp. 6-7. Retrieved from: LINK

Kumaranayake, L. (2008). The economics of scaling up: cost estimation for HIV/AIDS interventions. AIDS

Journal. Lippincott, Vol. 22, Suppl. 1, pg. S23-S33. Retrieved from: LINK

McPhee, M. et al. (2013) Global healthcare leadership development: trends to consider. Journal of Healthcare Leadership, Vol 3, Issue 5,  pp. 21–29.

Mell, A. & Walker, O. (2014) The Rough Guide to Economics: From First, Principles to the Financial Crisis. London, UK: Penguin Limited.

Levitt, S.D. & Dubner, S.J. (2009) Freakonomics. New York, NY: William Morrow.

Levitt, S D. & Dubner, S.J. (2011) Super Freakonomics. New York, NY: William Morrow.

Rashid, M. & Antonioni. P. (2016). Macroeconomics For Dummies. Brentwood, CA: John Wiley & Sons

Roy, C. (2009). The Roy Adaptation Model. New York, NY: Pearson.

Schmieder, J. & Mallette, L. (2007) SPELIT. San Bernardino, CA.

World Health Organization (2018). Belize Statistical Profile. Retrieved from: LINK

mHealth: Achieving Equitable Healthcare In Emerging Countries Using Mobile Technologies

by Theresa Dawson

 

Abstract

Access to quality healthcare plays a critical role in the economic growth of developing countries. The growing field of mobile technology in healthcare, known as mHealth, has potential for enhancing the healthcare delivery systems of these emerging markets. The benefits and value propositions of mHealth are illustrated in global use case models. The healthcare system of Belize, a developing country, is examined utilizing a SPELIT analysis (Schmeider-Ramirez & Malette, 2007) of the social, political, economic, legal, intercultural, and technological aspects as well as the World Health Organization Health Services development framework. Economic policy changes are recommended, and the addition of an mHealth strategy to the Belize national healthcare vision is proposed.

Background

Global health challenges are significant barriers to global economic development in developing countries, particularly disease and lack of prevention, epidemics, and the spread of communicable disease, combined with a shortage of healthcare workers. The quality of citizens’ health and well-being affects the human capacity needed for a country to progress (Vital Wave, 2009). Indeed, common indicators of a country’s development, as measured by the United Nations Human Development Index (2016), include assessments of a country’s birth and death rates, life expectancy, health, and education. As part of an initiative to develop solutions to meet these challenges, since 2010 the World Health Organization (WHO) has formally asked for manufacturers, institutions, universities, and individuals to submit innovative health technology solutions for low and middle-income countries (WHO, 2016). This has resulted in a comprehensive compilation of innovative technologies and worldwide use cases for solutions using mobile communications that have potential to improve and meet healthcare needs in those countries with inadequate resources (WHO, 2015). Consequently, the use of mobile communications to deliver health-related services has resulted in the field of mobile health known as mHealth. Thus, mHealth is beginning to play a key role in transforming the global healthcare delivery system by providing technological solutions to enhance healthcare provisions in developing countries.

What is mHealth?

mHealth refers to the use of mobile technologies for facilitating the delivery of healthcare services. There are 900 global mHealth products and services, and this global mHealth market is expected to exceed 30 billion in U.S. dollars (Lauler, 2013). Key areas of mHealth employment include improved access, education and awareness, remote data collection, disease tracking, remote monitoring and treatment support, and communication and training for healthcare workers (Gorski et al., 2016; Vital Wave, 2009). The 2009 United Nations and Vodafone mHealth report (Vital Wave, 2009) described worldwide evidentiary mHealth use cases. Gorski et al. (2016) posit that such use cases are important in illustrating strategies and sustainable value propositions for mHealth implementation.

As an example, distance and access can be a barrier to care. Many citizens in rural areas must travel long distances for healthcare. Lack of transportation, travel, and wait time makes seeking health services in urban areas challenging. Using hotlines, connecting doctors to patients via phone, text, video, or utilizing screening applications for patients to self-monitor their condition can alleviate and reduce time traveling and waiting for health services. This approach provides a broader reach in serving and meeting the needs of those requiring medical care.

When short messaging service (SMS) was used in Africa for campaigns to provide HIV/aids awareness, the improved awareness helped individuals understand conditions of disease and alternatives for prevention and treatment. Subsequently, there was an increase of

40% of citizens who elected to undergo testing for HIV, seeking treatment as needed, thus reducing the spread of the disease (Vital Wave, 2009).

In Uganda, healthcare workers used personal devices to collect data for the Uganda Health Information Network (Vital Wave, 2009). Because those that live in rural areas may not visit health facilities regularly, data collection in the field is important to assess need and efficacy of healthcare services provided by the government. Additionally, tracking disease and outbreaks using mobile phones and web-based technology can help in decision making for containment and prevention of outbreaks.

Remote monitoring plays an important role in preventing complications for chronic diseases by assisting with adherence to treatment plans that might otherwise put a patient at risk for complications. Specifically, healthcare workers can call patients to monitor their medication regime, or patients can use their phone to remind themselves to take medications or to record and track their blood sugar or blood pressure. This recorded data can be provided to the local health clinic for patient monitoring. Remote monitoring can be especially effective for a disease like tuberculosis (TB), where proper medication compliance can cure the disease. In South Africa, healthcare workers used SMS monitoring for TB medication compliance resulted in a 90% medication regime compliance, over 20% to 60% without the reminder (Vital Wave, 2009).

Finally, training a healthcare workforce is critical, and mobile technology can be used to provide information and education for healthcare professionals. In Coban, Guatemala a nursing school used a combination of mobile phones, landlines, and telegraphic devices that transmit handwriting, to train nurses residing in a rainforest (Innovation and Technology for Development Centre, 2014). Mobile technology can allow workers to communicate with one another to provide additional support for diagnosis and treatment. Utilization of mobile apps and use of artificial intelligence can provide reinforcement and empower patients to take responsibility to monitor their own health.

Why mHealth in Emerging Countries?

While quality healthcare is often difficult to obtain in developing countries, cell phones and wireless devices are becoming more commonly used, according to the International Telecommunication Union (ITU). The ITU reports there are over six billion wireless subscribers with over 70% of them residing in low- and middle-income countries (WHO, 2011). The growth of this technology, particularly in low-income settings, can compensate for the lack of infrastructure that hinders access to quality healthcare. Wireless technology can connect patients to healthcare workers, help patients monitor their own conditions, and allow healthcare workers to communicate with one another. There is great potential in using this technology as a solution for providing improved global health resources and for facilitating patient centered care.

mHealth as a Solution for Improving Equitable Healthcare Access in Belize

Belize, a Central American country with a population of approximately 360,000, is located on the Caribbean coast of Central America.  Belize borders Mexico in the north and Guatemala to the west and south. The Caribbean Sea is to the east. Forest covers 60% of the country, making the terrain difficult to access. Agriculture such as bananas and sugar cane are located in the low-lying areas. Offshore, the Belize Barrier Reef is the second longest barrier reef in the world. Belize achieved full independence from British Colonial rule in 1981 (Central Intelligence Agency [CIA], 2018). Male and female distribution is equal and approximately 55% of the population lives in rural areas. The population is young with just 6% over the age of 60 (Ministry of Health, 2014).

In Belize there has been increased report of non-communicable diseases, such as diabetes mellitus type2, heart disease, cardiovascular disease, cancer, and depression. The leading causes of death are heart disease and complications related to diabetes (Ministry of Health, 2014). These preventable and treatable diseases are contributing to a reduction of overall life expectancy. Additionally, there are incidences of communicable diseases such as dengue, vector borne malaria, and HIV (Ministry of Health, 2014). These problems are associated with high costs and an increasing need for healthcare workers.

The use of mHealth as a solution for potentially improving the healthcare delivery system in the country of Belize was explored using a social, political, economic, legal, intercultural, and technological (SPELIT) approach (Schmeider-Ramirez & Malette, 2007), to examine the environment of the issue of healthcare access in Belize. Incorporated into the SPELIT analysis was the use of a strategic healthcare analysis tool, the World Health Organization (WHO) System Assessment Framework (WHO, 2018). The WHO framework is comprised of essential building blocks required for an effective healthcare delivery system. These system building blocks include leadership and governance, healthcare financing, health workforce, medical technology, service delivery, and health information systems.

Environment of the Issue (SPELIT)

Social determinants of Belize healthcare
Where an individual resides and grows up are social elements that impact one’s health and well-being. Poverty, access to clean water, quality of housing, education, and lifestyle choices all have an effect on health. According to the World Fact Book, approximately 41% of Belizeans live below the poverty line (CIA, 2018), and the Caribbean Development Bank’s (2009) poverty report emphasizes that in Belize there is a high correlation between lack of income and health and well-being. Over half of the population lives in rural areas, 99% have access to drinking water, and 90% have access to improved sanitation conditions (CIA, 2018). While education plays a role for disease prevention, health literacy is also a key to wellness. Many Belizeans have limited access to education, as high costs prohibit them from attending high school; therefore, formal education and science-backed information about health and wellness is often lacking.

While there are private medical care associations in Belize, the government implements a national insurance plan overseen by the Ministry of Health. This national insurance plan provides affordable healthcare to the citizens of Belize. National funding is concentrated on urban areas, and these areas are served by hospitals. Those living in poor and remote areas have fewer resources and might be served by a small health center with a nurse as the primary point of care, with a weekly visiting physician (Belize Ministry of Health, 2014). There is additionally the presence of non-governmental organizations that provide healthcare services to underserved areas (Pan American Health Organization, 2009).

Physicians are trained in the UK, Cuba, US, Guatemala, and Mexico. There are offshore medical schools, and the University of Belize has a nursing school. Locally trained professionals are in high demand and are often recruited to practice out of the country. As a result, the government has formed agreements with Cuba and Nigeria to supply nurses to Belize (Belize.com, 2018; Pan American Health Organization, 2009).

Political aspects of Belize healthcare

The government of Belize is a parliamentary democracy (National Assembly) under a constitutional monarchy with a system of English common law (CIA, 2018). The Ministry of Health, located in the capital city of Belmopan, is run by a Chief Executive Officer who works with a Director of Health Services to oversee the Belize healthcare system. Services are organized by region, overseen by a Regional Manager and Deputy Regional manager. The National Health Information Steering Committee leads the strategy and advises the Ministry of Health. This committee is comprised of 13 members of the Ministry of Health and various government officials (Belize Ministry of Health, 2010). This Steering Committee makes decisions about health needs of citizens, issues of public and private healthcare delivery, government healthcare policies, regulations, and service quality standards (Ministry of Health, 2014).

Economic factors affecting Belize healthcare. Major economic industries are agriculture, tourism, and fisheries. The service industry and tourism account for 55% of the country’s GDP (Ministry of Health, 2014). High unemployment, debt, and a trade imbalance contribute to the economic issues that account for the cause of poverty. The country lacks training programs for job creation; it lacks infrastructure support for education, community development, and social programs (CIA, 2018).

Approximately 5.8% of the GDP is spent on healthcare (CIA, 2018).  The total health expenditure is primarily from public sources. The Belize Health Care Sector reform program was a 30 million (U.S. dollars) project intended to provide universal health access to all citizens (Belize Ministry of Health, 2014). While this universal healthcare plan was intended to make healthcare accessible for all citizens of Belize, there is an inequitable distribution of resources, with rural regions receiving less investment.

Legal considerations for Belize healthcare.  There are legislative proposals pending for regulating medical and dental care, including nursing, midwifery, and distribution of pharmaceuticals and medical equipment. The legislation is intended to provide the Ministry of Health with the constitutional authority for regulating the health care system (Ministry of Health, 2014). While there was a national e-government policy formulated in 2008, it appears there are no national laws or regulations for electronic health systems that establish a system of privacy protections for consumers.

Intercultural influences of Belize healthcare. Belize is comprised of an ethnically diverse population containing four ethnic groups: Creole, Maya, Garinagu, and Mestizo (CIA, 2018). Culture plays a part in the high incidences of non-communicable diseases such as diabetes and hypertension, as these are related to diet and lack of awareness of nutrition and its effects on disease.

Current use of healthcare technology. In 2004, the government invested in a Health Information System, an IT solution with a goal to expand health information to rural areas and to improve data and reporting of information. Utilizing an electronic medical record system allows portability of healthcare information among the regions (Belize Ministry of Health, 2010).  However, challenges such as weak IT support, lack of standards, and poor interoperability have rendered this system inefficient. Wasden (2014) reports that to take advantage of mHealth in providing service delivery, a market needs an electronic health record system. He further posits that integrating electronic healthcare records to communicate within a system with hospitals and physicians is a prerequisite for a successful mHealth strategy. While the system is not efficient, it is a strength that Belize has the infrastructure in place and is working towards effective use of the electronic system. Furthermore, 63% of Belizeans have mobile phones and 44% are internet users (CIA, 2018), making use of mobile technology for healthcare delivery to be a feasible option.

Problem Statement

Belize suffers from healthcare deficiencies, including a rise in the incidence of non communicable diseases such as diabetes, heart attack, stroke, and depression. Furthermore, Belizeans have poor awareness and education about the prevention and consequences for these diseases. Consequently, there is needed improvement in overall education, particularly in the areas of health awareness, nutrition, and disease prevention. In addition, there is an inequality in healthcare access for all citizens, with those in rural and poor areas lacking consistent access to physicians, nurses, and medicine. Finally, a shortage of healthcare workers results in an infrastructure that cannot meet the needs of the people.

Key Economic Principles That Have an Effect on the Quality of Healthcare in Belize

Production, resources, and scarcity. Healthcare can be viewed as a service that can be produced, with resources being personnel required for delivery of those services. Production of health care workers in Belize is limited to a few in-country training institutions and import of workers from other countries. By not supporting a high school educational system, the government is in effect limiting the number of students that can enter the university system to produce a pool of needed health care resources in the communities of Belize. The shortage of healthcare workers, or scarcity of personnel resources, results in unmet needs of the Belizean people. Furthermore, by not supporting healthcare workers with an efficient system, workers are enticed to practice in other countries.

Human capital. Human capital refers to the knowledge and skills of people. The knowledge and skills provide economic value. Human capital is related to economic growth as measured by investment in education, resulting in higher earnings and higher spending (Nickolas, 2018). Health expenditures are also an investment in human capital (Chang & Ying, 2005). To improve health, it is important to reduce the disparity of quality health services in the country. Lee, Kiyu, Millman, and Jimenez (2007) state that research shows a strong correlation between a strong national health system and health outcomes. They posit that strong human and social capital can be created by developing a national health care system strategy of strengthening communities through service delivery in health care centers and clinics and by improving education in schools.

Investing in education and an equal distribution of health care access will improve disease prevention and life expectancy, thereby preserving human capital for working and contributing to the economy. Establishing mHealth education and training programs for building a workforce will be an investment in human capital.

Efficiency and equity. Economic maximization of resources can be viewed according to efficiency and equity. Efficiency is a means to the greatest production, and equity is how those resources are distributed fairly across a population (Parkin, 2017). The quality resources for health education, diagnosis, and treatment in Belize are not only lacking but not used efficiently and equally in urban and rural areas. Most healthcare professionals are located in urban areas, and there are gaps in staffing and distribution of medical equipment in the regions (Pan American Health Organization, 2009).

The WHO states that there is inequity in healthcare in emerging countries. There is not a fair and equal distribution of healthcare services throughout the world, and in particular, those in emerging countries suffer from a shortage of healthcare workers. Belize should include reduction of healthcare inequalities as a goal of the country’s health policy and strategy in order to maximize service delivery, focus on prevention, and reduce overall costs associated with disease.

Alternatives

The use of mHealth is a viable alternative and adjunct to the current healthcare delivery system of Belize. There are many key benefits to the implementation of a mobile health access program, specifically in the areas of access, quality, education, and training. For those patients that live in remote areas, where education about a condition or access to care is difficult to obtain, health and wellness information can be delivered via mobile phones. Accordingly, physician services can be delivered via mobile solutions such as monitoring of blood sugars associated with diabetes or blood pressure levels associated with hypertension. Moreover, data can be collected at the nearest health center and integrated into an electronic health record system to monitor patient status. Subsequently, quality of care can improve when sharing of information between patients and healthcare professionals is done efficiently and securely. Access to electronic information can additionally help to make better diagnostic and treatment decisions. Equally important, mobile health tools can provide learning and training for healthcare professionals. These mobile health approaches can allow patients to be educated and to take control over managing their health, thus decreasing risks associated with a chronic disease.

Objectives and Action Needed for Implementation

Involvement of Key Leaders and Stakeholders

There are multiple stakeholder interests for mHealth implementation in Belize. For the patient, improved care and taking responsibility of care is needed. For the healthcare provider, delivering quality care efficiently is paramount. For the government, equitable delivery of a national health system is a priority. For the mobile tech companies, there is great potential in emerging countries for providing equipment services and platforms.

For mHealth to be a viable solution for an emerging country such as Belize, it will be important to engage these healthcare stakeholders to develop a national strategy. Support will be needed from the Ministry of Health, given the government’s role in overseeing the national health care system. Support will also be needed from private healthcare companies, health educators at the universities, health care center workers, and regional overseers. Additionally, support from the Belize telecommunication providers such as Speednet or BTL Belize Telemedia Limited could not only assist with network connectivity, but these companies have a customer base and knowledge of consumer habits that will allow them the ability to market any new mHeatlh technologies with a large distribution network (Accenture, 2014). Additionally, mHealth technology companies are eager to enter and invest in emerging markets to provide products that focus on disease prevention, education, and data collection.

Action Steps

An mHealth implementation plan in Belize can be strategically designed using resources from the WHO’s (2012) “National eHealth Strategy Toolkit.” This toolkit provides a strategic framework for developing and implementing healthcare technology solutions on a national level. First and foremost, it will be important for the government to develop a national vision for mHealth. The Ministry of Health will be required to implement leadership and invest in technology and workforce training. It will be essential that the Ministry of Health forms alliances with technology companies and health workers to provide healthcare services using mobile devices. For example, mobile devices such as smartphones and tablets can be given to healthcare workers. Once a national strategy is developed, the government, private sector, and organizations working to bring development to Belize can pilot an mHealth program and move to a scalable solution for equitable healthcare.

 


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