|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 2 | Page : 133-139
Using Maslow's hierarchy to highlight power imbalances between visiting health professional student volunteers and the host community: An applied qualitative study
Tracey Evans1, Orezioghene Akporuno2, Katrina M Owens2, Brittany Lickers2, Jazmin Marlinga3, Henry C Lin1, Lawrence C Loh4
1 Department of Evaluation and Research, The 53rd Week Ltd., Brooklyn, NY, USA
2 Student Success Centre, McMaster University, Hamilton, Ontario L8S 4L8, Canada
3 Department of Evaluation and Research, The 53rd Week Ltd., Brooklyn, NY, USA; Cumming School of Medicine, University of Calgary, 2500 University Dr. NW Calgary, Alberta, Canada T2N 1N4, Canada
4 Department of Evaluation and Research, The 53rd Week Ltd., Brooklyn, NY, USA; Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
|Date of Web Publication||19-Sep-2017|
Lawrence C Loh
c/o Peel Public Health, 7120 Hurontario Street, 7th Floor, Mississauga, ON, L5M 2C2, Canada
Source of Support: None, Conflict of Interest: None
Background: Health professional students from high-income countries increasingly participate in short-term experiences in global health (STEGH) conducted abroad. One common criticism of STEGH is the inherent power differential that exists between visiting learners and the local community. To highlight this power differential, this paper explores perceived benefits as described by volunteer and community respondents and applies Maslow's hierarchy of needs to commonly identified themes in each respondent group. Methods: A semistructured survey was used to collect qualitative responses from both volunteers and community members located in a Dominican Republic community, that is, a hotspot for traditionally conducted STEGH. Thematic analysis identified themes of perceived benefits from both respondent groups; each group's common themes were then classified and compared within Maslow's hierarchy of needs. Results: Each respondent group identified resource provision as a perceived benefit of STEGH, but volunteer respondents primarily focused on the provision of highly-skilled, complex resources while community respondents focused on basic necessities (food, water, etc.) Volunteer respondents were also the only group to also mention spiritual/religious/life experiences, personal skills development, and relationships as perceived benefits. Applying Maslow's hierarchy thus demonstrates a difference in needs: community respondents focused on benefits that address deficiency needs at the bottom of the hierarchy while volunteers focused on benefits addressing self-transcendence/actualization needs at the top of the hierarchy. Conclusions: The perceived difference in needs met by STEGH between volunteers and the host community within Maslow's hierarchy may drive an inherent power differential. Refocusing STEGH on the relationship level of the hierarchy (i.e., focusing on partnerships) might help mitigate this imbalance and empower host communities.
Keywords: Education, ethics, global health, medical education, medical missions, volunteering
|How to cite this article:|
Evans T, Akporuno O, Owens KM, Lickers B, Marlinga J, Lin HC, Loh LC. Using Maslow's hierarchy to highlight power imbalances between visiting health professional student volunteers and the host community: An applied qualitative study. Educ Health 2017;30:133-9
|How to cite this URL:|
Evans T, Akporuno O, Owens KM, Lickers B, Marlinga J, Lin HC, Loh LC. Using Maslow's hierarchy to highlight power imbalances between visiting health professional student volunteers and the host community: An applied qualitative study. Educ Health [serial online] 2017 [cited 2020 Jul 7];30:133-9. Available from: http://www.educationforhealth.net/text.asp?2017/30/2/133/215085
| Background|| |
Among health professional students in high-income countries, recent years have seen an increasing interest in short-term experiences in global health (STEGH) being undertaken in developing countries, with associated academic interest around the form, function, and ethics of participating in such efforts.,, Despite notable variations in form, broad definitions in literature often describe such experiences as groups of volunteer health professions students from high-income countries visiting a lower or middle-income country over a period of 7–90 days in a culturally immersive experience that is traditionally focused on service, learning, and/or research.,
Factors driving participation in STEGH are even more complex. While one documented driver is a desire on the part of volunteers to provide positive community change, literature has also documented many other motivators encouraging participation, such as a desire to visit and experience a different country, a desire to develop both formal and soft skills (e.g., cultural sensitivity), or assistance with career planning and/or mentorship.,, Similarly, literature has increasingly documented concerns around potential burdens imposed on communities that host STEGH, such as misalignment between local priority needs and volunteer program goals, potential disruption of the local economy, harms from services provided and lack of follow-up, “cultural colonialism,” and the development of dependence on volunteer teams., Minimal local partnership and guidance is a commonly cited reason for these burdens. Taken together, the concern becomes that STEGH occurs under the guise of “providing developmental aid” when in reality, the goal is for students to travel and gain international work experience.
A key ethical concern expressed in literature is that a power differential exists between the visiting volunteers from high-income settings and members of the host community. This power differential can be defined around the concept that in traditional forms of service-focused volunteering, members of the host community may be reluctant to disagree or decline offers of assistance even if it causes harm or does not align with community needs or priorities.,,, To date, however, specific data illustrating this imbalance have not been presented in literature. This paper addresses this gap by reporting on a qualitative study conducted in a STEGH “hotspot,” which surveys visiting health professions students and community members around the perceived benefits of STEGH. By subsequently mapping themes from these responses onto Maslow's hierarchy of needs, one is able to use the reported benefits in each group's responses to illustrate differences in needs that might lead to a power differential between volunteers and the communities they serve and also propose strategies that might mitigate this imbalance.
The specific locale for our research was in La Romana, Dominican Republic, which has long seen an influx of volunteer health professional student groups focused on assisting marginalized Haitian populations in the community. The focus community consists of Haitian migrant workers and Dominicans of Haitian descent that are employed in the local sugarcane industry. This group typically lives in material poverty with their families in rural villages called bateyes, their situation perpetuated by discrimination on the basis of their ethnic background by mainstream Dominican society and government policy. Visiting health professional students participate in STEGH that provide primary medical care and support public health projects (e.g., around sanitation and water) through existing outreach efforts operated by a local mission hospital. La Romana thus presents an optimal opportunity to explore perceived benefits of STEGH on the part of student volunteers and community members and to differentiate these groups' experiences within Maslow's hierarchy of needs.
| Methods|| |
A research team was assembled which jointly consisted of volunteer researchers as well as leadership from the local mission hospital that hosts many of the visiting STEGH volunteer teams to the community. Hospital leadership had identified an interest in a comparison of perceived benefits of STEGH between local community and volunteer respondents The guiding question for this evaluation was based on a hypothetical scenario: “If student volunteer teams were to stop visiting this community tomorrow, what benefits would be lost?”
The research team developed a semistructured interview guide consisting of probes targeted toward eliciting responses around perceived benefits within social, economic, cultural, and political domains that might be lost if short-term health professional student volunteers were to withdraw from the community. In total, ten initial questions were developed; these were designed to be explored in individual interviews. Targeted respondents included visiting volunteers as well as local community members. Three pilot interviews were conducted with random subjects for each group studied. Responses to questions were used to optimize questions for understanding and standardization. The final list of questions is specified in [Table 1].
Interviews were conducted over a 1-week field visit in early 2015. The local mission hospital directed the timing of this field visit, which occurred on a week during which healthcare-focused volunteer groups would be available for interview. The mission hospital also selected appropriately serviced bateyes from whom the community sample would be drawn; these bateyes were selected owing to their proximity to the city and the relatively high frequency, by which volunteer groups visited to provide services. In all, respondents were drawn from three concurrently visiting health professional volunteer groups and community members from the two identified bateyes. The former groups were visiting from different academic institutions in the United States and consisted of student health professionals at different points in the same course of study, participating under the supervision of qualified faculty members. Each group ranged in size from 6 to 25 participants. Community members were general members of the community who benefited from the work of volunteer teams but were not involved in working directly with the volunteer teams, i.e. they were either receiving services from relevant visiting teams, but were not say more about these groups. For both populations studied, a snowball technique was employed, starting with an interview of the identified leader of the group or community, who then identified additional respondents of interest.
Given the focus on health professional students, volunteer respondent recruitment also specifically targeted respondents who were participating in health and/or healthcare-related volunteer activities. For community respondents, bateyes identified by the local partner were selected as representative bateyes based on population, proximity to the city, and number of visits by volunteer groups annually as it was felt that larger bateyes closer to the city would be most highly frequented by volunteer groups and thus more able to provide comment. Say more about the characteristics. Recruitment of respondents proceeded with the assistance of a translator, who also acted as a cultural broker to identify community leaders and subsequent interviewees in the bateyes surveyed.
Responses were collected by voice recording and transcribed and translated into written format. These responses then underwent thematic analysis to identify perceive benefits as expressed by volunteer and community respondents. Responses were coded by two different investigators from the research team (one from the local hospital and one from the visiting researcher groups); any disagreement on coding was addressed through review by another dyad pair. Common themes for each group were then identified by saturation whereby at least six respondents relationship to the whole? from the group being analyzed (volunteer or community member) discussed a theme in whole or in part during their response as noted by coding. These themes were then summarized for each respondent group. Summarized volunteer and community themes were then compared head-to-head to identify specific similarities and differences in perceptions on the benefits of volunteer trips for each group.
Ethics approval for this project was obtained from the University of Toronto Research Ethics Board (protocol #28419).
| Results|| |
The students interviewed, while from different institutions, were within the same course of study; and thus, their responses were considered in aggregate. In total, ten health professional student volunteers (including eight undergraduate students, one postgraduate student, and one faculty supervisor) and 21 local community members were interviewed.
Benefits perceived by volunteers
Volunteer respondents identified four common themes of perceived benefits of STEGH around relationships, resource provision, spirituality and religious meanings, and skills training.
One common benefit identified by volunteer respondents focused on relationships built with community members during their volunteer trips. Specific mention was made of the negative impact that ending these volunteer trips would have on those relationships. While some respondents suggested that the language barrier and the short amount of time (i.e., 10 days) spent in the community acted as barriers to the development of strong bonds with the local community, most felt that they had in fact developed long-lasting relationships within the communities in which they were working. As one volunteer respondent, a returning visitor, explained, “Members of the community look forward to our visits and would be disappointed if we were to discontinue their short-term volunteer work.” Respondents broadly suggested that they are now “familiar faces” to local partners and that failing to continue visiting would give rise to feelings of abandonment among the community members, to whom they reported having grown close ties.
Relationships between the various volunteer groups that visit the bateyes were another theme of interest. One respondent mentioned a sense of competition between various volunteer groups, and even highlighted the resultant desire for exclusivity. This respondent stated that “Certain groups feel a sense of ownership towards the projects that they are working on, and do not want other groups to visit 'their' batey.” Other respondents stated that their overall group of health professional students was supportive of collaboration with other visiting groups and that these would foster valuable relationships, particularly on returning home.
Volunteers highlighted the resources they brought to the bateyes as another part of their contribution to the community, which ranged from medical supplies to clothing. One particular theme from responses around health-care resources suggested that a perceived lack of local leadership and capacity limited effective deployment and use of material resources. For example, one respondent suggested, “Just sending material resources for the healthcare system without volunteer expertise would be dreadfully bad.” When explored further, this respondent stated that there might be negative implications for the local community: “They really lack the capacity to properly and effectively deploy donated resources.”
Another theme that arose around resources was the need to strike a balance between providing essential resources for the community and simply offering “handouts.” Several volunteers mentioned that beyond the supplies required for the projects they were working on, they also made a note of bringing additional gifts and resources for the bateyes visited. One volunteer highlighted this: “I brought a suitcase full of clothing for the community so that I could maximize my giving.” Several volunteers referenced the financial inputs that the volunteers brought during their visits that was paid to the local hospital as fees for their experience.
Spirituality and religious meaning
Many of the respondents identified that their spiritual and/or religious identity played an important part in encouraging them to volunteer in the first place and guided their journey throughout their trips. Respondents stated that they were attending as part of a spiritual experience, with conversations about meaning and purpose being a central component of their interest in participating in the trip. Some even mentioned that they had attended church within the bateyes and had engaged in “positive conversations with locals about God, religion, and their faith.” Several volunteers expressed a “renewal in their faith” and a “strengthened belief in goodness in the world.”
While most respondents mentioned having some sort of religious identity, opinions pertaining to the role that religion should play in their trip varied among volunteers. One volunteer stated that “Besides providing clinical service, my trip is 100% faith based.” However, by contrast, other volunteers mentioned that promoting religion among the locals was difficult and that they used actions and “avenues of love and kindness” to “spread God's message” instead of actually trying to directly preach a religious message.
Volunteers also made reference to the “high quality and much-needed” assistance that they provided, particularly those who were there for medical and primary care purposes. Perhaps surprisingly, skills transfer, capacity building, and lifestyle training did not seem to be priorities for the volunteers though some expressed concerns. One respondent summed up their specific concerns around the sustainability of volunteers' efforts in stating: “Teams come in and pull teeth when someone has a toothache, but they're not educating the individuals on how they can keep their teeth clean in the first place through proper hygiene.”
Several of the volunteers suggested that the short duration of their visit limited their ability to offer skills training and to promote lifestyle changes; when asked about the sustainability of their projects, many volunteers expressed concerns about the locals' lack of ability to maintain the programs that had been implemented after the volunteers' departure, both because of a lack of resources and of capacity.
Benefits perceived by community
Community respondents largely identified two key perceived benefits from STEGH, centered around resources, and entertainment.
The most commonly referenced impact that community members observed as a result of the volunteers was an increase in access to resources. Provision of food, medical supplies and services, vitamins that are otherwise inaccessible and clothes were all referenced as benefits of having the volunteers come visit. One of the elderly community members stated through an interpreter: “I have diabetes and am unable to work. Without making money, I rely heavily on the provisions brought by the volunteers to take care of my health. The volunteers' service also provides me with access to healthcare services.”
Most locals felt that resources, gifts, and provisions were expected of volunteers during their visits. At one point throughout the research process, several community members were observed in an argument around who participate in the study because they mistakenly thought they would be remunerated financially. Locals were very focused on the material resources provided to them by the volunteers. Few if any respondents referenced the impact of volunteers' skills, expertise, and capacities as resources, for which they now had access.
For some community members, the idea of the volunteer trips no longer taking place was so unthinkable that they refused to discuss how the absence of volunteers would impact them with the researchers. One stated, “That is a very unsettling thought. Our quality of life would diminish drastically as a result of the loss in resources and gifts that the volunteers have been bringing to our community.” Others, while attesting to the fact that the absence of volunteers would no doubt have a negative impact on their communities, felt confident that even without the volunteers' support, they would still be able to access necessary medical services and could sustain themselves adequately. Several locals mentioned that although they would miss the volunteers' in their absence, they knew that they would always have God watching over them, which is what mattered most to them.
A second less common theme among locals had to do with the entertainment that international volunteers provided to the communities. Throughout the research project, researchers observed volunteers interacting with local children and saw them singing songs together despite their language barrier. Many older community respondents discussed the fact that the volunteers bring a lot of joy, entertainment, and sometimes even presents to their children and that their absence would impact the children the most.
Comparison and application of Maslow's hierarchy
In exploring various categories of benefits that might be perceived to be lost by a hypothetical withdrawal of volunteer programs from La Romana, one can see notable differences in the themes identified by volunteer and community member respondents. While both groups identified resources as a perceived benefit that would be lost, the focus differed: community members largely described an expectation of receiving gifts and material donations that would meet basic needs, while volunteers emphasized that the skills they brought were one of their most valuable resources, and expressed a desire to judiciously give gifts and avoid providing “handouts.” In addition to this, visiting volunteers tended to highlight themes of benefits around relationships, spiritual/religious experiences, and spiritual skills training. Community respondents uniquely identified entertainment and joy.
One criticism that has been levelled against traditional short-term volunteer experiences is that it fosters community dependence by entrenching unequal power dynamics between the visitors and the host community.,,, Applying Maslow's hierarchy of needs to the disparate responses observed between the groups in this study demonstrates a difference in needs that might fuel this observation. Long regarded as a framework for understanding human needs that must be successively addressed for individuals to be happy, Maslow proposes categories that range from basic “deficiency needs,” to safety, love and belongingness, and finally to self-actualization.
Applying this hierarchy to the responses collected, the nature of the benefits identified by community respondents largely falls into the “deficiency needs” category. This likely reflects their disempowered state and limited resource context; as a result, food, shelter, water, and healthcare are the basic needs respondents focused on as being met by volunteer experiences. Beyond that, community respondents did not identify relationships, religious/spiritual “life purpose” experiences, or skills training as benefits from volunteer experiences, with the exception of the notably temporary benefit of “joy and entertainment.”
By comparison, the benefits of volunteer experiences described by volunteer respondents largely qualify as “growth needs,” within the concept of self-actualization at the top of Maslow's hierarchy. In considering the benefits of their experience, which also double as reasons for participating, volunteer respondents focused on themes around spiritual and life experiences, skills building, helping others and connecting with something greater than oneself. These perceived “higher-tier” benefits have long been documented by other literature on the topic.,, The overall focus of student volunteer responses can thus be described as being at the self-actualization level of the hierarchy, with the goal of achieving self-transcendence by helping others.
This differential nature of benefits is what continues to drive participation in short-term volunteer experiences by health professional students: community members welcome volunteers with the hopes of having their basic needs met, and student volunteers participate to pursue self-actualization needs. This means that while both parties are outwardly supportive of volunteer experiences, their support largely arises for entirely different reasons. Applying Maslow's hierarchy suggests that, when considered carefully, the community is the more dependent and less privileged partner in traditional volunteering models. A focus on volunteers' self-actualization results in a simplistic, immediate-fix focus of the community members' broader health needs, which does not sustainably address underlying influential health determinants.
Maslow's hierarchy can be additionally applied to further to identify potential solutions to this disparity. Given that volunteer experiences occur in a local community, the focus of such experiences should be less about meeting basic needs or self-transcendence, but about creating and maintaining an equal partnerships. By encouraging a refocusing of volunteer experiences on fulfilling the relationship needs as described in the hierarchy, experiences should be encouraged to be less about self-actualization of volunteers or meeting the basic needs of the community. Encouraging volunteers and host community members to focus on making developing a meaningful, open, and transparent partnership would mitigate the power differential and foster conversations around how volunteer experiences could meaningfully address local community priorities. The opportunity to optimize community impacts of STEGH (including those run by students), by focusing on partnerships rather than service provision, has been recognized in literature., Over time, one might imagine that a healthy and equal partnership will empower community leaders to have frank discussions about if and how student STEGH volunteer teams can meaningfully address community needs as community leaders will be encouraged to focus more on directing rather than simply supporting or hosting STEGH groups and their activities.
It is worth noting that our study is subject to certain limitations. First, the material resources and time available to conduct field work precluded a longer, detailed exploration of diverse, large volunteer cohorts over an extended period of time. However, the themes identified in this paper very much serve as a starting point for further exploration and research, and in particular, the differences in perceived needs that have been met is in keeping with the hypothesized power differential described in other literature on the subject. In addition, the findings were limited to two bateyes in a single community in the Dominican Republic with input from three health professional volunteer teams and may not reflect the findings of groups elsewhere. That said, the hypothesised power differential is likely in any circumstance where a volunteer from a high income country undergoes an experience in a low or middle income country, so parallels are likely to exist. Finally, Maslow's hierarchy is being used as a proxy here to demonstrate the power differential through a difference in needs. However, given that the hierarchy of needs has evidence to support its application, with individual seeking basic needs before more abstract needs as described, one might expect that this is a reasonable proxy and in fact would be more amenable to conducting a research study where the question of power differential is explicitly asked of participants.
| Conclusions|| |
Maslow's hierarchy of needs can be used to conclusively demonstrate the significant disparity that exists based on reported benefits perceived by student volunteer participants and host community members arising from short-term volunteering in La Romana, Dominican Republic. These findings reinforce concerns that traditionally service-focused short-term volunteer experiences might perpetuate these disparities, resulting ineffective, or worse yet, harmful impacts on the host community.
To mitigate potentially negative impacts and to optimize sustainability, further application of Maslow's hierarchy suggests that encouraging student volunteer experiences to focus on developing an equal, meaningful partnership between visitors and the host community will optimize the impacts of such efforts. A strong and transparent relationship will also make it easier to empower and privilege the voice of the local partner in identifying and planning for key program priorities that might be addressed by visiting volunteers, which will help address many of the current concerns around unidirectional short-term experiences that fail to adequately account for the community's input in their endeavors. This will require concerted efforts to educate and equip student volunteers with a mindset of responsibility, design programs that foster these relationships, select appropriate skill mixes of student volunteers, and embed the work of these volunteers long-term development projects with a defined endpoint, and provide broader societal context through laws and policies to encourage the development of partnerships as one strategy in promoting the responsible conduct of STEGH abroad.
We gratefully acknowledge the assistance and support of the staff and leadership at Good Samaritan Hospital, La Romana, who provided local guidance in the drafting of the survey and the data collection phases of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): Ethical principles to optimize community benefit and learner experience. Acad Med 2016;91:633-8.
Dowell J, Merrylees N. Electives: Isn't it time for a change? Med Educ 2009;43:121-6.
Dacso M, Chandra A, Friedman H. Adopting an ethical approach to global health training: The evolution of the Botswana-University of Pennsylvania partnership. Acad Med 2013;88:1646-50.
Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: A methods study to evaluate quality of care. BMC Health Serv Res 2008;8:121.
Crump JA, Sugarman J. Guidelines for global health training. Health Aff (Millwood) 2011;30:1215.
Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: A call for more training and opportunities. Acad Med 2007;82:226-30.
McBride AM, Lough BJ, Sherraden MS. Perceived impacts of international service on volunteers: Interim results from a quasi-experimental study. Washington, DC: The Brookings Institution; 2010.
Evert J, Bazemore A, Hixon A, Withy K. Going global: Considerations for introducing global health into family medicine training programs. Fam Med 2007;39:659-65.
Friedman A, Loh L, Evert J. Developing an ethical framework for short-term international dental and medical activities. J Am Coll Dent 2014;81:8-15.
Loh LC, Cherniak W, Dreifuss BA, Dacso MM, Lin HC, Evert J. Short term global health experiences and local partnership models: A framework. Global Health 2015;11:50.
Palacios C. Volunteer tourism, development and education in a postcolonial world: Conceiving global connections beyond aid. J Sustain Tour 2010;18:861-78.
Crump JA, Sugarman J; Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 2010;83:1178-82.
DeCamp M, Rodriguez J, Hecht S, Barry M, Sugarman J. An ethics curriculum for short-term global health trainees. Global Health 2013;9:5.
Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service-learning trips on medical students. Acad Med 2012;87:820-8.
Ferrara BJ, Townsley E, MacKay CR, Lin HC, Loh LC. Short-term global health education programs abroad: Disease patterns observed in Haitian migrant worker communities around La Romana, Dominican Republic. Am J Trop Med Hyg 2014;91:871-5.
Loh LC, Valdman O, Dacso MM. Coalicion de Salud Comunitaria (COSACO): Using a Healthy Community Partnership framework to integrate short-term global health experiences into broader community development. Global Health 2016;12:15.
Taormina RJ, Gao JH. Maslow and the motivation hierarchy: Measuring satisfaction of the needs. Am J Psychol 2013;126:155-77.
Collins KJ, Collins RJ, Wood JB. Long-term benefits of short North-South exchange visits. Lancet Glob Health 2015;3:e365.
Rodriguez A, Ho T, Verheyden C. International programs in the education of residents: Benefits for the resident and the home program. J Craniofac Surg 2015;26:2283-6.
Yuen MK, Carlos CM, Phan L, Wiener AA, Lin HC, Loh LC. More than just the T-shirt: Reflections from first-time participants in global health service. Can Fam Physician 2014;60:556-7.