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OBJECTIVE: To explore and characterize the ethical and safety challenges of global health experiences as they affect medical students in order to better prepare trainees to face them. METHODS: Semi-structured interviews were conducted with 23 Canadian medical trainees who had participated in global health experiences during medical school. Convenience and snowball sampling were utilized. Using Moustakas's transcendental phenomenological approach, participant descriptions of ethical dilemmas and patient/trainee safety problems were analyzed. This generated an aggregate that illustrates the essential meanings of global health experience ethical and safety issues faced. RESULTS: We interviewed 23 participants who had completed 38 electives (71%, n=27, during pre-clinical years) spending a mean 6.9 weeks abroad, and having visited 23 countries. Sixty percent (n=23) had pre-departure training while 36% (n=14) had post-experience debriefing. Three macro-level themes were identified: resource disparities and provision of care; navigating clinical ethical dilemmas; and threats to trainee safety. CONCLUSIONS: Medical schools have a responsibility to ensure ethical and safe global health experiences. However, our findings suggest that medical students are often poorly prepared for the ethical and safety dilemmas they encounter during these electives. Medical students require intensive pre-departure training that will prepare them emotionally to deal with these dilemmas. Such training should include discussions of how to comply with clinical limitations.

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Nutritional and hygienic practices contribute to high morbidity and mortality rates related to malnutrition in Madagascar. This study, a research effort that brought together charitable organisations, non-governmental organisations (NGOs) and university collaborators, investigates women's health knowledge in the Anosy region of Madagascar. The needs assessment sought to characterise women's knowledge and understanding of nutrition and hygiene. Eight focus groups of 13-60 women each were conducted in the seven most impoverished communes of the Anosy region (n=373). Participants were recruited with the aid of a UK-Malagasy partnered NGO, Azafady. Study findings show that women fully understand the interplay between poor nutrition, hygiene and malnutrition but are unable to change everyday practices because the barriers to better nutrition and hygiene seem beyond their control. These findings may be used to prioritise projects and research seeking to improve nutrition and hygiene, thus reducing malnutrition in the Anosy region.

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BACKGROUND: The link between political freedom and health is unclear. We aimed to determine the association by exploring the relationship of historical and cumulative freedom levels with important health outcomes. METHODS: We obtained countrywide health indicators for life expectancy, infant mortality, maternal mortality ratio, % low birth weight babies, Gini coefficient (a measure of wealth inequality) and various markers of freedom based on political rights and civil liberties. We applied multivariable logistic regression to examine the association between health indicators and within-country years of freedom as determined by Freedom House rankings. RESULTS: The total proportion of free years from 1972-2005, the duration of current freedom level, and the Gini coefficient show independent positive associations with health indicators, which remain after the adjustment for national wealth, total government expenditure, and spending on health. Countries identified as having high total proportion of free years demonstrated significantly better health outcomes than countries with low levels of freedom (life expectancy, Odds Ratio [OR] 7.2, 95% Confidence Interval [CI], 2.3-22.6, infant mortality OR 19.6, 95% CI, 5.6-67.7, maternal mortality ratio, OR 24.3, 95% CI, 6.2-94.9, and % low birth weight babies OR 3.8, 95% CI, 1.4-10.8). This was also the case for infant mortality (OR 3.4, 95% CI, 1.0-8.4), maternal mortality ratio (OR 4.0, 95% CI, 1.2-12.8), and % low birth weight babies (OR 2.6, 95% CI, 1.0-6.6) among countries considered as having medium levels of freedom. INTERPRETATION: We found strong associations between country-level freedom and important health outcomes. The cumulative level of freedom over time shows stronger associations with all health indicators than the duration of current freedom level.