





































COMMUNITY ENGAGED RESEARCH ORUCHE | NON-COMMUNICABLE DISEASES 

Community Engagement to 
Improve the Management of 
Non-Communicable 
Diseases  
Experiences from Medical Service Trips in Southeastern Nigeria 

UKAMAKA M. ORUCHE, JENNY LIU, TAMARA OTEY, AUGUSTINA HONE, IFEANYI 

OKWUCHUKWU, YVONNE COMMODORE-MENSAH 

ABSTRACT 

In rural communities in low-and middle-income countries like Nigeria, healthcare is a 
patchwork of services. Only a small portion of the healthcare provision in Nigeria 

comes from a unified health 
system. Therefore, remote and 
rural communities receive 
minimal preventive health 
services. Medical missions can 
play a critical role in closing gaps 
in care and improving healthcare 
access for vulnerable populations. 
However, long-term sustainability 
is difficult to achieve without 
deliberate community engagement 
from planning to evaluation. In 
this manuscript, the authors 
describe a collaborative, 
community-engaged global health 
service project in rural 
southeastern Nigeria that included 
medical missions and provided 
continuous care of non-
communicable diseases post-
mission for sustained impact. The 

authors conclude with insights gained regarding the challenges of engaging 
communities at a distance through translational collaboration as well as implications 
for conducting such work. 

Keywords: Low- and middle-income countries, non-communicable diseases 
(NCDs), Medical mission, sub-Saharan Africa, Nigeria, Community engagement

Authors

UKAMAKA M. ORUCHE 
Indiana University 
School of Nursing 

JENNY LIU 
Institute for Health & 
Aging, Department of 
Social & Behavioral 
Sciences  
University of California  

TAMARA OTEY  
Goldfarb School of 
Nursing at Barnes-
Jewish College 

AUGUSTINA HONE 
Indiana University 
School of Nursing 

IFEANYI 
OKWUCHUKWU  
Providence Care 
Community Health 
Initiative, Nigeria 

YVONNE 
COMMODORE-
MENSAH  
John H opkins School of 
Nursing  

Picture 1. Volunteer nurses registering patients at 
check-in station. 

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BACKGROUND 

Nigeria is a low-and middle-income country 
(LMIC) in West Africa, which has a healthcare 
workforce concentrated in urban tertiary health 
care centers, contributing to inequity of 
healthcare services in rural areas and poor 
management of non-communicable diseases 
(NCDs) (World Health Organization [WHO], 
2020). In rural communities in LMICs like 
Nigeria, healthcare is a patchwork of healthcare 
services. Only a small portion of the healthcare 
provision in Nigeria comes from a unified health 
system. Therefore, remote and rural communities 
receive zero to minimal preventive health services 
(Innocent, Uche, & Uche, 2014). LMICs have 
limited health resources, which contribute to high 
morbidity and mortality from NCDs, such as 
diabetes and hypertension (Roth et al., 2018). 
Both diabetes and hypertension are expected to 
increase over the next few decades, especially in 
sub-Saharan African (SSA) countries like Nigeria 
(Adeloye, 2014; Adeloye & Basquill, 2014; Cho et 
al., 2018). If left untreated, diabetes and 
hypertension can cause cardiovascular disease, 
stroke, and eye diseases (Feigin et al., 2016). 
However, preventive care and primary care for 
NCDs are limited in LMICs, resulting in many 
undiagnosed cases. Other cases are diagnosed 
late, often through free public health outreach 
programs or “medical missions” (Sykes, 2014), 
resulting in suboptimal treatment and poor 
management (Burnier & Egan, 2019; Danaei et 
al., 2011). Misconceptions about the treatment of 
NCDs, such as believing that diabetes and 
hypertension are healed after completing a month 
of medication, also contribute to the high burden 
of these conditions (Amira & Okubadejo, 2007; 
Osamor & Owumi, 2011).  

In many LMICs, gaps in health services are 
partially filled by medical missions or short-term 
medical service trips (MSTs) by non-
governmental organizations. Medical missions are 
defined as travel by trained health professionals, 
to foreign countries, with a specific medical 
purpose for a designated period, ranging from one 

week to years, depending on the organization 
(Malay, 2017). Similarly, short-term MSTs 
address the unmet health care needs of LMICs 
(Sykes, 2014). Increasingly, travel teams also 
include non-medical or allied health 
professionals. Although they prioritize medically 
underserved populations, medical missions often 
operate in silos, stay for short periods, lack long-
term funding, and ultimately are difficult to 
sustain (Adepoju, 2019). Medical missions are not 
widely studied, nor are reports of medical 
missions widely disseminated (Sykes, 2014). The 
reports that are published in professional journals 
often only report the frequency of procedures or 
the number of patient visits. Rarely do reports 
demonstrate a thorough understanding of the 
social, cultural, and medical characteristics of the 
patient population served. Thus, little is known 
about optimizing and sustaining this service 
delivery channel in harmony with public health 
goals and the broader healthcare ecosystem. The 
lack of research on medical missions has led to 
lost opportunities to identify lessons learned and 
best practices (Sykes, 2014).  

Global health service projects should improve the 
health and well-being of the most marginalized 
populations from LMICs (Center for Disease 
Control, [CDC], 2015; Pratt, 2020), which can be 
accomplished by engaging the community 
through research and global health service 
projects. Indeed, community-engaged experts 
have recommended guiding principles for forming 
effective community-engaged global health service 
projects in disadvantaged communities (CDC, 
1997; 2015). Items included the host community 

Global health service projects should 
improve the health and well-being of 

the most marginalized populations 
from LMICs (Center for Disease 

Control, [CDC], 2015; Pratt, 2020), 
which can be accomplished by 

engaging the community through 
research and global health service 

projects. 

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defining and directing the program, planning for 
sustainability programs, regularly evaluating 
programs for impact, and mutually learning from 
and respecting local professionals. 

In Nigeria, the community includes local 
government leaders, policy-makers, tribal 
hierarchy, community organizations, community 
members, and their families. Anambra is a state in 
southeastern Nigeria and the eighth-most 
populated state in the Federal Republic of Nigeria. 
Over 60% of its people live in urban areas, making 
it one of Nigeria’s most urbanized communities. 
Although Anambra State has the lowest poverty 
rate in Nigeria (Anambra State Government - 
Light of The Nation, n.d.), its rural communities 
need sustainable global health service projects. To 
effectively engage the community, attention must 
be given to existing dynamics of power, diversity, 
and stakeholders (Pratt, 2020). A voice must be 
given to those who feel powerless, such as 
individuals who are female, poor, under educated, 
and disabled (Pratt, 2020). This manuscript 
describes a collaborative, community-engaged, 
global health service project in rural southeastern 
Nigeria. Compared to traditional medical missions 
as defined above, the global health service project 
described here included not only medical missions 
but also continuous care of NCDs post-mission.  

The Centers for Disease Control (CDC) recognized 
the critical importance of involving the 
community and collaborating with its members to 
improve health. In its seminal publication, 
“Principles of Community Engagement,” the CDC 
defined community engagement as the “the 
process of working collaboratively with and 
through groups of people affiliated by geographic 
proximity, special interest, or similar situations to 
address issues affecting the well-being of those 
people” (CDC, 1997, p. 9). Consistent with this 
definition, community engagement processes 
(described herein) were facilitated through the 
collaboration of two leaders (a medical director 
and a nurse), connected by their shared affiliation 
to the community and shared mission to improve 
the health of the community using their assets, 

clinical experiences, and social connections. The 
two leaders sought input from respected residents 
and patients in the community and recruited local 
health care professionals to provide culturally 
relevant and acceptable services. Applying 
community engagement principles and processes 
was critical to the conceptualization and 
implementation of an effective and sustained 
project that improved the health of the 
community.  

The purpose of this global health service project 
was to increase access to care for NCDs and 
improve patients’ self-management of conditions, 
including diabetes and hypertension. Using 15 
years (2004-2018) of field notes and 
programmatic data, we describe the processes and 
mechanisms utilized with respect to (1) working 
within the social and cultural context to treat 
NCDs and (2) engaging the community to improve 
healthcare; additionally, we (3) share lessons 
learned related to the importance of community 
engagement for long-term program sustainability. 

ORIGIN AND EVOLUTION OF THE 
GLOBAL HEALTH SERVICE PROJECT 

A Nigerian expatriate U.S.-based registered nurse 
(U.O.) was driven by a personal passion to give 
back. The journey began in December of 2003 
when the nurse traveled to Amichi in Nigeria with 
her nuclear family to visit extended family and 
celebrate Christmas. While there, the nurse had 
planned to visit and tour the only hospital in the 

The two leaders sought input from 
respected residents and patients in the 

community and recruited local health 
care professionals to provide culturally 

relevant and acceptable services. 
Applying community engagement 

principles and processes was critical to 
the conceptualization and 

implementation of an effective and 
sustained project that improved the 

health of the community. 

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town to understand how medical and nursing care 
were structured and delivered to patients 
compared to the U.S. However, when she visited 
the hospital, the medical director, a physician, was 
not available, and therefore she did not tour the 
hospital. Rather, she left a duffle bag filled with 
band-aids, vitamins, and over-the-counter 
medical supplies. She had no other plans to return 
to the hospital before traveling back to the U.S. 
However, her 14-year-old son got sick with 
symptoms indicative of possible malaria, which 
she did not know how to treat. Therefore, she and 
her husband returned to the hospital with their 
son for treatment. Incidentally, the medical 
director was present and treated her 14-year-old 
son. The nurse reflected that she could not forget 
the exam room where her son was treated. The 
hospital environment was very clean, and the staff 
was warm and kind. However, they were working 
with very limited resources, as depicted in Picture 
2 of the injection room. She made a promise to 
herself that she would renovate it (Picture 3). The 
nurse requested and received an appointment to 
tour the hospital on January 1, 2004.  

The medical director (O. O.) was driven by a 
passion for improving the health of the local  
community. He had been in this position for one 
year, having been recruited by the hospital 
administrators to elevate the quality of service to 
residents of the community. He had been away 

from the hospital at a meeting the first time the 
nurse came and dropped off the duffle bag of 
medications. He appreciated that the nurse took 
the time to inquire about their well-being and 
bring medical supplies and hoped that she would 
return as promised. He urged the nurse to return 
for a tour of the hospital. The medical director and 
nurse decided to collaborate to develop a global 
health service project. 

Host community defining and directing 
the program.  

Before starting the global health service project, it 
was necessary to define the purposes of the 
engagement effort and the goals of the 
community. On New Year’s Day, when people 
often celebrate with their loved ones, the medical 
director and nurse embarked on a four-hour tour 
of the hospital. During this needs assessment tour, 
the medical director and nurse discussed what the 
hospital and staff needed to care for patients. The 
medical director said they needed running water 
and medications. The nurse was astonished, 
thinking, “Really? What hospital operates without 
running water?” The medical director explained 
that the hospital had to bring water into the 
facility; if they did not, patients’ families would 
have to bring their own water. The medical 
director described that they did not have access to 
authentic, quality medications. When available, 

Picture 2. Injection room before renovation Picture 3. Injection room after renovation 

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medications were unaffordable for both patients 
and the hospital. After learning about these 
difficulties, the medical director and nurse agreed 
to work together on a mission to improve access to 
health care services for the 50,000 residents of 
Amichi and the 23 surrounding towns in Anambra 
state.  

Keys to Community Engagement: Trust 
and Shared Leadership.  

The agreement to work together was supported by 
two principles fundamental to community 
engagement: trust and shared leadership. First, 
the medical director and nurse understood that 
building trust was important for soliciting buy-in 
and participation. While health services projects 
led by “outsiders” may struggle with building a 
trusting relationship within communities, this 
global health services project successfully built a 
trusting relationship because the leaders were 
community members. The medical director was 
trusted in the community, given that he had 
served and lived in the community for three years, 
and the nurse was trusted, given that she was a 
native of the town with strong ties to the 
community and cultural competence (i.e., asset-
based engagement). Together, these two leaders 
recruited volunteers and colleagues to help 
transform the healthcare system. Second, shared 
leadership was important for improving access to 
affordable and quality health care services that 
can be achieved with genuine collaboration. The 
medical director and nurse shared leadership, co-
directing the global health service project. They 
leveraged their respective assets and expertise to 
accomplish their shared mission on behalf of the 
community. Additionally, the medical director 
and nurse shared leadership, co-leading the global 
health service project. For example, to improve 
the quality of care, the medical director agreed to 
oversee all patient treatment and leverage existing 
nursing staff, whose buy-in was supported with 
small stipends in addition to their regular salaries, 
to provide patient care on a designated day of the 
week. To make care affordable, the nurse agreed 
to request medications from charity organizations 

in the U.S., such as Americares. These donated 
medications would be dispensed at no cost to 
patients in Anambra, Nigeria. The two leaders 
committed to serving all persons irrespective of 
demographic, socioeconomic, religious, political, 
or other affiliations. The partnership was not 
codified in any written contract; rather, it was 
achieved through informal commitments and 
trust. 

ANNUAL MEDICAL MISSION EVENTS 

Partnering with the community was necessary to 
create change and improve health. In 2004, the 
medical director and other Nigerian-based 
volunteers collaborated with a U.S. volunteer 
team, including the nurse, her husband, and a 
U.S.-based physician, and conducted the first
medical mission in the community. Since then,
they have inspired the development of three other
medical mission teams. The medical director and
nurse worked collaboratively, led different
components, and leveraged their respective social
connections to improve the health of the
community and its members. The Nigerian-based
medical director coordinated volunteers, arranged
community public service announcements, and
arranged on-site amenities (e.g., chairs, tables,
and refreshments) for volunteer workers.
Volunteers were recruited via text messages and
word-of-mouth. Volunteers came from other parts
of Nigeria (e.g., Lagos) as well as the U.S. This
local collaboration facilitated trust among
community members who saw the local volunteers
as trusted partners. The multidisciplinary
volunteers of health professionals included
nurses, doctors, and allied health professionals.
To increase reach, medical missions were
announced at key community gathering spaces,
such as places of worship, schools, and markets.
We recruited the services of the “town crier” who
announced the mission to the residents.

The U.S.-based nurse oversaw fundraising. She 
solicited donations from family, friends, and 
colleagues in person and through letters. She 
explained that the goal of the global health service 

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project was to improve access to good, quality care 
and that monetary donations would be used only 
to purchase medications and medical supplies for 
patients. Additionally, she procured supplies for 
the medical missions from foundations and 
organizations in the U.S. (e.g., Timmy Global 
Health in Indianapolis, IN; Americares in 
Stamford, CT). Timmy Global Health provided 
administrative support by collecting donations 
and keeping records. Once the donations were 
received, the nurse requested relevant 
medications (e.g., high blood pressure and 
diabetes medications) and medical supplies (e.g., 
blood pressure monitors, glucometers, and test 
strips). She delivered them to Nigeria for medical 
missions and follow-up care. The size of the 
annual mission was tailored according to the 
amount of funding. We relied upon the medical 
director’s first-hand knowledge of the 
community’s most common health conditions to 
determine which medications and medical 
supplies to purchase. Understanding the most 
prevalent health conditions, the medical director 
and nurse used their limited resources to treat 
these conditions and sought partnerships with 
experts in these areas (e.g., opticians, 
optometrists, ophthalmologists). Given patients’ 
needs, the volunteers usually included general 
practitioners (e.g., family medicine or internists) 
and eye doctors (usually opticians, optometrists, 
ophthalmologists). These volunteers were found 
through connections with the medical director in 
Nigeria. The medical director and nurse also 
collaborated with the university in the area and 
had their physician staff, residents, medical and 
nursing students volunteer during the medical 
missions. Non-health professional volunteers also 
were included to manage wait lines, 
housekeeping, hospitality, and coordinate meals 
for volunteers. The medical director and the nurse 
handled any logistical problems, such as delayed 
volunteer arrival, medication stock-outs, or 
emergent medical cases.  

Logistically, to reach as many members of the 
community as possible, the annual medical 
mission event typically lasted one to three days for 

eight hours (about 8 a.m. to 5 p.m.) each day. 
Therefore, preparing for this annual medical 
mission event required both the U.S. and Nigeria 
teams to coordinate their resources. Preparing for 
each annual medical mission event began six to 12 
months prior. During each day of the medical 
mission event, patients were served on a first-
come-first-serve basis. However, infants, older 
adults, disabled, or medically urgent cases were 
prioritized as they appeared. Each patient was 
assigned a participant number and received blood 
pressure, blood glucose, weight measurements, 
necessary treatment (e.g., wound care), 
medications from the pharmacy, and reading 
glasses as needed (see Pictures 1, 4, 5, and 6). The 
volunteer nursing staff supervised the pharmacy. 
These volunteer nursing staff also dispensed 
medication as ordered by doctors and educated 
patients on administering the medication, side 
effects, and signs of complications (see Picture 5). 
They encouraged patients with chronic conditions, 
such as high blood pressure and diabetes, to 
return to the follow-up clinic.  

The host community’s health care professional 
volunteers fueled and sustained this annual 
medical mission component of the global health 
service project. Compared to the U.S.-based 

Picture 4. Nurse measuring blood pressure for an adult 
patient. 

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health professional volunteers, the host country’s 
health professional volunteers had a greater 
understanding of the community’s common 
health conditions, environmental and behavioral 
factors contributing to NCDs, and the health 
beliefs and practices affecting care utilization. 
Therefore, they had more culturally relevant 
communication strategies to increase the 
likelihood that patients would accept and adhere 
to treatment recommendations.  

In contrast, volunteer doctors from the U.S. often 
struggled with their initial patient encounters. 
Compared to their local counterparts, they spent 
too much time with patients, wanted laboratory 
tests and results to confirm diagnoses, and used 
more resources to achieve the same patient goals. 
Although challenged, U.S.-based physicians often 
adapted after several patient encounters. For 
example, by their sixth patient encounter, they 
learned how to treat patients in this low-resourced 
community with limited laboratory diagnostics 
and tests.  

Community engagement was sustained by 
identifying and mobilizing community assets and 
strengths and developing the community’s 
capacity and resources to make decisions and act. 
The power of the medical director’s connection 
with the community cannot be overstated. In the 
absence of these connections, there would not 
have been the same number and caliber of health 
professional volunteers from the community.  

These connections were critical to effective and 
sustained community engagement. The medical 
director and nurse provided honoraria to 
volunteers as a small token of their invaluable 
contributions to the community. Honoraria took 
different forms, including small amounts of 
money, certificates, pens, and bags. One year, 
stethoscopes, donated by a sponsor, were 
distributed to volunteer nursing staff and nursing 
students. Although the volunteers from the U.S. 
paid for their flight tickets to and from Nigeria, 
the nurse personally provided them free 
accommodations and meals.  

PATIENT POPULATION SERVED 

 To determine community health needs and 
resource allocation, the medical director and 
nurse gathered demographic and clinical 
information from patients. Each patient was given 
a registration card at check-in, upon which staff 
volunteers recorded the patient’s age, gender, 
weight, blood pressure, blood sugar reading, 
medical diagnosis, prescribed medication(s), and 
any follow-up recommendations. Data showed 
many patients presented with malaria, 
osteoarthritis (especially women), ulcers, and 
upper respiratory infections. The most prevalent 
health conditions were diabetes (52%), 
hypertension (45%), and eye problems (74%) (see 
Figure 1). Regarding eye problems, patients 
sought treatment for presbyopia, glaucoma, ocular 
allergy, refractory error, pterygium, and 
blindness. Although the eye conditions the team 
treated were related in part to chronic health 
conditions such as diabetes, the lack of access to 
specialized care and prohibitive costs of such care 
also played a role (International Agency for the 
Prevention of Blindness 2014; World Health 
Organization, 2013).  

There were factors that affected community 
engagement efforts, and consequently, the 
number of patients served during the annual 
medical mission events. First, extensive coverage 
of our outreach efforts in the local community was 

Picture 5. Nurse providing medication education to mother and 
child. 

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necessary to create awareness and drive patients 
towards our services. Over time, experience 
showed that there was more demand for services 
than were offered during the yearly intensive days 
of the mission. In fact, the more days we offered, 
the more patients we served. In the early years, 
the annual medical mission event lasted three 
days and served about 225 patients per day. Over 
time, as we honed in on community needs, the 
medical mission event lasted a day and served 250 
patients. The medical director and nurse became 
more confident in their knowledge of the 
community’s needs, which allowed them to 
become more effective at identifying and 
mobilizing local health professional volunteers. 
The volunteers became more invested in the 
medical mission events, recruited colleagues, and 
returned each year as they became familiar with 
expectations, policies, and procedures and valued 
the community. In essence, the event ran much 
more smoothly, and because less time was spent 
removing roadblocks (e.g., lack of familiarity with 
procedures), more time was spent on patients. 

The average number of patients seen per day 
varied by the number of volunteer doctors and 
nurses available per day. The medical director and 
nurse aimed to have five doctors and ten nurses 
each day. Second, it was necessary to tap into local 
leaders who had clout or were respected in the 
local community. The number of patients served 
during a mission day increased when the message 
was delivered more frequently and to more 
community venues. The effectiveness of the public 
announcement to the community also varied 
according to whether the town announcer or the 
medical director publicized the event. Many 
throughout the community knew the town 
announcer. He drove around, announcing the date 
and location of the mission over a loud 
microphone. On the other hand, the medical 
director distributed letters and flyers to key 
community settings (e.g., churches, market 
places). Compared to the medical director and his 
methods, the town announcer was more effective 
in reaching community residents. Using culturally 
appropriate strategies, such as asking the town 

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60

80

100

120

140

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Health Conditions

Figure 1 

Number of Patients and Health Conditions Addressed during the Medical Missions in 2018 

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announcer or “town crier” to pass along 
information to the community, was important to 
facilitate community engagement.  Third, eye care 
was a major issue that only surfaced through 
formal and informal data collection.  For example, 
patients would ask every year if we had an eye 
doctor on site. More patients were served when 
opticians and/or ophthalmologists volunteers 
were available and provided eye care services. In 
fact, the number of patients served doubled if eye 
care was provided in addition to care for other 
health conditions.  

Since its inception in 2004, the medical director, 
nurse, and their team of volunteers have provided 
39 service days, during which they served 7,376 
unique children and adults (2,459 males and 
4,917 females) from 23 surrounding 
communities. The team also has conducted 50 
cataract surgeries for adults, distributed 3,000 
reading glasses, and provided routine follow-up 
care as needed. Below are descriptions of three 
patients who illustrate the impact of the team’s 
work and inspirations to continue the medical 
missions. Pseudonyms rather than patients’ real 
names are used. 

Mrs. Eunice. Mrs. Eunice was in her 30s and 
presented with her four children, ages 2 to 8 years 
old. She reported that she was stressed and 
worried about the children because they all had 
fevers over the past three days, which she 
attributed to malaria. She said that she was at a 
loss until an acquaintance told her about our free 
medical mission, which the acquaintance had 
heard about from a public announcement at a 
community event. Mrs. Eunice shared that she 
was especially stressed because she also was 
caring for her husband, who had a stroke a few 
weeks prior. She was unable to bring him to the 
clinic because she could not obtain transportation 
for him. Given the children’s young ages, we 
prioritized their services. Each had their blood 
pressure, blood glucose, and weight measured, 
and then were evaluated by a doctor and tested for 
malarial parasites. Each child received free anti-
malarial medications from the pharmacy, where a 

nurse instructed Mrs. Eunice about how to 
administer the medications. We encouraged her to 
return with her husband to the follow-up clinic.  

Mr. Adazi. Mr. Adazi was in his 60s. He 
regularly attended the annual medical mission 
and occasionally sought follow-up care. He was 
diagnosed with diabetes, for which he took oral 
hypoglycemic medication for blood glucose 
control. He regularly received the medications at 
no cost from our free clinic. He stated that his 
symptoms had improved. For instance, he shared 
that he was waking up less frequently to urinate at 
night. He reported that these improvements 
motivated him to take his medication regularly. 
Our team also provided education on healthy food 
choices and blood glucose monitoring so he could 
better manage his diabetes.  

Mrs. Uzo. Mrs. Uzo was in her early 70s. She has 
sought care from the medical mission and follow-
up clinic since the inception of the program. Mrs. 
Uzo had bilateral knee arthritis, for which our 
team provided regular steroid injections. Over 
time, we observed gradual worsening of her knees, 
which led to her needing crutches. Our team 
provided her with medications through our 
follow-up clinic. Although we wanted to perform a 
knee replacement surgery, it was cost-prohibitive 
and something the mission could not provide for 
free.  

Picture 6. Volunteer student from U.S. and nurse from host 
community sorting reading glasses. 

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SUSTAINABILITY AND CONTINUITY OF 
THE GLOBAL HEALTH SERVICES 
PROJECT  

Global health service projects must plan for the 
continuous care of NCDs after the annual medical 
mission events. The ability of this global health 
service project to provide follow-up care is what 
sets it apart from traditional medical missions. 
Since starting this health service project, the 
medical director and nurse have inspired three 
other medical mission teams. However, only the 
medical director and nurse have instituted 
continuous care of NCDs post-mission. They 
believed that the provision of follow-up care was 
not only a professional responsibility but also an 
ethical imperative.  

Therefore, they offered a weekly clinic for follow-
up visits after the annual medical mission event 
ended. The weekly follow-up clinic was designed 
to facilitate continuous care and help patients gain 
the knowledge and skills necessary for self-
management. A member of the community 
donated a building from which the follow-up 
clinic operates every Wednesday. This donation 
was a testament to community buy-in and 
engagement. The donor renovated the building to 
include exam rooms, pharmacy, and waiting 
areas. The medical director, led and conducted the 
clinic with a small crew of three nurse assistants 
who received a small stipend for their time. Every 
Wednesday for half a day, patients were seen for 
different ailments. Visits began with checking vital 
signs and were followed by medical consults. If 
needed, medications were dispensed at the 
pharmacy.  

Since 2007, the weekly follow-up clinic has 
expanded its services to two days a week, 
including one day on the weekend to meet the 
needs of both walk-in and scheduled patients 
throughout the year.  

Regular evaluation of impact, mutual learning, 
and respect for local professionals was critical to 
effective community engagement. Like the annual 
medical mission events, collecting formal and 

informal data from community members was 
necessary to address key health issues (e.g., high 
blood pressure, diabetes, eye diseases) affecting 
community members’ well-being. For example, 
within the early years of the project, the medical 
director and nurse confirmed that the most 
prevalent health conditions in the community 
were diabetes, hypertension, and eye diseases.  

Subsequently, they used this data gathered onsite 
to benefit the community. The human and 
medical resources were targeted to screen, treat, 
and educate patients about diabetes, 
hypertension, and eye diseases. The health 
conditions for which there was the greatest 
demand (e.g., eye care) received the most resource 
allocation. Therefore, the nurse and medical 
director sought partnerships with experts in these 
areas (e.g., opticians, optometrists, 
ophthalmologists).  

Additionally, consistent availability of 
medications in the pharmacy and provision of 
walk-in clinics were concerns that only surfaced 
through community stakeholder discussions. The 
medical director and nurse deliberately sought 
feedback from patient stakeholders to understand 
patterns in attendance (e.g., did more patients 
keep an appointment if it was scheduled or walk-
in) and adherence to medication regime (e.g., did 
patients purchase medication prescribed or not 
when they had to buy from outside pharmacies). 
All data were de-identified, digitalized, and in a 
database, and used for annual reports to 
individual and organizational medical and 
financial sponsors. Since 2014, a donor and 
volunteer base maintained records on a website at 
www.providencechi.com.  

LESSONS LEARNED FROM THE FIELD 

Lesson 1. Thoughtful and deliberate 
approach to community engagement 
required to enhance long-term 
sustainability.  

Consistent with community-engaged inquiry, the 
medical director and nurse were involved in all 

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aspects of the global health service project, which 
included two components – an annual medical 
mission and follow-up clinics. Their collaboration 
was vital to the success and sustained operations 
of both the medical missions and follow-up 
clinics.  

While the medical director committed to 
garnering resources in Nigeria, the nurse 
committed to leveraging her connections in the 
U.S. to meet the healthcare needs of the 
community. The medical director contributed 
assets related to his knowledge of the lay of the 
land and all of its cultural nuances and, therefore, 
was instrumental to the development and 
implementation of the global health service 
project in the community. He advertised the 
medical mission and invited volunteers from the 
community, health professional organizations, 
and the local university. Although the medical 
director and nurse did not explicitly discuss power 
dynamics, they made a verbal commitment to 
work together towards a shared mission. They 
nurtured this collaboration with mutual respect, 
inclusion, equal leadership, and acknowledgment 
of partners in reports and publications.  

Consequently, they extended services to all 
members of the community without 
discrimination. The multidisciplinary team of 
health professional volunteers was essential to 
providing high-quality care to thousands of 
patients while keeping labor costs to a minimum. 
Several volunteers have served an average of five 
years, and this is a testament to the mission’s 
success in engendering community service. 
Partnerships with committed and reliable 
individuals and organizations facilitated 
credibility, community buy-in, execution of 
annual medical missions, and program 
sustainability.  

Lesson 2: Mutual learning and respect for 
local professionals.  

Both the medical director and nurse needed each 
other to actualize and achieve the global health 
service project. Although the donated money, 

medications, and medical supplies from the U.S. 
were helpful, neither the medical director nor 
nurse would have been able to provide or sustain 
services over the course of 15 years without the 
host country collaborators (e.g., medical director, 
volunteer team, and partner university). While the 
medical director accessed the medications and 
medical supplies needed to improve the 
community’s health, the nurse realized her 
passion to give back to this community – all from 
a distant continent away – thanks to the trusted 
partnership and shared affiliation with the 
community. However, engaging with communities 
from a distance is not for the faint of heart, as 
trust is essential. For example, individuals must 
trust that people will do what they say they will 
do, relying on each person’s intrinsic motivation 
and commitment to public health. Additionally, 
transparency is important, especially given that 
partners may not always agree. For example, the 
nurse once suggested increasing care access and 
utilization by providing blood pressure screens at 
the marketplace. However, regulations prevented 
public health screenings to ensure equal access to 
patient populations by local health care providers. 
If the medical director had not redirected the 
nurse, and the nurse had proceeded with this care 
delivery idea, they would have been perceived as 
taking patients and revenue away from the local 
professionals. The nurse acknowledged the 
medical director’s advice and did not pursue this 
idea to maintain relationships with providers in 
the community. In sum, the partners needed to be 
open to adapting care practices and delivery 
structures to meet the needs of all community 
stakeholders. Furthermore, regular 
communication fostered trust and accountability 
among partners and community stakeholders. The 

Although the medical director and nurse did not 
explicitly discuss power dynamics, they made a 
verbal commitment to work together towards a 

shared mission. They nurtured this collaboration 
with mutual respect, inclusion, equal leadership, 
and acknowledgment of partners in reports and 

publications. 

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nurse and medical director maintained regular 
communication via WhatsApp, sometimes 
multiple times a day. Communication required a 
reliable medium or platform, particularly in a low-
resourced community where broadband was not 
readily available. They learned flexibility and 
patience, which helped them persist and achieve 
their shared mission of improving the health of 
the community. 

Lesson 3. Capacity building within the 
host community to enhance 
sustainability.  

Both the medical director and the nurse believed 
they had a responsibility to develop the host 
country’s workforce capacity so that the program 
could continue when the U.S. team left. They also 
recognized the importance of developing a 
pipeline for the next generation of leaders. For 
example, one year, a U.S.-based physician trained 
the host country medical director on how to 
administer steroid injections to women who had 
osteoarthritis of the knees. Both the U.S.-based 
nurse and Nigeria-based medical director have 
mentored young clinicians. They engaged nursing 
students, medical students, and residents from 
the local university in the medical missions. Since 
2013, the global health service project has 
maintained a small crew of four paid staff, 
including the medical director and four nursing 
staff, to run the follow-up clinic. The art of 
community service has been infectious. Although 
Nigeria is considered a developing country with 
limited resources and a weak healthcare 
infrastructure, community-based care (i.e., global 
health service projects) delivered by expatriate 
and local health care professional volunteers filled 
critical gaps in healthcare. In the U.S., 
underserved populations in urban areas could 
benefit from similar community-based outreach 
projects.  

Lesson 4. Planning for the continuous 
care of non-communicable diseases post-
mission.   

Follow-up care is critical to not only track patient

 progress but also promote education (e.g., signs 
and symptoms of hypertension), treatment, and 
self-management. Misconceptions about the 
treatment of non-communicable diseases were 
common, and intervention beyond the initial visit 
was critical. Many patients believed that chronic 
conditions, such as diabetes and hypertension, 
heal after completing a month of medication. 
Given that there would still be ongoing healthcare 
needs, the team taught patients that diabetes and 
high blood pressure do not just go away and 
helped them develop self-management skills 
through diet and increased physical activity. 
Unlike other medical mission teams in Amichi, 
our team was the only one that provided follow-
up clinical visits. This allowed for effective and 
sustained behavior changes that improved the 
health of the community. Ideally, medical mission 
teams would form a coalition and pull their 
resources to scale staff and service capacity, 
thereby increasing follow up clinics from a few 
days to every day of the week. That kind of 
coalition would optimize and sustain this service 
delivery channel in harmony with public health 
goals and the larger healthcare ecosystem.  

Lesson 5. Data collection is key to regular 
evaluation of programs for impact. 

 There is a need for medical mission programs to 
collect data, use it, and share findings. Data 
collection serves several functions. First, data 
were needed to identify areas for improvement. 
Second, data were needed to assess and document 
the impact of medical missions on patient 
population outcomes. Documenting the impact on 
populations could better position teams to seek 

The success of the mission was grounded in 
community-engaged partnerships between 

the host and U.S. teams with committed 
individuals and organizations who facilitated 

credibility, community buy-in, coordination of 
resources, execution of annual medical 

missions, provision of follow-up care, and 
program sustainability. 

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sustained funding from organizations such as the 
Bill and Melinda Gates Foundation, Rotary 
International, and other global organizations. 
Lastly, careful tracking of the impact of medical 
missions on healthcare costs is needed. 
Quantifying the economic benefits of addressing 
these health conditions may motivate government 
agencies to lend their support to non-profit 
organizations working to improve access to and 
affordability of care for underserved populations. 
Having alignment between the global health 
service project and local government’s priorities 
may improve internal and external funding and 
long-term sustainability.  

POLICY AND PRACTICE IMPLICATIONS 

The team’s field experiences can be of benefit to 
health policy and practice in local communities. 
First, community-engaged medical missions and 
follow-up care engender public service, build 
goodwill, and break down walls. Nurses, 
physicians, and other health professionals seeking 
to establish medical missions will need to develop 
collaborative partnerships with the community, 
provide follow-up care services, and build 
workforce capacity in host communities to ensure 
sustainability. While these collaborations can 
address the health care needs of the host 
community, visiting volunteers also can learn 
from the host community to inform work in rural 
and underserved communities in the United 
States. This team collaboration has the potential 
to drive policies that lead to systemic changes in 
funding, structure, and delivery of health care. 
Second, the critical importance of data cannot be 
overstated. Medical mission teams need to 
systematically collect sociodemographic and 
clinical data to help determine the prevalence of 
health conditions in communities and inform 
data-driven decision-making. These local data 
from various teams conducting medical missions 
can be de-identified, aggregated, and submitted to 
local public health agencies, then analyzed to 
inform need and large-scale implementation 
across communities. Third, given care gaps in eye 

care, there is a need for the provision of eye care 
services both during the medical mission and 
during follow-up clinics. For example, an 
optometrist and optician could visit once a month 
to serve patients during the follow-up clinics. 
Patients who need eye care would be scheduled 
ahead of time. Similar models could be adopted 
and scaled up across communities by local health 
governments. 

CONCLUSION 

We have described our experiences with 
conducting an ongoing global health services 
project in rural Southeastern Nigeria. Our local 
and global collaboration, which consists of U.S.-
and Nigerian-based health care professionals, has 
spanned 15 years. Community engagement and 
stakeholder involvement have contributed to the 
sustainability of the medical mission project. The 
success of the mission was grounded in 
community-engaged partnerships between the 
host and U.S. teams with committed individuals 
and organizations who facilitated credibility, 
community buy-in, coordination of resources, 
execution of annual medical missions, provision 
of follow-up care, and program sustainability. The 
medical director and nurse successfully shared 
knowledge and skills among volunteers from the 
host country and the U.S. The multidisciplinary 
volunteers included not only professional nurses 
but also the next generation of health 
professionals, including nursing and medical 
students. The medical director and nurse modeled 
mutual respect and trust, patient-centered care, 
and commitment to community service. 
Therefore, volunteers returned every year to work 
and support the health of the community. 
Additional work is required to monitor health 
outcomes, evaluate the impact of our medical 
mission, and create a cost-effective and 
sustainable model to improve the health of this 
population. Thoughtful consideration of the types 
of data to collect and implement uniformly is 
critical to tracking trends in population health 
over time.  

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