Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya

Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.

Tele-health and cancer care in the era of COVID-19: New opportunities in low and middle income countries (LMICs)

In the current era of COVID-19 pandemic where at least some degree of social distancing is the norm and hospitals have emerged as hotspots for acquiring the infection, it has become important for oncologists to devise methods of providing care to cancer patients while minimizing patients’ exposure to healthcare settings. In light of the on-going pandemic, it has been recommended that in-patient visits for cancer patients should be substituted by virtual visits and patients should be advised to proceed directly for infusion treatment. Telemedicine and tele-health based interventions have emerged as reasonably practical solutions to these impediments in the delivery of care to cancer patients. Technological advancements have resolved the issue of connectivity for telemedicine even to the remotest places. Teleconsultation is becoming an acceptable alternative for patients and health care providers in this era of information technology. Albeit the challenges that we are facing are diverse and therefore cannot have a singular full proof answer, telemedicine and tele-health based interventions seem to offer promise in effectively complementing our efforts in that direction. Telemedicine is beneficial for both patients and doctors in term to provide quality care without shifting to physical location.

Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences

Introduction Global health conferences are important platforms for knowledge exchange, decision-making and personal and professional growth for attendees. Neocolonial patterns in global health at large and recent opinion reports indicate that stakeholders from low- and middle-income countries (LMICs) may be under-represented at such conferences. This study aims to describe the factors that impact LMIC representation at global health conferences.

Methods A systematic review of articles reporting factors determining global health conference attendance was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles presenting conference demographics and data on the barriers and/or facilitators to attendance were included. Articles were screened at title and abstract level by four independent reviewers. Eligible articles were read in full text, analysed and evaluated with a risk of bias assessment.

Results Among 8765 articles screened, 46 articles met inclusion criteria. Thematic analysis yielded two themes: ‘barriers to conference attendance’ and ‘facilitators to conference attendance’. In total, 112 conferences with 254 601 attendees were described, of which 4% of the conferences were hosted in low-income countries. Of the 98 302 conference attendees, for whom affiliation was disclosed, 38 167 (39%) were from LMICs.

Conclusion ‘Conference inequity’ is common in global health, with LMIC attendees under-represented at global health conferences. LMIC attendance is limited by systemic barriers including high travel costs, visa restrictions and lower acceptance rates for research presentations. This may be mitigated by relocating conferences to visa-friendly countries, providing travel scholarships and developing mentorship programmes to enable LMIC researchers to participate in global conferences.

Social media and global cardiovascular disparities

Social media have become pervasive in modern life, academic practice, and medicine, even more so in response to the COVID-19 pandemic. Ladeiras-Lopes et al.1 present a timely overview of social media in cardiovascular medicine, highlighting successes to date and opportunities to responsibly incorporate social media in clinicians’ and researchers’ toolbox. Indeed, the power and growth of social media cannot be disregarded. For professional platforms like Twitter, the reach of tweets can be as much as hundreds of thousands of unique users: a large and fast gain for minimal (280-character) effort. The potential of social media platforms has further been clear through its ability to foster social networks, remote mentorship, virtual journal clubs, post-publication peer review, and more.2 In today’s world, where virtual communication, education, and telemedicine are increasingly leveraged, opportunities arise to take existing social media tools beyond our immediate environments and seek to connect with and learn from peers and colleagues in low- and middle-income countries (LMICs) and remote areas.3

Disparities in cardiovascular medicine persist as 18 million people die each year from cardiovascular diseases, of which a vast majority takes place in LMICs.4 Six billion people lack access to safe, timely, and affordable cardiac surgical care,4 whereas little is known regarding the global distribution of non-surgical cardiac care providers. Nevertheless, many challenges, such as inefficient supply chains, limited training programmes, remote populations, lack of financial risk protection, and other barriers to care remain common across all cardiovascular disciplines. In addition, beyond health system disparities, language barriers contribute to the vast gap in country- or population-specific research in the global health and global surgery context. Moreover, this has commonly been skewed with anglophone predominance, requiring a paradigm shift to instill more equitable practices within today’s academic ecosystem.

Social media has shown vast potential in the realms of global health and global surgery, creating networks of clinicians, trainees, and researchers all the way to the last mile.5 While current social media engagement is focused largely on online dialogue, it is increasingly leveraged as a tool to foster global collaboration, community engagement, education, and awareness regarding global health issues.6 Importantly, social media have been used to facilitate telemedicine and teleconsult communication channels to gain expertise from colleagues remotely or to educate residents and fellows, especially in lower-resource or remote settings.7,8 The current pandemic further leverages such channels and networks to host virtual conferences and shift to virtual education, ranging from video-conference calls to online training modules and low-cost, low-to-high-fidelity virtual reality and simulators.3 Similar opportunities arise to utilize such networks, specifically with regards to social media, in the fields of global cardiology and global cardiac surgery.

Social media platforms aid in creating global networks that transcend borders and promote international collaboration. For example, the Global Cardiac Surgery Initiative brings together trainees and young surgeons in cardiac surgery from around the world to advance the field of global cardiac surgery, illustrating what can result from such networks in terms of mentorship, sponsorship, and support for trainees and early-career researchers.9 Education and research are no longer limited by distance or time zones, giving way to open-access information through low-cost or free-of-charge webinars and conferences. Experts in the field share evidence-based and experience-based education and advice, recordings of which are readily available for whenever needed. Cases, some one-of-a-kind as observed in the current pandemic, may be discussed among colleagues and how to best manage them considering available resources and training. Accordingly, social media facilitates virtual training, presenting a variety of topics directed to students, trainees, faculty, and even patients. Moreover, virtual coaching of the entire cardiac surgery team present in the operating room, including perfusionists, scrub technicians, and nurses, remains an area of opportunity to explore to truly leverage the heart team mentality at the core of our work and such online engagement.

During this pandemic, social media has proven to be an effective tool for rapidly disseminating novel information, guidelines, and recently published papers.10 This allows for global efforts to continue in a timely fashion despite known or unforeseen barriers, such as the COVID-19 pandemic. Therefore, recognizing and understanding such barriers constitutes an important aspect of global health. One may utilize such platforms to present ongoing projects and the difficulties they encounter along the way. Additionally, social media allows for increasing awareness regarding understudied and under-addressed topics, such as global cardiac surgery. It makes connecting and interacting with others dedicated to global health, as well as other medical and non-medical disciplines, amiable, and approachable. These are of importance to create a true interdisciplinary and intersectoral health system that aims to consider multiple points of views and cover all issues thoroughly, as opposed to conventional vertical-only global health interventions. It is time for governments, global organizations, and individuals to search for long-due solutions and implement radical changes, in which social media can be a fundamental tool. Global research collaborations allow for increased awareness of each countries’ disparities and ideas to dissipate them, as well as finding sponsor organizations and partners with similar goals, facilitating resource collection and allocation in a sustainable manner. Social media may provide an opportunity for generating international registries to better understand population-specific characteristics and differences in access to care. Finally, it serves as an invaluable tool to inspire and mentor trainees to pursue certain career options, at home and abroad. The impact on the formation of present and future cardiology and cardiac surgery leaders will continue to grant encouraging results, extending to all corners of the world.

Global cardiovascular disparities prevail and substantially impede progress towards the Sustainable Development Goals and countries’ paths towards universal health coverage. Social media is a tool that should be leveraged to foster awareness surrounding these global disparities and accelerate shared learning, network building, and knowledge generation and dissemination within global cardiovascular care.

The influence of travel time to health facilities on stillbirths: A geospatial case-control analysis of facility-based data in Gombe, Nigeria

Access to quality emergency obstetric and newborn care (EmONC); having a skilled attendant at birth (SBA); adequate antenatal care; and efficient referral systems are considered the most effective interventions in preventing stillbirths. We determined the influence of travel time from mother’s area of residence to a tertiary health facility where women sought care on the likelihood of delivering a stillbirth. We carried out a prospective matched case-control study between 1st January 2019 and 31st December 2019 at the Federal Teaching Hospital Gombe (FTHG), Nigeria. All women who experienced a stillbirth after hospital admission during the study period were included as cases while controls were consecutive age-matched (ratio 1:1) women who experienced a live birth. We modelled travel time to health facilities. To determine how travel time to the nearest health facility and the FTHG were predictive of the likelihood of stillbirths, we fitted a conditional logistic regression model. A total of 318 women, including 159 who had stillborn babies (cases) and 159 age-matched women who had live births (controls) were included. We did not observe any significant difference in the mean travel time to the nearest government health facility for women who had experienced a stillbirth compared to those who had a live birth [9.3 mins (SD 7.3, 11.2) vs 6.9 mins (SD 5.1, 8.7) respectively, p = 0.077]. However, women who experienced a stillbirth had twice the mean travel time of women who had a live birth (26.3 vs 14.5 mins) when measured from their area of residence to the FTHG where deliveries occurred. Women who lived farther than 60 minutes were 12 times more likely of having a stillborn [OR = 12 (1.8, 24.3), p = 0.011] compared to those who lived within 15 minutes travel time to the FTHG. We have shown for the first time, the influence of travel time to a major tertiary referral health facility on the occurrence of stillbirths in an urban city in, northeast Nigeria

Trends in national and subnational wealth related inequalities in use of maternal health care services in Nepal: an analysis using demographic and health surveys (2001–2016)

Background
Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001–2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services.

Methods
The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis.

Results
The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001–2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016.

Conclusion
Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers.

Challenges in Providing Surgical Procedures During the COVID-19 Pandemic: Qualitative Study Among Operating Department Practitioners in Pakistan

ackground: Operating Department Practitioners (ODPs) are neglected human resources for health with regard to both professional development and research for patient safety. The surgical theatre is associated with the highest mortality rates and with the onslaught of the COVID-19 pandemic. ODPs are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics.

Methods: A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes.

Results: Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear.

Conclusions: The public health sector, in Pakistan and other developing regions, need to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwis

Designing devices for global surgery: evaluation of participatory and frugal design methods

Introduction:
Most people living in low- and middle-income countries have no access to surgical care. Equipping under-resourced health care contexts with appropriate surgical equipment is thus critical. “Global” technologies must be designed specifically for these contexts. But while models, approaches and methods have been developed for the design of equipment for global surgery, few studies describe their implementation or evaluate their adequacy for this purpose.

Methods:
A multidisciplinary team applied participatory and frugal design methods to design a surgical device for gasless laparoscopy. The team employed a formal roadmap, devised to guide the development of global surgical equipment, to structure the design process into phases. Phases 0–1 comprised primary research with surgeons working in low-resource settings and forming collaborative partnerships with key stakeholders. These participated in phases 2–3 through design workshops and video events. To conclude, surgical stakeholders (n=13) evaluated a high-fidelity prototype in a cadaveric study.

Results:
The resulting design, “RAIS” (Retractor for Abdominal Insufflation-less Surgery), received positive feedback from rural surgeons keen to embrace and champion innovation as a result of the close collaboration and participatory design methods employed. The roadmap provided a valuable means to structure the design process but this evaluation highlighted the need for further development to detail specific methodology. The project outcomes were used to develop recommendations for innovators designing global surgical equipment.

To inform early phases in the design roadmap, engaging a variety of stakeholders to provide regular input is crucial. Effective communication is vital to elucidate clear functional design requirements and hence reveal opportunities for frugal innovation. Finally, responsible innovation must be embedded within the process of designing devices for global surgery.

Conclusion:
A community-wide effort is required to formally evaluate and optimize processes for designing global surgical devices and hence accelerate adoption of frugal surgical technologies in low-resource settings.

Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey

There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF)

Methods
A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5–24% was mild, 25–49% was moderate and 50–90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education.

Results
A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9–10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8–14.8)] compared to those with formal education levels [8.9% (CI 8.1–9.7), p<0.001] for primary school and [5.9% (4.6–7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities.

Conclusion
This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.

Mortality during and following hospital admission among school-aged children: a cohort study

Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya.
Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality.
Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria.
Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.