The Role and Duty of Global Surgery in Increasing Sustainability and Improving Patient Care in Low and Middle-Income Countries

Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energy-intensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts.

Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces ‘informal recycling’ schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from high-income countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.

How Should US Health Care Lead Global Change in Plastic Waste Disposal?

Disposal of health care waste is one of the biggest threats to global sustainable health care. Current practices of dumping domestic and international health care waste into the earth’s terra firma and oceans also undermine global health equity by adversely affecting the health of vulnerable communities. While the United Kingdom works toward circular health care economy streams that produce minimal waste, the United States continues to amplify downstream environmental and health effects of health care organizational waste management decisions. This article suggests how to reframe social and ethical responsibility for health care waste production and management by assigning strict accountability to health care organizational leaders, incentivizing circular supply chain implementation and maintenance, and encouraging strong collaborations across medical, plastic, and waste industries.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey

Background
The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda.

Methods
Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles.

Results
There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups.

Conclusions
Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study

Objective:
Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments.

Methods:
a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks.

Results:
18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4.

Conclusion:
populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Self-reported involvement in road traffic crashes in Kenya: A cross-sectional survey of a nationally representative sample

Background
Road traffic crashes (RTCs) are a global public health burden whose resulting morbidity and mortality disproportionately impact low- and middle-income countries with stressed health systems. There is a paucity of published studies that evaluate the sociodemographic distribution of RTCs using nationally representative samples from the African region.

Aim
To examine population-wide associations between sociodemographic factors and involvement in RTCs in Kenya.

Methods
Data were obtained from the 2014 Kenyan Demographic Health Survey, representing all 47 counties in Kenya, from May to October of 2014. We estimated the prevalence of RTCs and utilized logistic regression for bivariate and multivariable analyses to determine the sociodemographic factors associated with RTCs. Study variables included age, place of residence, household wealth index, educational attainment, and history of alcohol consumption. We computed odds ratios (ORs) and their corresponding 95% confidence intervals (CIs).

Results
A higher prevalence was reported among men (8.76%) versus women (3.22%). The risk factors among men included being 20−34 years of age, living in a rural area (OR 1.38, 95% CI 1.09, 1.74), drinking alcohol (OR 1.33, 95% CI 1.11, 1.59), and having not higher than a primary (OR 1.90, 95% CI 1.19, 3.03) or secondary (OR 1.68, 95% CI 1.04, 2.71) education. The strongest risk factors for women included the being aged 45−49 (OR 2.30, 95% CI 1.44, 3.67) and 20−24 years (OR 1.81, 95% 1.17, 2.79) as well as being in the fourth wealth quintile (OR 1.83, 95% CI 1.15, 2.91).

Conclusion
Men and the most economically productive age groups were more likely to report being involved in RTCs. Strategies to reduce the occurrences of RTCs should prioritize the most vulnerable sociodemographic groups.

The burden of labour and delivery-related complications among pregnant women at Mokopane Hospital of Limpopo Province

The burden of labour and delivery-related complications are health problems that are life-threatening for the fetus and pregnant women. Mokopane hospital in Waterberg of Limpopo Province reports many maternal health complications. There has not been an investigation into the burden of delivery complications and therefore this study aims to investigate the burden of labour and delivery complication experienced by women giving birth at Mokopane hospital of Limpopo province. Purpose: of this study was to explore the burden of labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo province. Methods: A cross-sectional, retrospective descriptive study was conducted. The study followed a quantitative approach and the researcher completed a questionnaire using clinical records from all delivery files of mothers delivered at maternity between January 2017 to December 2019 Mokopane hospital. Findings: The major finding of this study was the majority of women were at a low risk of pregnancy (69%) followed by a high risk of pregnancy (24%). The study further revealed that (73.7%) of women at Mokopane hospital were delivered through the normal virginal procedure and (25.8%) delivered through Caesarean section. Moreover, about 86% of the mothers were normal after delivery whilst 14% were sick or had complications. Conclusion: This study, therefore, recommends that educational programs about labour and delivery-related complications and related programs should be prioritised for pregnant women. KEY CONCEPTS The burden: Is the intensity or severity of disease and its possible impact on daily life (Gidron 2013). In the context of this study, the burden will refer to the death and loss of health due to labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo Province. Labour: This is the process of rhythmic uterine contractions which results in cervical dilatation, a descent of the presenting part; and delivery of the fetus, placenta, and membrane. (Anthony & Van Der Spuy, 2002; Clark, Van de Velde, & Fernando, 2016). In the context of this study, labour will be defined as a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Delivery related complication: Is an acute condition arising from a direct cause of maternal death, such as antepartum or postpartum haemorrhage, obstructed labour, postpartum sepsis, a complication of abortion, pre-eclampsia or eclampsia, ectopic pregnancy and ruptured uterus, or indirect causes such as anaemia, malaria and tuberculosis. (WHO, 2018). In the context of this study, delivery related complications will include amongst others severe antenatal bleeding, Postpartum haemorrhage, nonconvulsive hypertensive disorder of pregnancy (pre-eclampsia), Eclampsia: preeclampsia plus convulsions, Convulsions, Prolonged labour, Premature rupture of the membranes, Retained placenta. Pregnant women: Is a woman who is in the period from conception to birth in which the egg is fertilised by a sperm and then implanted in the lining of the uterus then develops into the placenta and embryo, and later into a foetus (Martin, 2015). In the context of this study, a pregnant woman will be described as a woman who is carrying a developing embryo or fetus within her body.

Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background
Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods
A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results
346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions
Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone

Background
Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic.

Methods
This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members.

Results
A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4–7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery.

Conclusion
PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013–2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Role of Primary Caregivers Regarding Unintentional Injury Prevention Among Preschool Children: A Cross-Sectional Survey in Low- and Middle-Income Country

Importance
Unintentional childhood injuries significantly strain healthcare resources, and their preventable measures can significantly reduce morbidity and mortality.

Objectives
To investigate the role of primary caregivers in preventing unintentional injuries and to identify the groups that require special health intervention programs to reduce the burden of this public health concern.

Methodology
A cross-sectional survey was conducted at three hospitals in Karachi, Pakistan. Parents of preschool children who visited pediatric clinics were invited to participate in the study by completing a self-administered questionnaire comprising questions about knowledge, attitudes, and practices towards preventing unintentional injuries among children.

Results
With an 80% response rate, the overall mean knowledge, attitude, and practices (KAP) score was 27.40 ± 3.48. Only 14.3% of the participants had a high KAP score, while 83.6% and 2.1% of the respondents had moderate and low KAP scores, respectively. People of lower socioeconomic status, unemployed, less educated, and families with more than one preschool child were less knowledgeable and non-adherent to unintentional preventive injury. It was found that 21% of the children had suffered from an unintentional severe injury in the past, and the internet was the most frequent source of gaining knowledge among parents.

Conclusion
Parental knowledge, attitude, practices, and adherence to child safety measures are sub-optimal in our cohort of studied participants. Raising awareness and providing the counseling are essential in reducing the burden of unintentional injuries.

Cost of open access publishing in otolaryngology-head and neck surgery

Objective
Open access (OA) publishing makes research more accessible but is associated with steep article processing charges (APCs). The study objective was to characterize the APCs of OA publishing in otolaryngology-head and neck surgery (OHNS) journals.

Methods
We conducted a cross-sectional analysis of published policies of 110 OHNS journals collated from three databases. The primary outcomes were the publishing model, APC for original research, and APC waiver policy.

Results
We identified 110 OHNS journals (57 fully OA, 47 hybrid, 2 subscription-only, 4 unknown model). After excluding 12 journals (2 subscription-only, 4 unknown model, 5 OA with unspecified APCs, and 1 OA that accepts publications only from society members), we analyzed 98 journals, 23 of which did not charge APCs. Among 75 journals with nonzero APCs, the mean and median APCs were $2452 and $2900 (interquartile range: $1082–3520). Twenty-five journals (33.3%) offered APC subsidies for authors in low- and middle-income countries (LMICs) and/or on a case-by-case basis. Eighty-five and 25 journals were based in high-income countries (HICs) and LMICs, respectively. The mean APC was higher among HIC journals than LMIC journals ($2606 vs. $958, p < 0.001).

Conclusion
APCs range from tens to thousands of dollars with limited waivers for authors in LMICs.