Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis

Background Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective.
Methods Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança’s previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability adjusted life year.
Results Esperança’s surgical missions’ program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate.
Conclusions The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations

Designing for Health Accessibility: Case Studies of Human-Centered Design to Improve Access to Cervical Cancer Screening

Our world faces immense challenges in global health and equity. There continue to be huge disparities in access to health care across geographies, despite the massive strides that have been made to address health issues. In this dissertation, I explore the role of human-centered design to improve global health access and reduce disparities. Human-centered design, a cross-disciplinary creative problem-solving approach, has been applied and studied in both academic research and practice, but its role in improving global health access remains poorly understood.

In this dissertation, I present research on designing for health accessibility in the context of one particular disease: cervical cancer. Every year, 300,000 women around the world die of cervical cancer and ninety percent of these deaths occur in low- and middle-income countries. Cervical cancer is an illustrative example of the global disparities in access to health care, given that cervical cancer is preventable and the majority of global cervical cancer mortality is in low- and middle-income countries.

My research examines the work of two organizations that created unique solutions to improve access to cervical cancer screening in India and Nicaragua. I develop case studies of each organization grounded in ethnographic fieldwork, including over 250 hours of observation and 15 interviews over two years. Through these case studies, I show how early efforts to understand the barriers inhibiting cervical cancer screening access allow design practitioners to create novel and feasible ways to address these barriers. This demonstrates the importance of design practitioners considering multiple dimensions of accessibility, including availability, physical accessibility, accommodation, affordability, and acceptability, while conducting design research in order to improve the potential impact of their ideas and prototypes. Overall, this dissertation establishes the foundation of a new paradigm to “design for accessibility” that can inspire further application and research across sectors to address the many social equity and accessibility challenges facing our world.

Oral Nutritional Supplementation in Children Treated for Cancer in Low- and Middle-Income Countries Is Feasible and Effective: the Experience of the Children’s Hospital Manuel De Jesus Rivera “La Mascota” in Nicaragua.

Children with cancer are particularly vulnerable to malnutrition, which can affect their tolerance of chemotherapy and outcome. In Nicaragua approximately two-thirds of children diagnosed with cancer present with under-nutrition. A nutritional program for children with cancer has been developed at “La Mascota” Hospital. Results of this oral nutritional intervention including difficulties, benefits, and relevance for children treated for cancer in low- and middle-income countries are here reported and discussed.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.

The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.