Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon

Introduction
Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants’ perceptions on leadership, medical errors, and the QI process in Cameroon.

Methods
Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation.

Results
A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants’ perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. Conclusions These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.

Global Surgery at the National Landscape: Perspectives after the XXXIV Brazilian Congress of Surgery

The XXXIV Brazilian Congress of Surgery included Global Surgery for the first time in its scientific program. Global Surgery is any action in research, clinical practice, and policy-making that aims to improve access and quality of care in surgical specialties. In 2015, The Lancet Commission on Global Surgery highlighted that five billion people lack safe, timely, and affordable surgical care. Even more critical, nine of ten people cannot access essential surgical care in low and middle-income countries, where a third of the worldwide population resides, and only 6% of global surgical procedures are performed. Although Brazilian researchers and institutions have been contributing to lay the movement’s foundations since 2014, Global Surgery remains a barely debated subject in the country. It is urgent to expand the field and break paradigms regarding the surgeons’ role in public health in Brazil. Accomplishing these standards requires a joint effort to strategically allocate resources and identify collaboration opportunities, including those from medical societies and regulatory bodies. As members of the International Student Surgical Network of Brazil – a nonprofit organization by and for students, residents, and young physicians focused on Global Surgery – we review why investing in surgery is cost-effective to strengthen health systems, reduce morbimortality, and lead to economic development. Additionally, we highlight and propose key recommendations to foster the field at the national level.

Causes of futile life-sustaining interventions from the perspective of physicians and nurses in university hospitals in Tehran

Background
Providing futile interventions can lead to moral distress for healthcare providers and impose high costs on healthcare systems. Despite this, evidence demonstrates that such interventions still continue in many parts of the world, particularly in Low and Middle Income Countries (LMICs). Therefore, this current study was conducted to investigate reasons for providing futile interventions from the perspective of physicians and nurses working at hospitals affiliated to Tehran University of Medical Sciences (TUMS)

Method
In this cross-sectional (descriptive-analytical) study, 249 participants including 128 physicians and 121 nurses working in hospitals affiliated to TUMS were recruited through convenience sampling. Data was collected using a 25-item questionnaire assessing causes of providing futile medical and life-sustaining interventions, grouped into 3 domains of “demands of patients/relatives”, “personal reasons of the healthcare team” and “organisation/infrastructural” limitations. Data was analysed using SPSS 16 and the extent to which participants agreed with each of the causes of futile interventions was expressed as a percentage. Comparisons between the views of physicians and nurses on individual questionnaire items was performed using the Chi-squared test. A linear regression analysis was used to compare the views of physicians and nurses in each of the 3 domains of the questionnaire, and for intra-group comparisons.

Results
For both physicians and nurses, the most common reasons for futile interventions related to patients and their relatives including demands/insistence on the continuation of treatment and false hope for the patient’s recovery. Compared to physicians, nurses gave greater importance to the domains of patient/relatives’ demands as well as personal reasons of the healthcare team. Physicians expressed strongest agreement with the domain of organisation/infrastructural limitations, including lack of guidelines and palliative care centres.

Conclusion
This study demonstrates that despite awareness of the healthcare team members regarding the futility of some interventions, they are still performed due to the reasons highlighted. Therefore, it clinical guidelines should be developed for appropriate end-of-life care, including restricting the use of futile interventions, increase public and professional awareness and knowledge around futile end-of-life interventions and strengthen palliative care services, thereby leading to greater efficiency and justice in the healthcare system.

Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis

Background
The accessibility of blood and blood products remains challenging in many countries because of the complex supply chain of short lifetime products, timely access, and demand fluctuation at the hospital level. In an effort to improve availability and delivery times, Rwanda launched the use of drones to deliver blood products to remote health facilities. We evaluated the effect of this intervention on blood product delivery times and wastage.

Methods
We studied data from 20 health facilities between Jan 1, 2015, and Dec 31, 2019, in Rwanda. First, we did a cross-sectional comparison of data on emergency delivery times from the drone operator collected between March 17, 2017, and Dec 31, 2019, with two sources of estimated driving times (Regional Centre for Blood Transfusion estimates and Google Maps). Second, we used interrupted time series analysis and monthly administrative data to assess changes in blood product expirations after the commencement of drone deliveries.

Findings
Between March 17, 2017, and Dec 31, 2019, 12 733 blood product orders were delivered by drones. 5517 (43%) of 12 733 were emergency orders. The mean drone delivery time was 49·6 min (95% CI 49·1 to 50·2), which was 79 min faster than existing road delivery methods based on estimated driving times (p<0·0001) and 98 min faster based on Google Maps estimates (p<0·0001). The decrease in mean delivery time ranged from 3 min to 211 min depending on the distance to the facility and road quality. We also found a decrease of 7·1 blood unit expirations per month after the start of drone delivery (95% CI −11·8 to −2·4), which translated to a 67% reduction at 12 months.

Interpretation
We found that drone delivery led to faster delivery times and less blood component wastage in health facilities. Future studies should investigate if these improvements are cost-effective, and whether drone delivery might be effective for other pharmaceutical and health supplies that cannot be easily stored at remote facilities.

Funding
Canadian Institutes for Health Research.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Barriers in surgical research: A perspective from the developing world

Research in surgery has led to significant advances over the last century in terms of how medicine is practised in and outside the operating rooms today. Surgical research in the developed countries is responsible for most of this advancement, but it is often inapplicable in resourcelimited settings in the developing world. Lower- and middle-income countries are in a unique position to take this work further, but they are limited by certain barriers. These barriers could broadly be classified under social and
cultural, infrastructure, financial, ethical, and personal categories. These barriers are often not fully realised, but can potentially be addressed with concerted efforts to continue the advancement of medicine for everyone.

Importance of Cytopathologic Diagnosis in Early Cancer Diagnosis in Resource-Constrained Countries

PURPOSE
The rising cancer burden in low- and middle-income countries (LMICs) stresses already weak health care systems and poses unique challenges. In resource-constrained LMICs and in circumstances where most patients must pay out of pocket for diagnostic tests, these may not be available or affordable for many. Cytopathology provides a simple, inexpensive, standardized, and low-technology diagnostic procedure that is increasingly used as an effective tool to address the hurdles faced in cancer control programs in LMICs. This review explores the potential role of cytopathology in LMICs in reducing the cancer burden.

METHODS
This review studied the existing literature across the globe regarding the utilization of cytopathology as a diagnostic or screening tool for various types of malignancies as well as its advantages and disadvantages, depending on the local situation.

RESULTS
Apart from the usefulness of cytopathology, this review also sheds light on the barriers to using cytopathology in LMICs. Most recently, SARS-CoV-2 has produced several unique challenges for cytopathology. These are being met with innovative measures to combat the effects of the pandemic and ensure the safe delivery of essential cytopathology services.

CONCLUSION
The usefulness of cytopathologic techniques has been demonstrated via various studies, even during the recent pandemic. If cytology is to be used appropriately, the focus needs to be on integrating it into the national cancer screening and diagnostic programs as well as providing well-trained human resources.

Strengthening research capacity through an intensive training program for biomedical investigators from low- and middle-income countries: the Vanderbilt Institute for Research Development and Ethics (VIRDE)

Background
Capacity strengthening initiatives aimed at increasing research knowledge and skills of investigators in low- and middle-income countries (LMICs) have been implemented over the last several decades. With increased capacity, local investigators will have greater leadership in defining research priorities and impact policy change to help improve health outcomes. Evaluations of models of capacity strengthening programs are often limited to short-term impact. Noting the limitations of traditional output-based evaluations, we utilized a broader framework to evaluate the long-term impact of the Vanderbilt Institute in Research Development and Ethics (VIRDE), a decade-old intensive grant development practicum specifically tailored for investigators from LMICs.

Methods
To assess the impact of VIRDE on the research careers of alumni over the past 10 years, we surveyed alumni on research engagement, grant productivity, career trajectory, and knowledge gained in grant writing. Descriptive statistics, including means and total counts, and paired sample t-tests were used to analyze the data.

Results
Forty-six of 58 alumni completed the survey. All respondents returned to their home countries and are currently engaged in research. Post-VIRDE grant writing knowledge ratings were significantly greater than pre-VIRDE. The number of respondents submitting grants post-VIRDE was 2.6 times higher than before the program. Eighty-three percent of respondents submitted a total of 147 grants post-VIRDE, of which 45.6% were awarded. Respondents acknowledged VIRDE’s positive impact on career growth and leadership, with 88% advancing in career stage.

Conclusions
Gains in grant writing knowledge and grant productivity suggest that VIRDE scholars built skills and confidence in grant writing during the program. A substantial proportion of respondents have advanced in their careers and continue to work in academia in their country of origin. Results show a sustained impact on the research careers of VIRDE alumni. The broader framework for research capacity strengthening resulted in an expansive assessment of the VIRDE program and alumni, illuminating successful program elements and implications that can inform similar capacity strengthening programs.

Innovations in surgery between the past and future: A narrative review of targeted literature

Innovation is the introduction of a new method or technology designed to change the way things are done. History is full of remarkable innovations in surgery over the years as surgeons have always been innovating and pioneering latest techniques and equipment that can benefit the mankind. Though persistent, progress has been far from uniform. Despite all the bells and whistles that these innovations bring to the table, the little acknowledged fact is that they are only accessible to a very small proportion of the global population. Five billion people on this planet do not even have access to an operating room when needed. It has been reported that conditions requiring surgery are responsible for one-third of all the deaths in the world. The current narrative review was planned to focus on the importance of innovations in surgery, to highlight the problems that were faced by resource-restricted countries in the past, and the necessity of innovative solutions to improve global surgical care in the future.

Factors Influencing Uptake and Utilization of Mutual Health Insurance in Cameroon: The case of Bamenda Ecclesiastical Province Health Assistance

Background: Mutual health insurance schemes are a tool to curb excessive out-of-pocket payments for healthcare services to the poor and vulnerable communities. However, the uptake and utilization of these insurance schemes are low. This study explores factors that influence the uptake and utilization of mutual health insurance schemes.

Methods: This was a descriptive qualitative case study conducted among 20 Adherents and seven staff of BEPHA Kumbo. Multiple data sources were used, including semi-structured interviews, focus group discussions, and a review of documents. We used the content analysis method to analyze the data.

Results: While mutual health insurance schemes can increase access to healthcare and potentially protect households against impoverishment caused by out-of-pocket payments, they face multiple factors that hinder uptake and utilization. The findings revealed that trust and access to the insurer were classified as enablers. At the same time, annual contribution, adverse selection, and no national policy were threats influencing uptake and utilization of the schemes.

Conclusions: MHI schemes can expand access to healthcare and improve the quality of care for its members. However, the lack of national policy threatens uptake and utilization and, hence, sustainability of these schemes.