Barriers to Trauma Care in South and Central America: a systematic review

Introduction
Trauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region.

Methods
OVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item bank.

Results
57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57).

Conclusion
Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries.

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

Background
Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda.

Methods
This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed.

Results
A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70–0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders.

Conclusions
This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.

Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.

Systematic review of barriers to, and facilitators of, the provision of high‐quality midwifery services in India

Background
The Indian government has committed to implementing high‐quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high‐quality midwifery care in India.

Methods
We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high‐quality midwifery care in India.

Results
Thirty‐two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands‐on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women’s experiences of maternity care, and improving health system infrastructure.

Conclusions
The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India’s plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Patient Barriers to Accessing Surgical Cleft Care in Vietnam: A Multi-site, Cross-Sectional Outcomes Study.

BACKGROUND:
Most people who lack adequate access to surgical care reside in low- and lower-middle-income countries. Few studies have analyzed the barriers that determine the ability to access surgical treatment. We seek to determine which barriers prevent access to cleft care in a resource-limited country to potentially enable barrier mitigation and improve surgical program design.

METHODS:
A cross-sectional, multi-site study of families accessing care for cleft lip and palate deformities was performed in Vietnam. A survey instrument containing validated demographic, healthcare service accessibility, and medical/surgical components was administered. The main patient outcome of interest was receipt of initial surgical treatment prior to 18 months of age.

RESULTS:
Among 453 subjects enrolled in the study, 216 (48%) accessed surgical care prior to 18 months of age. In adjusted regression models, education status of the patient’s father (OR 1.64; 95% CI 1.1-2.5) and male sex (OR 1.61; 95% CI 1.1-2.4) were both associated with timely access to care. Distance and associated cost of travel, to either the nearest district hospital or to the cleft surgical mission site, were not associated with timing of access. In a sensitivity analysis considering care received prior to 24 months of age, cost to attend the surgical mission was additionally associated with timely access to care.

CONCLUSIONS:
Half of the Vietnamese children in our cohort were not able to access timely surgical cleft care. Barriers to accessing care appear to be socioeconomic as much as geographical or financial. This has implications for policies aimed at reaching vulnerable patients earlier.