Strategies to Improve Women’s Leadership Preparation for Early Career Global Health Professionals: Suggestions from Two Working Groups

Background: Despite advances in gender equality, women still experience inequitable gaps in global health leadership, and barriers to women’s advancement as leaders in global health have been well described in the literature. In 2021, the Johns Hopkins Center for Global Health conducted two virtual working groups for emerging women leaders to share challenges and suggest solutions to advance women’s leadership in global health. In this paper, we present emerging themes from the working groups, provide a framework for the results, and discuss strategies for advancing women’s leadership in global health.

Objectives: The objective of this paper is to synthesize and share the themes of the two working group sessions to provide strategies for improving women’s leadership training and opportunities in the field of global health.

Methods: Approximately 182 women in the global health field participated in two virtual working group sessions hosted by the Johns Hopkins Center for Global Health using the Zoom platform. Participants were divided into virtual breakout rooms and discussed pre-assigned topics related to women’s leadership in global health. The participants then returned to share their ideas in a plenary session. Notes from the breakout rooms and transcripts from the plenary session were analyzed through a participatory and iterative thematic analysis approach.

Findings: We found that the working group participants identified two overarching themes that were critical for emerging women leaders to find success in global health leadership. First, the acquisition of individual essential skills is necessary to advance in their careers. Second, the institutional environments should be setup to encourage and enable women to enter and succeed in leadership roles. The participants also shared suggestions for improving women’s leadership opportunities such as including the use of virtual technologies to increase training and networking opportunities, intersectionality in mentorship and sponsorship, combatting impostor syndrome, and the importance of work-life balance.

Conclusions: Investing in women and their leadership potential has the promise to improve health and wealth at the individual, institutional, and community levels. This manuscript offers lessons and proposes solutions for increasing women’s leadership through improving individual level essential skills and fostering environments in which women leaders can emerge and thrive.

Global Neurosurgery in the Context of Global Public Health Practice–A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well.

For example, vitamin B12 and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs.

Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeons

Mobile-Social Learning for Continuing Professional Development in Low- and Middle-Income Countries: Integrative Review

Background:
Access to continuing professional development (CPD) for health care workers in low- and middle-income countries (LMICs) is severely limited. Digital technology serves as a promising platform for supporting CPD for health care workers by providing educational content virtually and enabling virtual peer-to-peer and mentor interaction for enhanced learning. Digital strategies for CPD that foster virtual interaction can increase workforce retention and bolster the health workforce in LMICs.

Objective:
The objective of this integrative review was to evaluate the evidence on which digital platforms were used to provide CPD to health care workers and clinical students in LMICs, which was complemented with virtual peer-to-peer or mentor interaction. We phrased this intersection of virtual learning and virtual interaction as mobile-social learning.

Methods:
A comprehensive database and gray literature search was conducted to identify qualitative, quantitative, and mixed methods studies, along with empirical evidence, that used digital technology to provide CPD and virtual interaction with peers or mentors. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eligible articles were written in English, conducted in an LMIC, and used a mobile device to provide CPD and facilitate virtual peer-to-peer or mentor interaction. Titles, abstracts, and full texts were screened, followed by an assessment of the quality of evidence and an appraisal of the articles. A content analysis was then used to deductively code the data into emerging themes.

Results:
A total of 750 articles were identified, and 31 (4.1%) were included in the review. SMS text messaging and mobile instant messaging were the most common methods used to provide continuing education and virtual interaction between peers and mentors (25/31, 81%). Across the included articles, participants had high acceptability for using digital platforms for learning and interaction. Virtual peer interaction and mentorship were found to contribute to positive learning outcomes in most studies (27/31, 87%) through increased knowledge sharing, knowledge gains, improved clinical skills, and improved service delivery. Peer-to-peer and mentor interaction were found to improve social support and reduce feelings of isolation (9/31, 29%). There were several challenges in the implementation and use of digital technology for mobile-social learning, including limited access to resources (eg, internet coverage and stable electricity), flexibility in scheduling to participate in CPD, and sociobehavioral challenges among students.

Conclusions:
The summary suggests that mobile-social learning is a useful modality for curriculum dissemination and skill training and that the interface of mobile and social learning serves as a catalyst for improved learning outcomes coupled with increased social capital.

Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda

Objectives
Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates.

Study Design
This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020.

Setting
Urban referral center in resource-limited setting.

Methods
Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications.

Results
Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038).

Conclusion
Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.

Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

Background
There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.

Methods
This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).

Results
Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS.

Conclusion
While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

Advancing eye health within universal health coverage: the role of programmatic data and implementation research

In the past 3 y, considerable attention has been paid to the importance of eye health as a global development priority, first by the World Report on Vision launched by the World Health Organization (WHO) in October 2019,1 then by the Lancet Global Health Commission on Global Eye Health, published in February 20212 and most recently by the Vision for Everyone Resolution adopted by the United Nations (UN) General Assembly in July 2021.3 All three documents provide compelling evidence on the magnitude, impact and costs of poor vision and call for coordinated global efforts to improve access to and the quality and equity of eye care services worldwide. The documents argue that the progress towards the Sustainable Development Goals (SDGs)4 will not be sufficient without integrating eye health within universal health coverage (UHC)5 and highlight the role of quality evidence and research in achieving this ambitious global agenda. The Lancet Global Health Commission gives particular attention to contextually relevant solution-focused implementation research and to translating research findings into policy and practice.2

International non-governmental organisations (iNGOs) have been at the forefront of the global efforts to eliminate avoidable vision impairment and improve access to eye care services in low- and middle-income countries (LMICs) for several decades. Their role in mobilising resources, service delivery, building local capacity and advocacy has been well recognised. In recent years, a number of iNGOs have made considerable investments in generating high-quality evidence and have become important players in eye health implementation research.

There are a number of critical strengths that iNGOs bring to international research. First, iNGOs have a good understanding of service delivery realities and frontline knowledge gaps and can help identify research questions that fit local priorities and meet the needs of local governments, healthcare providers and communities. Second, integrating implementation research into ongoing programmatic activities is both practical and cost-effective. Third, iNGOs are closely engaged with national and local decision-making processes and are well positioned to facilitate the uptake and use of research findings.

This special issue clearly illustrates how iNGOs can contribute to generating crucial evidence to answer operational questions they face and to advance global knowledge on eye health. We are delighted to introduce a collection of articles that present evidence from secondary data analysis and implementation research integrated into eye health programmes supported by the iNGO Sightsavers in sub-Saharan Africa and Asia. This is the first of three supplements to be led by Sightsavers in 2022 and 2023. The two later supplements will focus specifically on evidence from our neglected tropical diseases (NTDs) programmes. In this supplement, we present research findings on a range of eye conditions, including cataracts, unaddressed refractive error (URE), glaucoma, trachoma and onchocerciasis. The articles draw on evidence from 12 countries and address a number of topics pertinent to eye health policies and services in LMICs. We are particularly pleased that several articles are based on a secondary analysis of our programmatic data and have been authored by the technical experts and managers supporting our programmes in the field.

The supplement opens with a guest editorial by Keel and Cieza of the WHO, who present the recent UN developments in support of eye health and highlight global priorities for action to facilitate the journey of member states towards universal eye health. The key messages of the guest editorial are echoed in the commentary by Jones, who discusses the state of eye health funding in LMICs and calls for a step change in delivering more and better financing for eye health within UHC.

The substantial impact of vision on other global health priorities is highlighted in the article by Gascoyne et al., who included disability metrics in a visual impairment survey in Kogi State in Nigeria and present new evidence on the intersection of vision impairment and mental health.

In recognition of the multiple health priorities facing populations in LMICs and the finite resources to address them, a number of articles explore questions on how to make the right policy choices and maximise the effectiveness and efficiency of eye care delivery. Hamill et al. report on the results of a pilot study assessing the feasibility and affordability of mapping areas with medium to low transmission of onchocerciasis in Ghana and Nigeria. They argue that as more and more countries approach onchocerciasis elimination thresholds, questions regarding the cost-effectiveness of treatment in hypo-endemic areas become more and more pressing and the role of implementation research generating such evidence should not be underestimated.

Another article in the series addresses questions of efficiency and equity of services in the context of trachoma elimination. Ul Hassan et al. use programmatic data from seven trachoma-endemic countries (Ethiopia, Kenya, Mozambique, Zambia, Tanzania, Uganda and Nigeria) and compare the effectiveness of different community mobilisation and case-finding approaches with a specific focus on gender. The article stresses the importance of routine multicountry service data in developing recommendations and guidance relevant to a variety of settings.

In India, Buttan et al. also analysed programmatic data from a pilot study that integrated targeted glaucoma screening into existing eye care services and assessed the feasibility and benefits of this approach. Glaucoma is a rapidly emerging global eye health priority that is very challenging for resource-poor settings and operational data on how to address it in a pragmatic and cost-effective way are lacking. Integrating implementation research into ongoing eye care programmes provides an excellent opportunity to build the evidence base so urgently needed by the sector.

Another global priority addressed in this supplement is developing an eye health workforce that is able to meet the growing needs for eye care globally. Two articles focus on task shifting, a strategy frequently used in eye health to address the constant shortages of eye care specialists in LMICs. In a commentary on primary eye care, Yasmin and Schmidt review lessons learned from eye care programmes in Tanzania, Sierra Leone and Pakistan. They argue that while the integration of certain eye care tasks into the roles of primary health and community workers is feasible, a system thinking approach is critical to ensure it is done in a coherent and sustainable way. Further, in a study in Liberia, Tobi et al. show that teachers can be trained to conduct vision screening of schoolchildren to an acceptable level of accuracy. However, based on the data generated by the programme, the authors warn that careful considerations should be given to teachers’ supervision and quality assurance systems.

Two further articles focus on patient-centred care, the theme that features centrally in the World Report on Vision1 and the new eye health agenda. Shrestha et al. explore characteristics and perspectives of patients with postoperative trichiasis in the Hadiya Zone of Ethiopia, while Bechange et al. report results of a multicountry qualitative study considering patients’ perspectives on cataract surgery in rural areas of Kenya, Zambia and Uganda. Both articles argue that patients’ perceptions of quality of care are important determinants of their health-seeking behaviour and need to be better understood to maximise the effectiveness and efficiency of surgical outreach.

Two remaining articles address the role of evidence and innovations in eye health. A commentary by Bartlett et al. describes Sighsavers’ experience of working with the Federal Ministry of Health of Nigeria on strengthening national electronic medical records systems and specifically the adaptation of the electronic data collection tool known as the Trachomatis Trichiasis (TT) Tracker commonly used in trachoma programmes to the needs of paediatric cataract services. Finally, Jolley et al. use the evidence gap map approach and present the current state of evidence from cataract-related systematic reviews relevant to LMICs. The authors point to the shortage of evidence on cataract-related health systems, equity and impact—the gaps also highlighted by the World Report on Vision and the Lancet Commission.

We would like to thank all the authors for the time they spent preparing the manuscripts and for sharing their valuable experiences and findings in an open and transparent way. Many thanks to our reviewers for their time and constructive comments and advice.

We are preparing this supplement at the time of the unfolding coronavirus disease 2019 pandemic. While the scale and impact of this unprecedented global crisis is yet to be fully understood, the increasing importance of evidence in decision-making is indisputable and the role of implementation research is becoming more prominent than ever before. We hope you enjoy reading these articles and find them useful in your own programmatic decisions and policy choices.

A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia

Background
The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution.

Methods
Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location.

Findings
In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement.

Interpretation
This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Background
Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

Methods
We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital’s 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

Findings
Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49).

Interpretation
Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

Funding
National Institute for Health Research Global Health Research Group.

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.

Inequalities in prevalence of birth by caesarean section in Ghana from 1998-2014

Background
Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014.

Methods
Using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results
The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014).

Conclusion
Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated.