Universal Eye Health and its relation to Digital Health: A Systematic Analysis

Background Despite the vigorous efforts of different Global public health sectors regarding eye health. It became now available, but not yet to everyone. From here appeared the urge of the development of Universal Eye Health (UEH) to ensure reducing social inequality in eye health services delivery and improving eye services’ coverage. Digital Health has also become an important frontier in health care services delivery nowadays. This research aims to study the availability and accessibility of UEH and the role of Digital Health as an additive factor in improving it. Methods This is an observational retrospective study. 2 methods where used for in-depth study of current situation of digital eye health in LMICs; Country profiles of the studied countries from different WHO regions and systematic analysis. Literatures have been searched at three search engines: PubMed, Google Scholar, and Cochrane Library. An overview of review articles was conducted using patient, intervention, comparison, and outcome (PICO) framework. Search keywords were; “Digital health”, “Smart health”, “eye health”, “Cataract”, and etc. Our 37 publications were identified as suitable regarding the three expected categories of outcomes. Results Digital health was found to be an important factor in the attainment of UEH in the studied countries. Three categories of outcomes representing the effect of digital health were found in the systematic analysis which helped in improving the eye health system: quality of life of patients with ocular diseases, quality of eye health services and access to the eye health services. Implication of these results on digital eye health in Egypt was identified as well. Conclusion Digital health was found to be an important additive factor in the attainment and expansion of UEH in many of the studied countries. Portable screening devices, Fundus photography, and retinal diagnostics AI innovations and Teleophthalmology have become the black horse of the eye field nowadays but still used in a limited range in many countries in need of such technologies. Using EHRs in research and gathering data for cataract surgical indicators still also used in a very narrow scope which needed to broaden. As it is strongly needed to monitor UEH indicators to be able to have a real assessment of the countries’ progress in their national eye plans and improve access and quality of eye services and of patient life, especially in LMICs.

The availability of psychological support following road travel injuries in Namibia: A qualitative study

Road traffic injuries (RTIs) are a major problem worldwide with a high burden of mental health problems and the importance of psychological support following road injury is well documented. However, globally there has been very little research on the accessibility of psychological services following road injury. Namibia is one of the countries most affected by RTIs but no previous studies have been done on this. In this qualitative study we investigated the availability of psychological services to RTI injured in Namibia. Our study findings are in line with those of other global studies in showing inadequate access to psychological support for injury survivors and we discuss the reasons. It is hoped these findings will help policymakers develop ways of enhancing access to psychological support for the many people injured in RTIs in Namibia. The models they develop may also be of use to other LMICs countries with high RTI rates.

We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings

Access to safe and timely surgical care saves lives, but its multiple barriers in low- and middle-income countries (LMICs) contribute to high postoperative mortality [1]. In these settings, surgical health systems are fragile due to a shortage of supplies such as drugs, anesthesia equipment and oxygen, the maldistribution of surgical specialists, poor referral systems, and an inability to routinely track processes and outcomes indicators for quality improvement. The ongoing Covid-19 pandemic has heightened barriers to surgical care in LMICs with resultant increases in unmet surgical needs. On the other hand, the pandemic has revealed the great potentials of telehealth.

Telehealth, which is the provision of healthcare-related services over a distance using electronic and telecommunication technologies, has created solutions to leapfrog certain barriers to surgical care in LMICs. Long distance travel to reach facilities and extended waiting times to see specialists can be circumvented by phone and online consultations. These virtual visits are not only cost saving but can prevent critical delays in patient care. Remote consultations can take on various forms. Firstly, initial visits and preoperative instructions can be done through telehealth platforms from the comfort of patient homes. In certain low acuity and elective cases, video visits may make it possible to determine the need for an operation or the need for in-person visitation to assist surgical planning. Additionally, mobile apps, direct phone calls, and instant messaging are suitable for preoperative education and assisting patients in navigating barriers to surgical access in addition to using video chat platforms. Likewise, mHealth apps and real-time video features allow for postoperative follow-up including routine wound inspection and utilize community health workers, nurses, or general medical doctors located closer to the patient than the hospital that provided the surgical care. The addition of artificial intelligence technology to mHealth could aid these cadres to identify wound infections. In Rwanda, machine learning is being harnessed to detect postoperative wound infections in rural women after Cesarean sections [2]. Finally, outreach by surgeons to rural areas can be strengthened by remote preoperative consultations to identify appropriate operative candidates, provide virtual spaces for planning with local teams, and conduct postoperative follow-up. Therefore, telehealth maximizes the impact of visiting specialists and improves the quality of patient care.

Poor communication and referral networks between health facilities are major barriers to timely and quality access to surgical care in LMICs. Telehealth allows doctors and nurses in rural and primary care facilities to communicate quickly with surgeons at regional and tertiary hospitals. The mHealth app, Vula Mobile, is used ubiquitously by South African rural doctors and nurses to refer persons with surgical conditions to specialists at higher level hospitals. A 2019 study showed that one-third of acute orthopedic conditions were managed on this platform through expert advice without the need for transfer [3]. The median response time on the app was less than 30 minutes. In addition, metadata from mHealth referral apps can be used to track volumes, referral times, and patient flow, which might be used for quality improvement efforts. This type of telehealth platform shows promise and might be scaled-up in other LMICs to better link networks of non-specialist health care providers and surgeons.

If higher bandwidth is available, real-time video platforms, which allow for in-depth consultations and case discussions, can be used to overcome specialist shortages in LMICs. Virtual multi-disciplinary conferences are being used in South–South and North–South collaborations. For example, the Global Cancer Institute has a network of over 500 doctors from Africa, Asia, and Latin America who present cancer cases for discussion with US oncology experts [4].

The limited case mix at some LMIC training hospitals and the shortage of surgical subspecialists can impede the acquisition of certain operative skills. Telesurgery, or intra-operative tele-mentoring, is where a senior surgeon located remotely can give immediate and continuous feedback to the operating surgeon. Early attempts at South–South telesurgery collaborations have shown good patient outcomes [5].

Another telehealth innovation for skills acquisition is simulation, or the use of models to imitate the steps of an operation. Simulators can be high-fidelity units with computer animation or low-fidelity models made from inexpensive materials like cardboard boxes and graspers to learn three-dimensional techniques such as laparoscopic suturing and knot tying. Simulation has been shown to be particularly useful during the Covid-19 pandemic to augment training since elective operative volume has decreased in almost every country worldwide…

An Ethnographic Study of Nursing on a Surgery Ship Providing Humanitarian Care

Less than half the world’s population has access to essential health services (United Nations, 2020), the majority of whom live in low to middle-income countries (LMICs; Meara et al., 2015). The inability to access health services denies people a life of dignity. To bridge this current gap in the provision of health care, nongovernmental organisations are responding by deploying specialist, short term healthcare teams (Ng-Kamstra et al., 2016). Nurses, as the largest group of health professionals, provide care within those teams. Substantial literature is linked to nurses deployed in a disaster response situation, However, there is limited research into nurses’ roles within teams meeting a humanitarian response outside that urgent disaster context, and what their contribution brings. The purpose of this ethnographic study was to explore nursing involvement within humanitarian healthcare provision to generate insight into the area of humanitarian nursing in an acute, short term, nondisaster context and to extend the research literature surrounding this topic. The study was framed within the context of a faith-based nongovernmental organisation delivering specialist surgery on a civilian hospital ship. The aim was to advance the mission and purpose of humanitarian (nondisaster) nursing, providing a detailed description of the culture of nursing care in that setting. An interpretivist standpoint, influenced by a social constructivist theoretical position, was taken. Data were collected over 6 months, using participant observation, a reflection of artefacts, and the collective voice of volunteer nurses. Thematic analysis was conducted considering Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Findings elucidated nursing within the context of a community of nursing practice (CoNP), revealing four major themes: (1) “What drew us here?” (expressions of motivation), (2) “Who we are and how we do what we do” (expressions of engagement), (3) challenges (embracing change), and (4) development (expressions of transformation). This study contributes new knowledge by describing the culture of nursing and how nurses enact their care in a previously undescribed humanitarian context. Based on the analysis of findings, a professional practice model (PPM) named HHEALED was proposed. An in-depth application of the model was made to the specific organisational context framing the study. Recommendations arising from this study address nurses’ social and professional roles within humanitarian care that could further validate and strengthen policies and programs for the delivery of humanitarian health care for a mobile platform providing specialist surgical care.

Letter: Global Neurosurgery Scope and Practice

To the Editor:

Russell Andrews, the global neurosurgery section editor at the World Neurosurgery journal, argues that it is difficult to define global neurosurgery because of the breadth of articles labeling themselves as global neurosurgery.1 There are numerous definitions of global neurosurgery, but we will discuss 2 commonly used definitions. First, the World Federation of Neurosurgical Societies’ Global Neurosurgery Committee (WFNS GNC) defines global neurosurgery as, “The clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.”2 Next, we can define global neurosurgery based on the definition of global surgery by Bath et al,3 that is, “the enterprise of providing improved and equitable [neuro]surgical care to the world’s population, with its core tenets as the issues of need, access, and quality.”3 The 2 definitions have more in common than they differ from one another, and the differences alone cannot explain the confusion around what is and is not global neurosurgery.

Multiple factors are responsible for the confusion around the definition and scope of global neurosurgery. A chasm separates the academic global neurosurgery community from neurosurgeons and neurosurgical organizations working toward increasing accessibility in low-resource settings.1,4 Academic neurosurgery is responsible for the 2 definitions mentioned above (de facto definitions), whereas many within the neurosurgical community are familiar with a de jure definition. Historically, global neurosurgery has been viewed as high-income country (HIC) neurosurgeons and neurosurgical organizations delivering care or investing in low- and middle-income countries (LMICs).1 This narrative is responsible for the misconception that global neurosurgery is humanitarian or international neurosurgery. While all humanitarian and international neurosurgery falls in the realm of global neurosurgery, all global neurosurgery is not international or humanitarian. This de jure definition puts LMICs on the receiving end of partnerships and fails to acknowledge that global neurosurgery initiatives equally benefit HIC institutions and neurosurgeons. For example, neurosurgery has benefited greatly from reverse innovation, including the development of endoscopic third ventriculostomy with choroid plexus cauterization in Uganda.5

Moreover, the de jure definition assumes that lack of access to safe, timely, and affordable neurosurgical care is only true in LMICs. We know from recent studies that this is not true—for example, Rahman et al6 reported significant disparities in the geographic distribution of US neurosurgeons. Also, in a review of out-of-pocket expenditures for cranial surgery at a US center, Yoon et al7 reported an increase in the proportion of patients facing financial risk.

To clarify the misconception, we must return to the WFNS GNC’s definition. This definition does not differentiate between HICs and LMICs, and it does not focus on times of humanitarian crisis. As a result, we can say that global neurosurgery is not defined by the country’s income category but rather by the existence of barriers to seeking, reaching, and receiving safe, timely, and affordable neurosurgical care. To reach this goal, global neurosurgery borrows from health systems research to devise holistic solutions that will increase access to care.2–4

Early global neurosurgeons learned that staff education and purchase of equipment and consumables without buy-in from local leadership or investments in information management were unsustainable and inefficient.3,4 As a result, global neurosurgeons have adopted a systems-engineering mindset to identify problems and map out solutions.4 They analyze interactions between the health system’s components (workforce, service delivery, infrastructure, information management, funding, and governance). They design interventions in collaboration with stakeholders because they understand that health systems are complex and have many essential parts.8 No part can independently provide the output of the whole, and the health system’s performance is not always improved if its parts are improved independently.8 Similarly, a sports team will not be improved simply because the best players at each position have been recruited. Team managers must factor in the relationships between players, players’ strengths and weaknesses, and team culture during recruitment.

Assessing the Performance of Artificial Intelligence Systems for the Screening of Diabetic Retinopathy: A Systematic Review and Meta-Analysis

Diabetic retinopathy is the most common microvascular complication of diabetes mellitus and one of the leading causes of blindness globally. Due to the progressive nature of the disease, earlier detection and timely treatment can lead to substantial reductions in the incidence of irreversible vision-loss. Artificial intelligence (AI) screening systems have offered clinically acceptable and quicker results in detecting diabetic retinopathy from retinal fundus and optical coherence tomography (OCT) images. Thus, this systematic review and meta-analysis of relevant investigations was performed to document the performance of AI screening systems that were applied to fundus and OCT images of patients from diverse geographic locations including North America, Europe, Africa, Asia, and Australia. A systematic literature search on Medline, Global Health, and PubMed was performed and studies published between October 2015 and January 2020 were included. The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and AI-based investigations were mandatory for studies inclusion. The abstracts, titles, and full-texts of potentially eligible studies were screened against inclusion and exclusion criteria. Twenty-one studies were included in this systematic review; 18 met inclusion criteria for the meta-analysis. The pooled sensitivity of the evaluated AI screening systems in detecting diabetic retinopathy was 0.93 (95% CI: 0.92-0.94) and the specificity was 0.88 (95% CI: 0.86-0.89). The included studies detailed training and external validation datasets, criteria for diabetic retinopathy case ascertainment, imaging modalities, DR-grading scales, and compared AI results to those of human graders (e.g., ophthalmologists, retinal specialists, trained nurses, and other healthcare providers) as a reference standard. The findings of this study showed that the majority AI screening systems demonstrated clinically acceptable levels of sensitivity and specificity for detecting referable diabetic retinopathy from retinal fundus and OCT photographs. Further improvement depends on the continual development of novel algorithms with large and gradable sets of images for training and validation. If cost-effectiveness ratios can be optimized, AI can become a financially sustainable and clinically effective intervention that can be incorporated into the healthcare systems of low-to-middle income countries (LMICs) and geographically remote locations. Combining screening technologies with treatment interventions such as anti-VEGF therapy, acellular capillary laser treatment, and vitreoretinal surgery can lead to substantial reductions in the incidence of irreversible vision-loss due to proliferative diabetic retinopathy.

We Asked the Experts: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.

Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

Background
Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs).

Methods
A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies.

Discussion
Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology.

Neurotrauma Registry Implementation in Colombia: A Qualitative Assessment

Objectives Latin America is among several regions of the world that lacks robust data on injuries due to neurotrauma. This research project sought to investigate a multi-institution brain injury registry in Colombia, South America, by conducting a qualitative study to identify factors affecting the creation and implementation of a multi-institution TBI registry in Colombia before the establishment of the current registry.

Methods Key informant interviews and participant observation identified barriers and facilitators to the creation of a TBI registry at three health care institutions in this upper-middle-income country in South America.

Results The study identified barriers to implementation involving incomplete clinical data, limited resources, lack of information and technology (IT) support, time constraints, and difficulties with ethical approval. These barriers mirrored similar results from other studies of registry implementation in low- and middle-income countries (LMICs). Ease of use and integration of data collection into the clinical workflow, local support for the registry, personal motivation, and the potential future uses of the registry to improve care and guide research were identified as facilitators to implementation. Stakeholders identified local champions and support from the administration at each institution as essential to the success of the project.

Conclusion Barriers for implementation of a neurotrauma registry in Colombia include incomplete clinical data, limited resources and lack of IT support. Some factors for improving the implementation process include local support, personal motivation and potential uses of the registry data to improve care locally. Information from this study may help to guide future efforts to establish neurotrauma registries in Latin America and in LMICs.

Case studies for implementing MCDA for tender and purchasing decisions in hospitals in Indonesia and Thailand

Background
A multi-criteria decision analysis (MCDA) approach has been suggested for helping purchasers in low- and middle-income countries in an evidence-based assessment of multi-source pharmaceuticals to mitigate potential adverse consequences of price-based decisions on patient access to effective medicines. Six workshops for developing MCDA-instruments for purchasing were conducted in Indonesia, Kazakhstan, Thailand, and Kuwait in 2017–2020. In Indonesia and Thailand, two pilot-initiatives aimed to implement the instruments for hospital drug purchasing decisions.

Objective
By analysing and comparing the experiences and progress from the MCDA-workshops and the two case-examples for hospital implementation in Indonesia and Thailand, we aim to gain insights, which will support future implementation.

Methods
The selection of criteria and their average weight were compared quantitatively across the MCDA-instruments developed in all four countries and settings. Implementation experiences from two case-examples were studied, which included (1) testing the instrument across a variety of drugs in seven hospitals in Thailand and (2) implementation in one specialty hospital in Indonesia. Semi-structured interviews were conducted via web-conferences with four diverse stakeholders in the pilot implementation projects in Thailand and Indonesia. The open responses were evaluated through qualitative content analysis and synthesis using grounded theory coding.

Results
Drivers for implementation were making ‘better’ decisions, achieving transparency and a rational selection process, reducing drug shortages, and assuring consistent quality. Challenges were seen on the technical level (definition or of criteria, scoring methods, access to data) or change-related challenges (resistance, perception of increased workload, lack of competencies or capabilities, lack of resources). The comparison of the MCDA instruments revealed high similarity, but also clear need for local adaptations in each specific case.

Conclusion
A set a of measures targeting challenges related to utility, methodology, data requirements, capacity building and training as well as the broader societal impact can help to overcome challenges in the implementation. Careful planning of implementation and organizational change is recommended for ensuring commitment and fit to local context and culture. Designing a collaborative change program for each application of MCDA-based purchasing will enable healthcare stakeholders to maximally benefit in terms of quality and effectiveness of care and access for patients.