The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants

Background
Musculoskeletal (MSK) conditions, MSK pain and MSK injury/trauma are the largest contributors to the global burden of disability, yet global guidance to arrest the rising disability burden is lacking. We aimed to explore contemporary context, challenges and opportunities at a global level and relevant to health systems strengthening for MSK health, as identified by international key informants (KIs) to inform a global MSK health strategic response.

Methods
An in-depth qualitative study was undertaken with international KIs, purposively sampled across high-income and low and middle-income countries (LMICs). KIs identified as representatives of peak global and international organisations (clinical/professional, advocacy, national government and the World Health Organization), thought leaders, and people with lived experience in advocacy roles. Verbatim transcripts of individual semi-structured interviews were analysed inductively using a grounded theory method. Data were organised into categories describing 1) contemporary context; 2) goals; 3) guiding principles; 4) accelerators for action; and 5) strategic priority areas (pillars), to build a data-driven logic model. Here, we report on categories 1–4 of the logic model.

Results
Thirty-one KIs from 20 countries (40% LMICs) affiliated with 25 organisations participated. Six themes described contemporary context (category 1): 1) MSK health is afforded relatively lower priority status compared with other health conditions and is poorly legitimised; 2) improving MSK health is more than just healthcare; 3) global guidance for country-level system strengthening is needed; 4) impact of COVID-19 on MSK health; 5) multiple inequities associated with MSK health; and 6) complexity in health service delivery for MSK health. Five guiding principles (category 3) focussed on adaptability; inclusiveness through co-design; prevention and reducing disability; a lifecourse approach; and equity and value-based care. Goals (category 2) and seven accelerators for action (category 4) were also derived.

Conclusion
KIs strongly supported the creation of an adaptable global strategy to catalyse and steward country-level health systems strengthening responses for MSK health. The data-driven logic model provides a blueprint for global agencies and countries to initiate appropriate whole-of-health system reforms to improve population-level prevention and management of MSK health. Contextual considerations about MSK health and accelerators for action should be considered in reform activities.

A Qualitative Analysis of Burn Injury Patient and Caregiver Experiences in Kwazulu-Natal, South Africa: Enduring the Transition to a Post-Burn Life

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy.

Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

Background: We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs). Methods: Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported. Results: Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh. Conclusions: Child’s age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among survivors of childhood mortality in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical care by children and adolescents with NI in LMICs.
Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all reports on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches, and we report a synthesized analysis of the barriers identified in the primary studies.
Results: Our literature searches identified 3,074 reports of which 16 were included in the final analysis. Fourteen studies (87.5%) originated from rural settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=15, 93.8%), geographical inaccessibility (N=11, 68.8%), inadequate healthcare resources (N=11, 68.8%), inadequate education/awareness (N=9, 56.3%), and prohibitive culture/beliefs (N=9, 56.3%). Factors reported in <50% of the studies related to the attitude of the patient, health worker, or society (N=7, 43.8%), poor doctor-patient communication (N=5, 31.3%), physical inaccessibility (N=3, 18.8%), and a lack of confidentiality for personal information (N=2, 12.5%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level.
Conclusions: Financial constraints, geographic inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs.
PROSPERO registration: CRD42020165296 (28/04/2020)

Rehabilitation for cancer survivors: How we can reduce the healthcare service inequality in low- and middle income countries.

Cancer diagnosis often substantially affects patient’s physical, psychological, and emotional status. The majority of cancer patients experience declining of energy, activity levels, social-cultural participation and relationships. In addition, cancer progression and side effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient’s quality of life. Although cancer rehabilitation has been implemented in many high income countries, it is either not yet or sub-optimally delivered in most low and middle income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high quality cancer rehabilitation in the developing countries.