Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist

Introduction
While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.

Methods
We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.

Results
A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.

Conclusion
As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

A retrospective analysis of peri-operative medication errors from a low-middle income country

Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004–2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.

GLOBOCAN 2020 Report on Global Cancer Burden: Challenges and Opportunities for Surgical Oncologists

Cancer is emerging as a major public health challenge globally. Recently, IARC (International Association of Research on Cancer) published global cancer burden using GLOBOCAN 2020 estimates for 36 cancers in 185 countries of the world. As per the estimates of the World Health Organization (WHO) in 2019, cancer is the first or second leading cause of death in 112 of 183 countries. The major takeaways of the GLOBOCAN 2020 report relevant to the surgical oncology community include the rising global burden of cancer, global disparity in cancer incidence and mortality in different geographic regions, and the impact of the human development index (HDI) on cancer incidence and projected global cancer burden by 2040. In this article, we discuss the implications of the GLOBOCAN report on future global cancer control strategies and the role of surgical oncologists in the fight against cancer.

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.

Confidence and knowledge in emergency management among medical students across Colombia: A role for the WHO basic emergency care course

Introduction
Globally, medical students have demonstrated knowledge gaps in emergency care and acute stabilization. In Colombia, new graduates provide care for vulnerable populations. The World Health Organization (WHO) Basic Emergency Care (BEC) course trains frontline providers with limited resources in the management of acute illness and injury. While this course may serve medical students as adjunct to current curriculum, its utility in this learner group has not been investigated. This study performs a baseline assessment of knowledge and confidence in emergency management taught in the BEC amongst medical students in Colombia.

Methods
A validated, cross-sectional survey assessing knowledge and confidence of emergency care congruent with BEC content was electronically administered to graduating medical students across Colombia. Knowledge was evaluated via 15 multiple choice questions and confidence via 13 questions using 100 mm visual analog scales. Mean knowledge and confidence scores were compared across demographics, geography and prior training using Chi-Squared or one-way ANOVA analyses.

Results
Data were gathered from 468 graduating medical students at 36 institutions. The mean knowledge score was 59.9% ± 23% (95% CI 57.8–62.0%); the mean confidence score was 59.6 mm ±16.7 mm (95% CI 58.1–61.2). Increasing knowledge and confidence scores were associated with prior completion of emergency management training courses (p<0.0001).

Conclusion
Knowledge and confidence levels of emergency care management for graduating medical students across Colombia demonstrated room for additional, specialized training. Higher scores were seen in groups that had completed emergency care courses. Implementation of the BEC as an adjunct to current curriculum may serve a valuable addition.

Telemedicine in India: A New Horizon for Transforming Healthcare

The health of ourselves and our loved ones is always our top priority as human beings; it is something we are concerned about on a daily basis. Regardless of age, gender, socioeconomic, cultural, or ethnic origin, health is regarded as our most valuable possession. When we think of the term “well-being,” we immediately think of health and an atmosphere devoid of illness. The ‘right to health’ is recognised as a fundamental or fundamental human right that affects the exercise of other human rights. The right to health is, at the very least, a right to specific conditions or facilities that could protect the population’s health. It also includes civil and political rights relating to the availability and accessibility of both public and private health-care services. This right also involves providing health care for the diagnosis and treatment of an illness or disease, as well as compensation for people who cannot afford to pay for it. According to the World Health Organization (WHO), “health is a state of complete physical, mental and social well-being and not just the absence of disease”. The right to health was first conveyed in the World Health Organization constitution in 1946. It states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”

Prevalence and Factors Associated With Caesarean Delivery in Nepal: Evidence From a Nationally Representative Sample

Background
Caesarian sections (CS) are life-saving management for a pregnant mother and fetus subject to obstetric complications. The World Health Organization (WHO) expected CS rates not to exceed 10 to 15 per 100 live births in any country. This study aimed to assess the prevalence of CS and its associated factors from the 2016 Nepal Demographic and Health Survey (NDHS), building on previous studies mentioned in detail in the latter part of the paper.

Methods
This study analyzed the secondary data from the 2016 Nepal Demographic and Health Survey (NDHS), conducted from June 19, 2016, to January 31, 2017. The survey is undertaken every five years; consequently, the data capture the information in the previous five years from the data collection period. We used the 2016 NDHS, which is implemented by the new Enumeration Area (EA) under the support of the Ministry of Health (MOH) and funded by the U.S. Agency for International Development (USAID). In the rural areas, the sample is stratified and selected in two stages. In the first stage, wards are selected as the primary sampling units (PSU), with households subsequently chosen from the PSUs. In the urban areas, the sample is nominated in three stages. In the first stage, wards are selected as PSUs; in the second stage, one EA is chosen from each PSU, and finally, households are selected from the EAs. Then data were collected from the women in the reproductive age group within the selected households.

Results
The prevalence of CS in Nepal conforms to the WHO standard with 7.8, 7.5, and 8.1 per 100 deliveries, or 9.8, 8.9, and 9.1 per women’s last births in the previous one, three, and five years, respectively. Older mothers of 30 years old or more, having high incomes, being overweight and obese, using the internet, ante-natal care (ANC) visits of more than four times, ANC by doctors, twin delivery, and having babies of 4 kg or more, had higher odds for a CS while having two or more children seemed to be protective towards CS.

Conclusion
These findings can be used to update health policies surrounding CS delivery to limit unnecessary CS and ensure better health as CS is not without complications

Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities

Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.

Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria.

Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.

Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.

Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as w

Cancer Screening Programs in Low- and Middle-Income Countries: Strategies for Success

Cancer is a leading global health problem and, as of 2020, accounts for 10 million deaths per year.1 The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by avoiding risk factors, early detection via screening, and proper treatment. The majority of cases occur in low- and middle-income countries (LMIC).2 Despite awareness of the magnitude of this problem by the global health community and the large-scale efforts to implement screening programs, very few programs are successful and, more importantly, sustainable. Although there are several barriers to implementation of a cancer screening program, the critical barriers are lack of awareness and acceptance of the screening programs by the people residing in the specific geographic regions. In the article by Pak et al. entitled Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program, the authors highlight the cultural and psychosocial barriers to cancer screening.3

The DESH program is a well-organized screening program with multiple components that consists of an initial baseline survey followed by implementation of mobile cancer screening and subsequent follow-up of patients regarding final diagnosis and treatment. The DESH program in Assam, India, focuses on breast, oral, and cervical cancers due to the high incidence of these cancers in this region and the availability of validated screening tests. The baseline survey was validated in a smaller cohort (n = 20) of local participants before widespread implementation to nearly 1000 participants. The survey consisted of multiple sections that focused on areas such as awareness of the carcinogenic effects of certain lifestyle choices, i.e., consumption of betel nuts and smoking, spiritual/religious beliefs, stigma around cancer diagnoses, and knowledge about screening programs and local health care facilities. Through this approach, they found that the majority (92.9%) of participants were not aware of cancer screening availability and had never undergone prior screening. Additionally, over 90% of the survey participants reported consumption of betel nuts, but less than half (46.9%) were aware of the carcinogenic effects of betel nuts. Finally, 42–57% of participants reported negative stigma towards cancer diagnosis. Specifically, more than 30% of participants believed that either cancer is a punishment from God or is caused by bad karma and evil spirits. Furthermore, 20% of participants described fear of cancer screening. These results highlight the complex interplay between knowledge gaps, misconceptions, and cancer stigma that could affect the acceptance, and thereby the success, of a screening program.

Taneja et al. identified similar sociocultural barriers regarding cervical cancer screening in India. Specifically, barriers identified included lack of awareness about screening, poor knowledge about initial symptoms, social stigma, cost, and familial obligations. Hence, it is not surprising that only 5% of eligible women have undergone screening for cervical cancer in India, compared with up to 84% in developed countries.4 This is disconcerting since cervical cancer has the potential for prevention and/or cure due to the length of the premalignant and preinvasive period, emphasizing the importance of a population-based screening program. The benefits of an effective screening program for this disease were demonstrated by Sankaranarayanan et al. in a study of over 130,000 healthy women, in which participants were randomly assigned to undergo cervical cancer screening with either human papillomavirus (HPV) testing, cytologic testing, or visual inspection with acetic acid (VIA). Single-round HPV testing was associated with a significantly reduced number of advanced cases [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.32–0.69] and mortality5 (HR 0.53, 95% CI 0.33–0.83) compared with the control group. The results of this study highlight that implementation of a successful screening program with the right screening test is associated with decreased mortality, even in low-resource settings. However, the main challenge is to screen enough people for the screening program to be effective. The National Cancer Prevention and Control Program launched in 2010 in Morocco, with augmented and expanded infrastructure and considered an exemplar for screening programs in LMIC, had major challenges with uptake of screening and poor participation in early identification of precancerous lesions.

The Role of WHO in Global Neurosurgery

It is indeed an honor to participate in this founding edition of the Journal of Global Neurosurgery. The inauguration of this journal is welcome and timely, as it advances this discipline’s academic interests and provides a vehicle for publishing more global authors. The World Health Organization (WHO) has long been involved with neurosurgical issues, primarily preventing and treating traumatic brain and spine injuries, epilepsy, and stroke.

WHO is the health technical branch of the United Nations (UN) whose primary functions include(1):
1.Provide leadership and engaging partnerships.
2.Shape the research agenda.
3.Develop norms and standards.
4.Articulate ethical, evidence-based policy options.
5.Provide technical support.
6.Monitor and assess health situations and trends.