Workforce Considerations, Training, and Diseases in Africa

'Seeing is believing' - gender disparities in otolaryngology-head and neck surgery in Africa: a narrative review

PURPOSE OF REVIEW

Various factors affect otolaryngology - head and neck surgery (OHNS) services in low- and middle-income countries (LMICs); including inadequate infrastructure, limited academic positions, unfavorable hospital research policies, and traditional misconceptions about gender and surgery, among others. Although gender inequalities exist globally, they are particularly pronounced in LMICs, especially in Africa.

RECENT FINDINGS

A comparative narrative literature review for relevant manuscripts from January 1, 2017 to through January 10th, 2024, using PubMed, Embase and Google Scholar for articles from the United States/Canada and Africa was done. 195 relevant articles were from the United States/Canada, while only 5 were from Africa and only 1 manuscript was relevant to OHNS. The reviewed articles reported that gender disparities exist in medical training, authorship, and career advancement. We highlight possible solutions to some of these disparities to promote a more gender-diversified workforce in OHNS in Africa as well as all over the world.

SUMMARY

Additional studies on gender disparities in Africa, are needed. These studies will highlight need for inclusive policies, structured and accessible mentorship programs; through which these disparities can be highlighted and addressed. This will in the long run ensure sustainability of OHNS care in LMICs.

Development of an online teaching platform to improve access to postgraduate pathology training in sub-Saharan Africa

Background

Resource barriers to the provision of accessible training in cancer diagnosis in lower- and middle-income countries (LMICs) limit the potential of African health systems. Long-term provision via teaching visits from senior pathologists and trainee foreign placements is unsustainable due to the prohibitive costs of travel and subsistence. Emerging eLearning methods would allow pathologists to be trained by experts in a cheaper, more efficient, and more scalable way.

Purpose

This study aimed to develop an online teaching platform, starting with hematopathology, for trainee pathologists in sub-Saharan Africa, initially in Nairobi, Kenya, and Lusaka, Zambia.

Methods

Course materials were prepared for both Canvas and the Zoom eLearning platforms using digitally scanned slides of lymph nodes and bone marrow trephines. Initial in-person visits were made to each site to establish trainee rapport and maximize engagement, evaluate different methods and course content, and obtain feedback to develop the project. The knowledge of trainees before and after course completion was used to measure initial effectiveness. Online teaching with the preferred platform is to be continued for 1 year before re-evaluation for long-term effectiveness.

Results

Canvas was selected as the preferred delivery platform as it is freely available and has good functionality to support all required tasks. Face-to-face teaching was considered optimal to establish the initial rapport necessary to maximize subsequent engagement with online teaching. Challenges have included sub-optimal internet speeds and connections and scheduling issues. Weekly online hematopathology teaching sessions using live image capture microscope sessions, Zoom, and Canvas have been delivered to students in Kenya and Zambia, with good attendance and interaction in case discussions.

Conclusion

Our team has successfully designed and delivered an online training program in hematopathology to trainee pathologists in Kenya and Zambia, which has been ongoing for over a year. This project is now being scaled to other sub-Saharan countries and other sub-specialties.

Outcomes of Short-Term Surgical Trips in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

This scoping review aims to explore the current body of literature to characterize how short-term surgical trips (STSTs) in Otolaryngology-Head and Neck Surgery (OtoHNS) contribute to surgical, educational, and sustainability-based outcomes in low- and middle-income countries (LMICs). We aim to use these data to synthesize aspects of STSTs that are successful with the hopes of shaping future global efforts.

DATA SOURCES

Data sources included Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

REVIEW METHODS

A comprehensive search was conducted on several databases from inception to October 14, 2021. We included primary studies exploring any surgical or educational outcomes of global short-term surgical endeavors within LMICs. Data were then extracted to evaluate the heterogenous body of literature that exists, characterizing the surgical, educational, and sustainability-based outcomes.

RESULTS

Forty-Seven studies were included in the final analysis. Most publications were focused on surgical interventions (39 of 47; 82.9%); 13 (27.7%) studies included education as the primary aim and 12 (25.5%) considered sustainability a significant aim. Of the 94 first and last authors, there were zero first authors and only one last author with an LMIC affiliation. Twenty-six studies (55%) mentioned that any patients were seen in follow-up, ranging from one day to five years.

CONCLUSION

Our scoping review demonstrates that most STSTs have focused primarily on surgical procedures with a lack of appropriate long-term follow-up. However, the available outcome-based information presented helps identify factors that characterize a strong short-term global surgical program.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:32-39, 2024.

Workplace Environment Microaggressions in Otolaryngology-Head and Neck Surgery: An International Survey

OBJECTIVE

To survey members of the otolaryngology community about their personal and observed experiences of being treated differently because of one's physical attributes, cultural norms, or preferences in the workplace.

STUDY DESIGN

Cross-sectional survey.

SETTING

International Electronic Survey.

METHODS

We invited members of the international otolaryngology community including 3 European or American otorhinolaryngological Societies to complete a survey about personal/observed experience of differential treatment in the workplace related to age, biological sex; disability, gender identity, language proficiency, military experience, citizenship, ethnicity/race, political belief, and sexual orientation. Results were analyzed according to participant ethnicity/race (white vs non-white) and gender (male vs female) RESULTS: Four hundred seven participants completed the evaluations: 301 white (74%) and 106 non-white (26%) participants. Non-white participants reported significantly more experiences of differential treatment (microaggressions) than white participants (p < .05). Non-white participants more frequently felt that they needed to work harder for the same opportunities as their peers and were more likely to consider leaving a position because of an unsupportive environment. In general, females reported more frequent experiences with differential treatment related to sexual orientation, biological sex, and gender identity than males.

CONCLUSION

We recognized reports of differential treatment as a proxy for microaggressions. Non-white members of the otolaryngology community self-report experiencing or observing more microaggressions than white members in the workplace. Acknowledging the existence and impact of microaggressions in the field of Otolaryngology is the first step towards cultivating an inclusive, diverse workforce where all members feel supported, validated, and welcomed.

Epidemiology and demographics of head and neck cancer in Africa: A scoping review

BACKGROUND

Low- to middle-income countries account for 70% of global cancer deaths. Evidence of the changing prevalence of head and neck cancer in Africa in terms of gender, race and epidemiology will inform future research and health planning.

AIM

To synthesise epidemiological literature for head and neck cancer in Africa from 2010 to 2020.

METHOD

A scoping review was completed. The Joanna Briggs Institute Population, context and concept framework confirmed the inclusion criteria. Studies from Africa that included participant demographics, the types, stages, signs and symptoms of head and neck cancer were selected. Five databases were used. Descriptive statistics was completed.

RESULTS

The Preferred Reporting Items for Systematic Reviews and MetaAnalysis guided the reporting of the findings. Of the 1891 articles downloaded, 66 were included in the final review. Nigeria produced the most studies and oral cancer at 74% was most prevalent. Substance abuse was the most prevalent cause. Diagnosis of head and neck cancers were in the late stage (stage IV) when signs and symptoms were severe. Males of lower socioeconomic status tended to have less health seeking behaviour.

CONCLUSION

Countries from North Africa produce the most research outputs on head and neck cancers. Gender differences were noted and may be linked to lifestyle choices. A range of head and neck cancers (HNCs) are prevalent however late diagnosis and severe symptomatology impact treatment options.Contribution: Earlier diagnosis and intervention to prevent late-stage diagnosis is necessary. Awareness campaigns linked to evidence on causes, habits and lifestyle choices, signs and symptoms are needed.

Vestibular migraine in low- and lower-middle-income countries: A scoping review

Background

Vestibular migraine (VM) is a common cause of dizziness that is underrecognized, underdiagnosed, and challenging to effectively treat. The prevalence, appropriate diagnostic workup, and therapies for VM in low- and lower-middle-income countries (LLMICs) remain understudied. The objective of this scoping review is to evaluate the current state of VM research in LLMICs.

Methods

PubMed, Embase, and Web of Science databases were searched to execute a scoping review of VM. Keywords "vestibular diseases" and "vertigo" were used in combination with terms referring to LLMICs as defined by the World Bank. Title and abstract screening, full-text review, and data collection were conducted by two authors independently.

Results

Twenty-six studies were included in the scoping review. Most studies were cross-sectional (57.7%) or case studies/series (23.1%) and were conducted in urban settings only (92.3%). Geographic distribution of studies was skewed, with 65.4% of articles originating from India. The prevalence of VM among clinic patients ranged from 0.3% to 33.3%. VM most frequently presented as headache, nausea and vomiting, and photophobia. Radiographic imaging, audiometry, and electronystagmography/videonystagmography were the three most commonly utilized diagnostic modalities in the dizziness workup. The most studied pharmacotherapies included calcium channel blockers, followed by beta-blockers and antiepileptics. Case studies and series discussed less common VM pharmacotherapies, such as ayurvedic medicine.

Conclusions

There is a need for more VM research in LLMICs, including innovative diagnostic approaches and therapies that can improve VM care globally. Equitable partnerships between LLMIC and high-income country researchers must expand vestibular research capacity and productivity in LLMICs.

Gender Disparities in Otolaryngology: A Case Report Reflecting Global Perspectives

OBJECTIVES

To explore the impact of female sex on the experiences of trainees and surgeons in otolaryngology from LMIC and HIC.

METHODS

This study includes perspectives of five consultants and two resident physicians from the United States, United Kingdom, Uganda, Kenya and South Africa.

RESULTS

Six themes emerged from these interviews. Overall, LMIC and HIC women shared similar experiences of microaggressions during patients, working along ancillary staff, related to pregnancy, imposter syndrome, difficulties during job search, and unique barriers as consultant.

CONCLUSIONS

The findings of this study highlight that gender disparities are present at all levels in Otolaryngology but can present differently depending on context. Laryngoscope, 133:547-551, 2023.

Otolaryngology Training in Uganda: The Mbarara University of Science and Technology Experience

Sub-Saharan Africa has a high otolaryngologic disease burden exacerbated by an inadequate number of otolaryngologists. The Otolaryngology department at Mbarara University of Science & Technology in Uganda is addressing this problem by having created Uganda's second national residency training program in 2010. We chronicled an early period in the program's development by reporting surgical case quantity and complexity, as defined by "key indicator procedure" classification per the United States Accreditation Council for Graduate Medical Education, and interpreting it with respect to a timeline of significant events. Procedure complexity, but not total number per year, increased over the study period-KIPs increased from 3% in 2012 (6 of 175 total procedures) to 29% in 2016 (35 of 135 total procedures). During this period of complexity increase, operating room capacity expanded, faculty received advanced training and increased in number, and operative equipment improved.

Otolaryngology education and training in the COVID-19 and post-COVID-19 digital era: a developing world perspective

PURPOSE OF REVIEW

This article reviews the literature on the challenges to Otolaryngology training in the developing world, the solutions that have been implemented thus far and the role of technology in first the Digital, and now the Covid era.

RECENT FINDINGS

There is an increasing prevalence of Otolaryngological pathology in the developing world. Efforts to treat this are hampered by multiple factors including appropriate medical training. A number of solutions have been implemented for this both in terms of face-to-face as well as virtual training.

SUMMARY

The Covid era has created new challenges for Otolaryngology training in the developed world, sparking a huge shift in the delivery of education. Traditional forms of training have disadvantaged colleagues in the developing world and so this change in training modalities may benefit the developing world.

Pioneering virtual otolaryngology specialist examinations in South Africa in the COVID-19 and post-COVID-19 era

PURPOSE OF REVIEW

South Africa, and the African continent, have a shortage of ear, nose and throat (ENT) specialists. The coronavirus disease 2019 (COVID-19) pandemic not only had an adverse impact on specialist training, but also impacted the ability of trainees to undertake the final examinations in order to qualify as ENT specialists.

RECENT FINDINGS

The response to the COVID-19 pandemic resulted in the postponement of the final examination of the Fellowship of the College of Otorhinolaryngologists of South Africa (FCORL (SA)). A virtual clinical examination was held via videoconferencing to assess clinical judgement, insight, reasoning and decision making.

SUMMARY

The virtual clinical assessment allowed trainees to undertake the final examination despite the COVID-19 pandemic, ensuring that they could be added to the limited number of specialists in South Africa and the African continent.

Otolaryngology burden of disease and surgical case triage in resource-limited settings: An example from Cameroon

OBJECTIVES

Otolaryngology services worldwide faced an unprecedented demand for case triage during the SARS-CoV-2 pandemic. We propose and apply a novel case-leveling schema in a resource-limited setting. Describing the surgical burden of otolaryngologic disease in this setting may critically inform resource planning to address global surgical disparities.

METHODS

This is a retrospective study of otolaryngology cases performed over a 28-month period (1/2016-4/2018) at a hospital in rural Cameroon. Case details were collated and categorized as a surrogate measure of otolaryngologic disease in resource-limited settings. A case-levelling schema based on temporal urgency and anticipated impact on health was proposed and applied.

RESULTS

1277 cases took place during the study. The largest proportion of cases were head and neck (517, 40%), followed by pediatrics (316, 25%). A four-tiered leveling system was generated: level 1 cases were immediately life-saving; level 2 cases were expected to result in a significant return to functions of daily living, or would prevent future death from cancer; level 3 cases aimed to significantly improve quality of life; level 4 cases were purely elective. Upon application of the schema, most cases were deemed to be level 2 (661, 52%).

CONCLUSION

We use our experience in a resource-limited setting to generate and apply a novel schema to be used for otolaryngology case triage in services facing unprecedented states of emergency such as the SARS-CoV-2 pandemic. This is the first study describing the surgical otolaryngologic disease burden in a resource-limited setting, data which may be used for future resource allocation.

LEVEL OF EVIDENCE

4.

The Unseen Global Burden of Disease

Due to geographic-specific patient and institutional-related barriers to care, data extrapolation and expert opinion on global burden of disease in otolaryngology-head and neck surgery may under- or overestimate the presence and effect of common head and neck conditions. The group of conditions that fail to present to local physicians and/or missed in data extrapolation methods is the unseen burden of disease. This article presents opinions from otolaryngology-head and neck surgery physicians in high- and low/middle-income countries to help explain the contributing factors and ultimately how to use this unseen burden of disease.

Training for hearing care providers

The lack of an appropriately trained global hearing-care workforce is recognized as a barrier to developing and implementing services to treat ear and hearing disorders. In this article we examine some of the published literature on the current global workforce for ear and hearing care. We outline the status of both the primary-care workforce, including community health workers, and specialist services, including audiologists, ear, nose and throat specialists, speech and language therapists, and teachers of the deaf. We discuss models of training health workers in ear and hearing care, including the role of task-sharing and the challenges of training in low and middle-income countries. We structure the article by the components of ear and hearing care that may be delivered in isolation or in integrated models of care: primary care assessment and intervention; screening; hearing tests; hearing rehabilitation; middle-ear surgery; deaf services; and cochlear implant programmes. We highlight important knowledge gaps and areas for future research and reporting.

What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa?

BACKGROUND

Children constitute 50% of Africa's population. Sub-Saharan Africa has the highest under-five mortality rates in the world. This study is the first to document the availability of paediatric ENT and paediatric surgery services in Africa.

OBJECTIVE

To determine the availability of paediatric ENT services in Africa, as well as that of paediatric surgery that would complement paediatric ENT.

METHOD

A descriptive observational study in the form of an online questionnaire was distributed by email to known ENT and paediatric surgeons based in Africa.

RESULTS

Surgeons from twelve of 23 African countries responded to the survey. Seven countries had both ENT and paediatric surgery responses. In 8 of the 11 countries, the number of ENT surgeons per country was<6% of that of the UK, with 1 ENT surgeon per 414,000 people and 1 paediatric surgeon per 1,181,151 people. Ten of 11 countries reported hearing assessments in schools were poor/unavailable. Seventy-three percent responded positively for access to rigid laryngoscopes, bronchoscopes, cameras and fibre optic cables, tracheostomy, anaesthesia and nurse practitioners. Access was reported as poor/unavailable for balloon dilators 73% (8/11 countries); CPAP machines 73% (8/11) and sleep studies 82% (9/11 countries). Flexible endoscopes were available in 50% (4/8 countries), 75% (6/8 countries) had access to a camera, monitor and stack. Thirty-eight percent (3/9 countries) reported no ENT specialists with paediatric training.

CONCLUSIONS

There is a great shortage of paediatric ENT and paediatric surgery services in Africa. More regional training opportunities and health infrastructure for these surgical specialties are needed. Collaborative development of paediatric ENT, surgery and anaesthesia should be considered to improve ENT-related child health in Africa.