Attitudes toward neurosurgery in a low-income country: a qualitative study

Insights into craniosynostosis management in low- and middle-income countries: A narrative review of outcomes, shortcomings and paediatric neurosurgery capacity

Craniosynostosis, marked by premature cranial suture fusion, necessitates prompt intervention to avert developmental, neurological, and aesthetic issues. While high-income countries have advanced in managing this condition, low- and middle-income countries grapple with substantial healthcare access disparities. This narrative review explores current craniosynostosis management in low- and middle-income countries. The review focused on studies published between 2008 and 2023. The focus was neurosurgical outcomes, and the search utilised databases like PubMed, EMBASE, Google Scholar, the Cochrane Library and Scopus, incorporating specific keywords and phrases. An in-depth analysis of 21 included studies reveals noteworthy positive outcomes, including low mortality, successful corrections and sustained efficacy. These advancements stem from enhanced pre-operative strategies, surgical techniques and postoperative care. Nonetheless, challenges persist, encompassing complications, mortality, reoperations, and treatment disparities, particularly in low- and middle-income countries constrained by financial and expertise limitations. The enhancement of clinical practice and the formulation of effective policies in the future entail several key strategies. These include the reinforcement of specialised healthcare infrastructure and diagnostic capabilities, the ongoing training and retention of neurosurgeons, the improvement of funding mechanisms, and the promotion of equitable access. Additionally, a crucial focus is placed on fortifying paediatric neurosurgical care in low- and middle-income countries. The recommendations underscore the importance of collaborative initiatives, the development of specialised healthcare infrastructure, and the implementation of strategic policies to not only advance pediatric neurosurgical care but also to address existing gaps in management.

Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges

BACKGROUND

Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC.

OBJECTIVE

To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa.

METHODS

We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included.

RESULTS

Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources.

CONCLUSION

Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.

Qualitative research methods in neurosurgery: an unexplored avenue

OBJECTIVE

Explore the value and potential of qualitative research to neurosurgery and provide insight and understanding to this underused methodology.

BACKGROUND

The definition of qualitative research is critically discussed and the heterogeneity within this field of inquiry explored. The value of qualitative research to the field of neurosurgery is articulated through its contribution to understanding complex clinical problems.

DISCUSSION

To resolve some of the misunderstanding of qualitative research, this paper discusses research design choices. We explore approaches that use qualitative techniques but are not, necessarily, situated within a qualitative paradigm in addition to how qualitative research philosophy aids researchers to conduct interpretive inquiry that can reveal more than simply what was said by participants. Common research designs associated with qualitative inquiry are introduced, and how complex analysis may contribute more in-depth insights is explained. Approaches to quality are discussed briefly to support improvements in qualitative methods and qualitative manuscripts. Finally, we consider the future of qualitative research in neurosurgery, and suggest how to move forward in the qualitative neurosurgical evidence base.

CONCLUSION

There is enormous potential for qualitative research to contribute to the advancement of person-centred care within neurosurgery. There are signs that more qualitative research is being conducted and that neurosurgical journals are increasingly open to this methodology. While studies that do not engage fully within the qualitative paradigm can make important contributions to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.

Public Awareness, Knowledge of Availability, And Willingness to Use Neurosurgical Care Services in Africa: A Cross-Sectional E-Survey Protocol

Background:

Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology:

The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination:

The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review

Background

Low- and middle-income countries (LMICs) bear the majority of the neurosurgical burden of diseases but lack the resources to meet these needs.

Objective

As we increase access to neurosurgical care in LMICs, we must understand patient attitudes toward neurosurgery.

Methods and Material

PubMed, LILACS, and African Journals Online databases were searched systematically from inception to January 4, 2020, for studies on neurosurgical patient perceptions in LMICs. The articles found were blindly reviewed with Rayyan by two authors. The two authors resolved conflicts between themselves, and when this was not possible, a third reviewer was consulted. All the articles included were then appraised, and the results were summarized.

Results

Six of the 1,175 articles met the inclusion criteria. The studies were set in Brazil, Ethiopia, India, Nigeria, South Korea, and Sub-Saharan Africa. Four of the studies (50%) were phenomenological studies, and the other two were grounded theory and narrative. The studies identified patient attitudes toward neurosurgical practitioners, diseases, and interventions. Ethiopian and Nigerian patients believed cranial diseases to be otherworldly and resorted to traditional medicine or spiritual healing first, whereas Brazilian patients were more comfortable with cranial diseases and even more so if they had had a previous craniotomy. The Indian paper was a recount of a neurosurgeon's experience as a spine patient.

Conclusions

There are few studies on neurosurgery patient perception in LMICs. LMIC neurosurgeons should be encouraged to study their patient beliefs concerning neurosurgical diseases and interventions, as this can explain health-seeking behaviors.

Challenging the myth of outpatient craniotomy for brain tumor in a Sub-Saharan African setting: A case series of two patients in Ibadan, Nigeria

BACKGROUND

The concept of modern neuro-oncology hinges on strategic innovation and refinement of procedures with the intention to enhance safety, optimize extent of tumor resection, and improve not only survival but also the quality of life as well. One of such refinements includes same-day hospital admission, as well as early discharge following brain tumor surgeries. The latter has been further stretched to same-day discharge in particular settings to reduce the risk of nosocomial infections, cut brain tumor surgery costs, and improve patients' satisfaction. We highlight the challenges and possible benefits of outpatient craniotomy in a sub-Saharan African setting portrayed by the presence of lean resources and a predominant "out of pocket" health-care financing.

CASE DESCRIPTION

Outpatient craniotomy was performed in two selected patients harboring intra-axial tumors: a right temporal low-grade glioma and a left frontal metastasis. The clinical outcome proved successful at short- and long-term in both patients; complications related to surgery and same-day discharge were not reported.

CONCLUSION

Outpatient craniotomy is practicable and safe in resource-challenged environments and can further make brain tumor surgery cost effective and acceptable in carefully selected patients. Further prospective studies in similar settings but involving larger groups of patients are warranted.

The shifting burden of neurosurgical disease: Vietnam and the middle-income nations

OBJECTIVE

The Global Burden of Disease (GBD) is an international collaboration and the largest comprehensive investigation of global health disease burden ever conducted. It has been particularly insightful for understanding disease demographics in middle-income nations undergoing rapid development, such as Vietnam, where 6 of the top 10 causes of death are relevant to the neurosurgeon. The burden of stroke—the number one cause of death in Vietnam—is particularly impressive. Likewise, road injuries, with a disproportionate rate of traumatic brain injury, continue to increase in Vietnam following economic development. Low-back and neck pain is the number one cause of disability. Simultaneously, more patients have access to care, and healthcare spending is increased.

METHODS

It is imperative that neurosurgical capital and infrastructure keep pace with Vietnam’s growth. The authors searched the existing literature for assessments of neurosurgical infrastructure or initiatives to address neurosurgical disease burden. Using GBD data, the authors also abstracted data for death by cause and prevalence of years of life lost due to disability (YLD) for common neurosurgical pathologies for Vietnam and comparison nations.

RESULTS

Interventions aimed at primary prevention of risk factors for neurosurgical disease and focused on the transference of self-sustainable technical skills were found to be analogous to those that have been successful in other regions. Efforts toward stroke prevention have been focused on causal risk factors. Multiple investigators have found that interventions aimed at increasing helmet use were successful in preventing traumatic brain injury. Government-led reforms and equipment donation programs have improved technical capacity. Nevertheless, Vietnam lags behind other nations in neurosurgeons per capita; cause-attributable death and YLD attributable to neurosurgical disease are considerably higher in Vietnam and middle-income nations compared to both lower-income nations and upper-income nations.

CONCLUSIONS

More than two-thirds of deaths attributable to neurosurgical pathologies in Vietnam and other middle-income nations were due to stroke, and one-fifth of both cause-attributable death and YLD was associated with neurosurgical pathologies. Vietnam and other middle-income nations continue to assume a global burden of disease profile that ever more closely resembles that of developed nations, with particular cerebrovascular, neurotrauma, and spinal disease burdens, leading to exponentially increased demand for neurosurgeons that threatens to outpace the training of neurosurgeons.

Neurosurgery in East Africa: Innovations

In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.

Frontoethmoidal meningoencephalocele: appraisal of a craniofacial surgical teaching program in Cambodia

OBJECTIVE The treatment of frontoethmoidal meningoencephaloceles (fMECs) in Cambodia was not possible before the development of a program that taught some Khmer surgeons (working at the Children's Surgical Centre in Phnom Penh) how to surgically correct these deformities without any foreign help. The results of that teaching program are discussed in this paper. METHODS Between 2004 and 2009, both local and visiting foreign neurosurgical and craniofacial surgeons (the visitors coming twice a year) worked together to operate on 200 patients, and a report on those cases was published in 2010. In subsequent years (2010-2016), the Khmer surgeons operated on 100 patients without the presence of the visiting surgeons. In this study, the authors compare the second case series with the previously published series and the literature in terms of results and complications. The operations were performed with limited surgical materials and equipment, using a combined bicoronal and transfacial approach in most cases. Most of the patients came from very poor families. RESULTS Organizing the postoperative follow-up of these low-income patients (mean age 12 years) was probably the most challenging part of this teaching program. Nine of the patients were lost to surgical follow-up. In the other cases, cosmetic results were judged by the surgeons as worse than the patient's preoperative appearance in 1 case, poor in 12 cases, average in 27, and good in 51-data that are significantly less encouraging than the results reported by the joint local/visiting teams in 2010 (p = 0.0001). Nevertheless, patients and parents tended to have a better overall opinion about the surgical results (rating the results as good in 84% of the 80 cases in which parent or patient ratings were available). Twenty postoperative complications were observed (the most common being temporary CSF leaks). The rate of immediate postoperative complications directly related to fMEC surgery was less than that in the previous series, but the difference was not statistically significant (20% vs 28.5%, p = 0.58). No death was noted in this case series (in contrast to the previous series). Social questionnaire results confirmed that fMEC correction partially improved the adverse social and educational consequences of fMEC in affected children. CONCLUSIONS In the current state of this program, the local surgeons are able to correct fMECs in their own country, without foreign assistance, with good results in a majority of patients. Such humanitarian teaching programs generally take years to achieve the initial aims.

Neurosurgical patients' perceptions of the "surgeon+": a qualitative study

OBJECTIVE

Neurosurgical patients bear a varying degree of anxiety when confronted with having to undergo surgery or even visit with a neurosurgeon in consultation. Previous studies have suggested that patient perceptions can heavily influence the patient-physician encounter. Accordingly, a better understanding of these perceptions can marshal our knowledge regarding strategies for improving patient-physician interactions during such an apprehensive time. The aim of the present study was to qualitatively examine patient values and preferences for a neurosurgeon who participates in extraclinical activities (i.e., a "neurosurgeon+") and understand the factors that influence these perceptions.

METHODS

Semistructured face-to-face interviews with 47 neurosurgical patients were conducted. Patients were recruited from the Toronto Western Hospital neurosurgery clinics for cranial and spinal conditions. Descriptive summary statistics were used to characterize the study participants. Family members were encouraged to contribute to the interviews. Interviews were audio-recorded, transcribed, and subjected to thematic analysis by using open and axial coding.

RESULTS

Patients generally indicated that they want to feel confident in their neurosurgeon. A number of factors contribute to this confidence, including a strong positive referral from another physician. Patients are inclined to search for information pertaining to the qualifications of neurosurgeons online, and a perception of the neurosurgeon's adeptness given his or her qualifications is important for patients. Although there were some differences in patient values between those in the cranial and spinal groups, overall, neurosurgical patients tend to positively view their neurosurgeon's involvement in extraclinical duties.

CONCLUSIONS

This study details the first comprehensive clinical qualitative study of patient perceptions of neurosurgeons and provides a descriptive framework for understanding patient values in this clinical domain.

A framework for the monitoring and evaluation of international surgical initiatives in low- and middle-income countries

BACKGROUND

An estimated two billion people worldwide lack adequate access to surgical care. To address this humanitarian emergency, an increasing number of international surgical partnerships are emerging between developed and low- and middle-income countries (LMICs). At present, there are no clear indicators that may be used to assess the effectiveness of such initiatives.

STUDY DESIGN

We conducted an international qualitative study of 31 surgeons from developed and LMICs involved in international partnerships across a variety of subspecialties. Thematic analysis and grounded theory were applied in order to develop a practical framework that may be applied to monitor and evaluate global surgical initiatives.

RESULTS

Several themes emerged from the study: (i) there is a large unmet need to establish and maintain prospective databases in LMICs to inform the monitoring and evaluation of international surgical partnerships; (ii) assessment of initiatives must occur longitudinally over the span of several years; (ii) the domains of assessment are contextual and encompass cultural, institutional and regional factors; and (iv) evaluation strategies should explore broader impact within the community and country. Based on thematic analysis within the domains of inputs, outputs and outcomes, a framework for the monitoring and evaluation of international surgical initiatives, the Framework for the Assessment of InteRNational Surgical Success (FAIRNeSS) is proposed.

CONCLUSIONS

In response to the increasing number of surgical partnerships between developed and LMICs, we propose a framework to monitor and evaluate international surgical initiatives.