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Ryan I, Shah KV, Barrero CE, Uamunovandu T, Ilbawi A, Swanson J. Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature. World J Surg 2023; 47:3070-3080. [PMID: 37831136 DOI: 10.1007/s00268-023-07197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa. METHODS A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted. RESULTS Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates. CONCLUSION NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.
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Affiliation(s)
- Isabel Ryan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Keshav V Shah
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Andre Ilbawi
- Department of Universal Health Coverage, WHO, Geneva, Switzerland
| | - Jordan Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Bognini MS, Oko CI, Kebede MA, Ifeanyichi MI, Singh D, Hargest R, Friebel R. Assessing the impact of anaesthetic and surgical task-shifting globally: a systematic literature review. Health Policy Plan 2023; 38:960-994. [PMID: 37506040 PMCID: PMC10506531 DOI: 10.1093/heapol/czad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/04/2023] [Accepted: 07/26/2023] [Indexed: 07/30/2023] Open
Abstract
The global shortage of skilled anaesthesiologists, surgeons and obstetricians is a leading cause of high unmet surgical need. Although anaesthetic and surgical task-shifting are widely practised to mitigate this barrier, little is known about their safety and efficacy. This systematic review seeks to highlight the existing evidence on the clinical outcomes of patients operated on by non-physicians or non-specialist physicians globally. Relevant articles were identified by searching four databases (MEDLINE, EMBASE, CINAHL and Global Health) in all languages between January 2008 and February 2022. Retrieved documents were screened against pre-specified inclusion and exclusion criteria, and their qualities were appraised critically. Data were extracted by two independent reviewers and findings were synthesized narratively. In total, 40 studies have been included. Thirty-five focus on task-shifting for surgical and obstetric procedures, whereas four studies address anaesthetic task-shifting; one study covers both interventions. The majority are located in sub-Saharan Africa and the USA. Seventy-five per cent present perioperative mortality outcomes and 85% analyse morbidity measures. Evidence from low- and middle-income countries, which primarily concentrates on caesarean sections, hernia repairs and surgical male circumcisions, points to the overall safety of non-surgeons. On the other hand, the literature on surgical task-shifting in high-income countries (HICs) is limited to nine studies analysing tube thoracostomies, neurosurgical procedures, caesarean sections, male circumcisions and basal cell carcinoma excisions. Finally, only five studies pertaining to anaesthetic task-shifting across all country settings answer the research question with conflicting results, making it difficult to draw conclusions on the quality of non-physician anaesthetic care. Overall, it appears that non-specialists can safely perform high-volume, low-complexity operations. Further research is needed to understand the implications of surgical task-shifting in HICs and to better assess the performance of non-specialist anaesthesia providers. Future studies must adopt randomized study designs and include long-term outcome measures to generate high-quality evidence.
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Affiliation(s)
- Maeve S Bognini
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Christian I Oko
- Division of Health Research, Lancaster University, Bailrigg, Lancaster LA1 4YW, United Kingdom
| | - Meskerem A Kebede
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Martilord I Ifeanyichi
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Darshita Singh
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Rachel Hargest
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Rocco Friebel
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- Center for Global Development, Abbey Gardens, Great College Street, London SW1P 3SE, United Kingdom
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Alayande B, Forbes C, Degu S, Hey MT, Karekezi C, Khanyola J, Iradukunda J, Newton M, Okolo ID, Jumbam DT, Chu KM, Makasa EM, Anderson GA, Farmer P, Kim JY, Binagwaho A, Riviello R, Bekele A. Shifting global surgery's center of gravity. Surgery 2022; 172:1029-1030. [PMID: 35715233 DOI: 10.1016/j.surg.2022.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/18/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Callum Forbes
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Selam Degu
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Matthew T Hey
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Claire Karekezi
- Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Judy Khanyola
- Center for Nursing and Midwifery, University of Global Health Equity, Kigali, Rwanda
| | - Jules Iradukunda
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Mark Newton
- AIC Kijabe Hospital, Kijabe, Kenya; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Isioma Dianne Okolo
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA
| | - Kathryn M Chu
- Center for Global Surgery, Stellenbosch University, Tygerberg South Africa; Department of Surgery, University of Botswana, Gabarone, Botswana
| | - Emmanuel M Makasa
- SADC Regional Collaboration Center for Surgical Healthcare, University of Witwatersrand, Johannesburg, South Africa; University Teaching Hospitals, Ministry of Health, Lusaka, Zambia
| | - Geoffrey A Anderson
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Paul Farmer
- University of Global Health Equity, Kigali, Rwanda; Partners in Health, Boston, MA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | | | | | - Robert Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda; University of Global Health Equity, Kigali, Rwanda.
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Rice B, Pickering A, Laurence C, Kizito PM, Leff R, Kisingiri SJ, Ndyamwijuka C, Nakato S, Adriko LF, Bisanzo M. Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme. BMJ Open 2022; 12:e059859. [PMID: 35768107 PMCID: PMC9244677 DOI: 10.1136/bmjopen-2021-059859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. DESIGN Retrospective cohort analysis with multivariable logistic regression. SETTING Single rural Ugandan emergency unit. PARTICIPANTS All patients presenting for care from 2009 to 2019. INTERVENTIONS Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision. PRIMARY OUTCOME MEASURE Three-day mortality. RESULTS 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)). CONCLUSIONS Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.
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Affiliation(s)
- Brian Rice
- Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Ashley Pickering
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Colleen Laurence
- Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Prisca Mary Kizito
- Emergency Medicine, Mbarara University of Science and Technology, Mbarara, Mbarara, Uganda
- Emergency Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Rebecca Leff
- Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Steven Jonathan Kisingiri
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Public Health, Liverpool John Moores University, Liverpool, Merseyside, UK
| | | | - Serena Nakato
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Lema Felix Adriko
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Mark Bisanzo
- Emergency Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
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Ottesen TD, Amick M, Kapadia A, Ziatyk EQ, Joe JR, Sequist TD, Agarwal-Harding KJ. The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States. J Bone Joint Surg Am 2022; 104:e47. [PMID: 35104253 DOI: 10.2106/jbjs.21.00512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.
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Affiliation(s)
- Taylor D Ottesen
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Michael Amick
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Yale University School of Medicine, New Haven, Connecticut
| | - Ami Kapadia
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Q Ziatyk
- Department of Family Medicine, Chinle Comprehensive Healthcare Facility, Chinle, Arizona
| | - Jennie R Joe
- Department of Family and Community Medicine, University of Arizona Health Sciences, Tucson, Arizona
- Native American Research and Training Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Thomas D Sequist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Department of Orthopaedic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Linder CL, Atijosan-Ayodele O, Chokotho L, Mulwafu W, Tataryn M, Polack S, Kuper H, Pandit H, Lavy C. Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method. BMC Musculoskelet Disord 2021; 22:1058. [PMID: 34933673 PMCID: PMC8693487 DOI: 10.1186/s12891-021-04942-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology. Methods The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment. Results 15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy. Conclusions The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.
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Affiliation(s)
- Cortland L Linder
- Royal London Hospital, Whitechapel Rd, Whitechapel, London, E1 1FR, UK
| | | | - Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Blantyre, Malawi.
| | - Wakisa Mulwafu
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Blantyre, Malawi
| | - Myroslava Tataryn
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Chris Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, Oxford University, Oxford, UK
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Zhao Y, Hagel C, Tweheyo R, Sirili N, Gathara D, English M. Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities. HUMAN RESOURCES FOR HEALTH 2021; 19:95. [PMID: 34348709 PMCID: PMC8336272 DOI: 10.1186/s12960-021-00637-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/23/2021] [Indexed: 05/13/2023]
Abstract
BACKGROUND Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0-19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted. METHODS We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library. RESULTS We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health). CONCLUSION As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.
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Affiliation(s)
- Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK.
| | - Christiane Hagel
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK
| | - Raymond Tweheyo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Department of Public Health, Lira University, Lira, Uganda
| | - Nathanael Sirili
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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8
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Zimba CC, Akiba CF, Matewere M, Thom A, Udedi M, Masiye JK, Kulisewa K, Go VFL, Hosseinipour MC, Gaynes BN, Pence BW. Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers. Int J Ment Health Syst 2021; 15:59. [PMID: 34116699 PMCID: PMC8196431 DOI: 10.1186/s13033-021-00480-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services. Methods Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers. Results Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow. Conclusion Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge. Trial registration This study reports finding of part of the formative phase of “The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building—A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi” registered as NCT03711786
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Affiliation(s)
| | - Christopher F Akiba
- Gillings School of Global and Public Health, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | | | - Annie Thom
- Malawi Ministry of Health, Lilongwe, Malawi
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9
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Whitaker J, Chirwa L, Munthali B, Dube A, Amoah AS, Leather AJM, Davies J. Development and use of clinical vignettes to assess injury care quality in Northern Malawi. Injury 2021; 52:793-805. [PMID: 33487406 DOI: 10.1016/j.injury.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting. METHOD Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level. RESULTS Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status. CONCLUSION These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings.
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Affiliation(s)
- John Whitaker
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi; Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Centre for Applied Health Research, University of Birmingham, Birmingham, UK; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Extraordinary Professor, Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town
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10
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van Heemskerken P, Broekhuizen H, Gajewski J, Brugha R, Bijlmakers L. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review. HUMAN RESOURCES FOR HEALTH 2020; 18:51. [PMID: 32680526 PMCID: PMC7368796 DOI: 10.1186/s12960-020-00490-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries. METHODS We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks. RESULTS Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties. CONCLUSION A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.
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Affiliation(s)
| | - Henk Broekhuizen
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jakub Gajewski
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairí Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
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11
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Strader C, Ashby J, Vervoort D, Ebrahimi A, Agbortoko S, Lee M, Reiner N, Zeme M, Shrime MG. How much is enough? Exploring the dose-response relationship between cash transfers and surgical utilization in a resource-poor setting. PLoS One 2020; 15:e0232761. [PMID: 32407327 PMCID: PMC7224483 DOI: 10.1371/journal.pone.0232761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical utilization in Guinea. The aim of the current study is to determine the size of that cash transfer so as to maximize compliance while minimizing cost. Methods Data were collected from nine coastal Guinean hospitals on their surgical capabilities and the cost of receiving surgery. These data were combined with publicly available data about the general Guinean population to create an agent-based model predicting surgical utilization. The model was validated to the available literature on surgical utilization. Cash transfer sizes from 0 to 1,000,000 Guinean francs were evaluated, with surgical compliance as the primary outcome. Results Compliance with scheduled surgery increases as the size of a cash transfer increases. This increase is asymptotic, with a leveling in utilization occurring when the cash transfer pays for all the costs associated with surgical care. Below that cash transfer size, no other optima are found. Once a cash transfer completely covers the costs of surgery, other barriers to care such as distance and hospital quality dominate Conclusion Cash transfers to incentivize health-promoting behavior appear to be dose-dependent. Maximal impact is likely only to occur when full patient costs are eliminated. These findings should be incorporated in the design of future cash transfer studies.
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Affiliation(s)
- Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Department of General Surgery, University of Massachusetts, Worcester, MA, United States of America
| | - Joanna Ashby
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- School of Medicine, University of Glasgow, Scotland, United Kingdom
| | - Dominique Vervoort
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aref Ebrahimi
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States of America
| | | | - Melissa Lee
- Harvard College, Cambridge, MA, United States of America
| | - Naomi Reiner
- Harvard Graduate School of Education, Cambridge, MA, United States of America
| | - Molly Zeme
- Harvard College, Cambridge, MA, United States of America
| | - Mark G. Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America
- Center for Health and Wellbeing, Princeton University, Princeton, NJ, United States of America
- * E-mail:
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12
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Pittalis C, Brugha R, Crispino G, Bijlmakers L, Mwapasa G, Lavy C, Le G, Cheelo M, Kachimba J, Borgstein E, Mkandawire N, Juma A, Marealle P, Chilonga K, Gajewski J. Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud 2019; 5:25. [PMID: 30820336 PMCID: PMC6378729 DOI: 10.1186/s40814-019-0409-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level. Methods This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model. Discussion We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.
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Affiliation(s)
- Chiara Pittalis
- 1Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland
| | - Ruairi Brugha
- 1Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland
| | - Gloria Crispino
- Statistica Medica, 26 Belarmine Court Enniskerry Road Stepaside, Dublin 18, Ireland
| | - Leon Bijlmakers
- 3Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 Nijmegen, GA Netherlands
| | - Gerald Mwapasa
- 4University of Malawi, College of Medicine, Mahatma Gandhi, Blantyre, Malawi
| | - Chris Lavy
- 5Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7HE UK
| | - Grace Le
- 5Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7HE UK
| | - Mweene Cheelo
- 6Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - John Kachimba
- 6Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Eric Borgstein
- 4University of Malawi, College of Medicine, Mahatma Gandhi, Blantyre, Malawi
| | - Nyengo Mkandawire
- 4University of Malawi, College of Medicine, Mahatma Gandhi, Blantyre, Malawi
| | - Adinan Juma
- ECSA Health Community Secretariat, 157 Olorien, Njiro Road, PO Box 1009, Arusha, Tanzania
| | - Paul Marealle
- Tanzania Surgical Association, P.O. Box 65098, Dar Es Salaam, Tanzania
| | - Kondo Chilonga
- 9Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Jakub Gajewski
- 10Institute of Global Surgery, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
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13
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Global surgical, obstetric, and anesthetic task shifting: A systematic literature review. Surgery 2018; 164:553-558. [PMID: 30145999 DOI: 10.1016/j.surg.2018.04.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature. METHODS We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups. RESULTS We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data. CONCLUSION Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust.
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White MC, Hamer M, Biddell J, Claus N, Randall K, Alcorn D, Parker G, Shrime MG. Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar. BMJ Glob Health 2017; 2:e000427. [PMID: 29071129 PMCID: PMC5640035 DOI: 10.1136/bmjgh-2017-000427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/26/2017] [Accepted: 08/31/2017] [Indexed: 11/18/2022] Open
Abstract
Over two-thirds of the world’s population lack access to surgical care. Non-governmental organisation’s providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist. From October 2014 to June 2015, we used a centralised selection strategy, aiming to find 70% of patients from the port city, Toamasina, and 30% from the national capital and two remote cities. From August 2015 to June 2016, a decentralised strategy was used, aiming to find 30% of patients from Toamasina and 70% from 11 remote locations, including the capital. Demographic information and self-reported barriers to care were collected. Wealth quintile was calculated for each patient using a combination of participant responses to asset-related and demographic questions, and publicly available data. A total of 2971 patients were assessed. The change from centralised to decentralised selection resulted in significantly poorer patients undergoing surgery. All reported barriers to prior care, except for lack of transportation, were significantly more likely to be identified in the decentralised group. Patients who identified multiple barriers to prior surgical care were less likely to be from the richest quintile (p=0.037) and more likely to be in the decentralised group (p=0.046). Our country-specific analysis shows that decentralised patient selection strategies may be used to overcome barriers to care and allow patients in greatest need to access surgical care.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK.,Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mirjam Hamer
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasmin Biddell
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Emergency Care, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Nathan Claus
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Kirsten Randall
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | | | - Gary Parker
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mark G Shrime
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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