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Rubin O, King C, von Schreeb J, Morsut C, Kovács G, Raju E. The COVID-19 quandemic. Global Health 2024; 20:19. [PMID: 38431647 PMCID: PMC10908106 DOI: 10.1186/s12992-024-01024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The terms syndemic and infodemic have both been applied to the COVID-19 pandemic, and emphasize concurrent socio-cultural dynamics that are distinct from the epidemiological outbreak itself. We argue that the COVID-19 pandemic has exposed yet another important socio-political dynamic that can best be captured by the concept of a quandemic - a portmanteau of "quantification" and "pandemic". MAIN TEXT The use of quantifiable metrics in policymaking and evaluation has increased throughout the last decades, and is driven by a synergetic relationship between increases in supply and advances in demand for data. In most regards this is a welcome development. However, a quandemic, refers to a situation where a small subset of quantifiable metrics dominate policymaking and the public debate, at the expense of more nuanced and multi-disciplinary discourse. We therefore pose that a quandemic reduces a complex pandemic to a few metrics that present an overly simplified picture. During COVID-19, these metrics were different iterations of case numbers, deaths, hospitalizations, diagnostic tests, bed occupancy rates, the R-number and vaccination coverage. These limited metrics came to constitute the internationally recognized benchmarks for effective pandemic management. Based on experience from the Nordic region, we propose four distinct dynamics that characterize a quandemic: 1) A limited number of metrics tend to dominate both political, expert, and public spheres and exhibit a great deal of rigidity over time. 2) These few metrics crowd-out other forms of evidence relevant to pandemic response. 3) The metrics tend to favour certain outcomes of pandemic management, such as reducing hospitalization rates, while not capturing potential adverse effects such as social isolation and loneliness. 4) Finally, the metrics are easily standardized across countries, and give rise to competitive dynamics based on international comparisons and benchmarking. CONCLUSION A quandemic is not inevitable. While metrics are an indispensable part of evidence-informed policymaking, being attentive to quandemic dynamics also means identifying relevant evidence that might not be captured by these few but dominant metrics. Pandemic responses need to account for and consider multilayered vulnerabilities and risks, including socioeconomic inequities and comorbidities.
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Affiliation(s)
- Olivier Rubin
- Department of Social Sciences and Business, Roskilde University, Roskilde, Denmark
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Claudia Morsut
- Department of Safety, Economics and Planning, Faculty of Science and Technology, University of Stavanger, Stavanger, Norway
| | - Gyöngyi Kovács
- HUMLOG Institute, Hanken School of Economics, Helsinki, Finland
| | - Emmanuel Raju
- Global Health Section and The Copenhagen Centre for Disaster Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, Mbarga NF, Ouamba JP, Mafuko JM, Musambi IM, Rougeon D, Grenier EC, Fernandes LG, Van Hulse J, Weerts E, Brodin N. Correction: Assessing independence in mobility activities in trauma care: Validity and reliability of the Activity Independence Measure-Trauma (AIM-T) in humanitarian settings. PLOS Glob Public Health 2024; 4:e0002953. [PMID: 38416786 PMCID: PMC10901302 DOI: 10.1371/journal.pgph.0002953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0001723.].
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Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, Hamid Qaradaya AE, Mafuko JM, Al-Abbasi O, Cherestal S, Fernandes L, Da Silva Frois A, Weerts E, Brodin N. Correction: Monitoring independence in daily life activities after trauma in humanitarian settings: Item reduction and assessment of content validity of the Activity Independence Measure-Trauma (AIM-T). PLOS Glob Public Health 2024; 4:e0003002. [PMID: 38412172 PMCID: PMC10898770 DOI: 10.1371/journal.pgph.0003002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0001334.].
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Gustavsson ME, von Schreeb J, Arnberg FK, Juth N. "Being prevented from providing good care: a conceptual analysis of moral stress among health care workers during the COVID-19 pandemic". BMC Med Ethics 2023; 24:110. [PMID: 38071309 PMCID: PMC10710698 DOI: 10.1186/s12910-023-00993-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Health care workers (HCWs) are susceptible to moral stress and distress when they are faced with morally challenging situations where it is difficult to act in line with their moral standards. In times of crisis, such as disasters and pandemics, morally challenging situations are more frequent, due to the increased imbalance between patient needs and resources. However, the concepts of moral stress and distress vary and there is unclarity regarding the definitions used in the literature. This study aims to map and analyze the descriptions used by HCWs regarding morally challenging situations (moral stress) and refine a definition through conceptual analysis. METHODS Qualitative data were collected in a survey of 16,044 Swedish HCWs who attended a COVID-19 online course in autumn 2020. In total, 643 free-text answers with descriptions of moral stress were analyzed through content analysis. RESULTS Three themes emerged from the content analysis (1) "Seeing, but being prevented to act; feeling insufficient/inadequate and constrained in the profession," (2) "Someone or something hindered me; organizational structures as an obstacle," and (3) "The pandemic hindered us; pandemic-related obstacles." The three themes correspond to the main theme, "Being prevented from providing good care." DISCUSSION The main theme describes moral stress as various obstacles to providing good care to patients in need and acting upon empathic ability within the professional role. The themes are discussed in relation to established definitions of moral stress and are assessed through conceptual analysis. A definition of moral stress was refined, based on one of the established definitions. CONCLUSIONS On the basis of the study results and conceptual analysis, it is argued that the presented definition fulfils certain conditions of adequacy. It is essential to frame the concept of moral stress, which has been defined in different ways in different disciplines, in order to know what we are talking about and move forward in developing prevention measures for the negative outcomes of this phenomenon.
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Affiliation(s)
- Martina E Gustavsson
- Global Disaster Medicine; Health Needs and Response. Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18, Stockholm, 171 77, Sweden.
| | - Johan von Schreeb
- Global Disaster Medicine; Health Needs and Response. Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18, Stockholm, 171 77, Sweden
| | - Filip K Arnberg
- National Centre for Disaster Psychiatry, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Niklas Juth
- Centre for Research ethics and Bioethics (CRB), Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
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Al-Hajj S, El-Hussein M, von Schreeb J, Hamieh C, Ahmad N, Souaiby N. Multicenter assessment of impairments and disabilities associated with Beirut blast injuries: a retrospective review of hospital medical records. Trauma Surg Acute Care Open 2023; 8:e001103. [PMID: 37810766 PMCID: PMC10551996 DOI: 10.1136/tsaco-2023-001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives This study aims to describe the injury patterns of the Beirut blast victims and assess hospitals' disaster management and preparedness during the 2020 Beirut port blast. Methods A cross-sectional retrospective multicenter study was conducted in two stages. Data were collected on blast victims presented to participating hospitals from August 4 till August 8, using three designed questionnaires. Stage 1 included all blast patients' records and stage 2 examined a subset of inpatient and outpatient records. Binary logistic regression was performed to assess the factors associated with death and disability for blast patients. Results A total of 3278 records were collected, 83% were treated at emergency departments and 17% were admitted to hospitals. Among those, 61 deaths and 35 long-term disabilities were reported. Extremity operations (63%) were mostly performed. Outpatients (n=410) had a mean age of 40±17.01 years and 40% sustained lacerations (40%). 10% of those patients sustained neurological complications and mental problems, and 8% had eye complications. Inpatients (n=282) had a mean age of 49±20.7 years and a mean length of hospital stay of 6±10.7 days. Secondary (37%) and tertiary (25%) blast injuries were predominant. 49% sustained extremity injuries and 19% head/face injuries. 11 inpatient deaths and 20 long-term disabilities were reported. Death was significantly associated with tertiary concussion and crush syndrome (p<0.05). Of the 16 hospitals, 13 implemented disaster plans (87%), and 14 performed a triage with a mean time of 0.96±0.67 hours. One hospital (6%) performed psychological evaluations, without follow-up. Conclusion Beirut blast victims suffered deaths and disabilities associated with their injuries. They predominantly sustained lacerations caused by shattered glass. Tertiary injuries were associated with death. Triage, disaster plans, and hospital preparedness should be effectively implemented to enhance patients' clinical outcomes. Level of evidence Prognostic and epidemiological/Level III.
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Affiliation(s)
- Samar Al-Hajj
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | | | - Johan von Schreeb
- Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Stockholm, Sweden
| | | | - Nesrine Ahmad
- Middle East and North Africa Program for Advanced Injury Research, American University of Beirut, Beirut, Lebanon
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Muhrbeck M, Egelko A, Haweizy RM, von Schreeb J, Älgå A. Exploratory laparotomy during the battle of Mosul, 2016-2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan. BMC Emerg Med 2023; 23:113. [PMID: 37741988 PMCID: PMC10518085 DOI: 10.1186/s12873-023-00882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND The Battle of Mosul (2016-2017) was an urban conflict resulting in over 9000 civilian deaths. Emergency Management Centre (EMC), located 90 km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating exploratory laparotomy (ex-lap) provide a unique window into the system of care delivery in conflicts, given the importance of timely, resource-intensive care. However, there is insufficient knowledge regarding the presentation and outcomes for conflict-related ex-lap in civilian institutions. METHODS This is a descriptive study retrospectively analyzing routinely collected data for all patients who underwent ex-lap at EMC for injuries sustained during the battle of Mosul. Differences in demographics, pre-hospital/hospital course, and New Injury Severity Scores (NISS) were analysed using student t-test, Hotelling T-squared, and linear regression. RESULTS During the battle, 1832 patients with conflict-related injuries were admitted to EMC. Some 73/1832 (4.0%) underwent ex-lap, of whom 22/73 (30.1%) were children and 40/73 (54.8%) were non-combatant adults. Men constituted 51/73 (69%) patients. Gunshot wounds caused 19/73 (26.0%) injuries, while ordnances caused 52/73 (71.2%). Information regarding hospital course was available for 47/73 (64.4%) patients. Children had prolonged time from injury to first laparotomy compared to adults (600 vs 208 min, p < 0.05). Median LOS was 6 days (IQR 4-9.5); however, 11/47 (23%) patients left against medical advice. Post-operative complications occurred in 11/47 (23.4%) patients; 6/11 (54.5%) were surgical site infections. There were 12 (25.5%) patients who underwent relaparotomies after index surgery elsewhere; 10/12 (83.3%) were for failed repairs or missed injuries. Median NISS was 18 (IQR 12-27). NISS were significantly higher for women (vs men; 28.5 vs 19.8), children (vs adults; 28.8 vs 20), and relaparotomy patients (vs primary laparotomy patients; 32.0 vs 19.0). Some 3 patients died, 2 of whom were relaparotomies. CONCLUSION At this civilian tertiary trauma centre, conflict-related exploratory laparotomies were associated with low morbidity and mortality. Long transport times, high rates of repeat laparotomies, and high numbers of patients leaving against medical advice raise questions regarding continuity of care along the Mosul Trauma Pathway. TRIAL REGISTRATION The study protocol was registered at Clinicaltrails.gov, ID NCT03490305, prior to collection of data.
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Affiliation(s)
- Måns Muhrbeck
- Department of Surgery in Norrköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Aron Egelko
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Älgå
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, Fouda Mbarga N, Ouamba JP, Mafuko JM, Mulombwe Musambi I, Rougeon D, Côté Grenier E, Gaspar Fernandes L, Van Hulse J, Weerts E, Brodin N. Assessing independence in mobility activities in trauma care: Validity and reliability of the Activity Independence Measure-Trauma (AIM-T) in humanitarian settings. PLOS Glob Public Health 2023; 3:e0001723. [PMID: 37695762 PMCID: PMC10495016 DOI: 10.1371/journal.pgph.0001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, lower limb, and upper limb). This study aimed to assess the AIM-T construct validity (structural validity and hypothesis testing) and reliability (internal consistency, inter-rater reliability and measurement error) in four humanitarian settings (Burundi, Iraq, Cameroon and Central African Republic). Patients with acute injury (n = 195) were assessed using the AIM-T, the Barthel Index (BI), and two pain scores. Structural validity was assessed through confirmatory factor analysis. Hypotheses were tested regarding correlations with BI and pain scores using Pearson correlation coefficient (PCC) and differences in AIM-T scores between patients' subgroups, using standardized effect size Cohen's d (d). Internal consistency was assessed with Cronbach's alpha (α). AIM-T was reassessed by a second rater in 77 participants to test inter-rater reliability using intraclass correlation coefficient (ICC). The results showed that the AIM-T structure in three subscales had an acceptable fit. The AIM-T showed an inverse weak to moderate correlation with both pain scores (PCC<0.7, p≤0.05), positive strong correlation with BI (PCC≥0.7, p≤0.05), and differed between all subgroups (d≥0.5, p≤0.05). The inter-rater reliability in the (sub)scales was good to excellent (ICC 0.86-0.91) and the three subscales' internal consistency was adequate (α≥0.7). In conclusion, this study supports the AIM-T validity in measuring independence in mobility activities and its reliability in humanitarian settings, as well as it informs on its interpretability. Thus, the AIM-T could be a valuable measure to assess outcomes after injury in humanitarian settings.
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Affiliation(s)
- Bérangère Gohy
- Department of Neurobiology, Division of Physiotherapy, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Humanity & Inclusion, Rehabilitation Technical Direction, Brussels, Belgium
| | - Christina H. Opava
- Department of Neurobiology, Division of Physiotherapy, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm Sweden
| | | | - Aude Brus
- Humanity & Inclusion, Innovation, Impact & Information Division, Brussels, Belgium
| | - Nicole Fouda Mbarga
- Médecins Sans Frontières, Operational Center Geneva, YaoundeYaounde, Cameroon
| | - Jean Patrick Ouamba
- Médecins Sans Frontières, Operational Center Geneva, YaoundeYaounde, Cameroon
| | - Jean-Marie Mafuko
- Médecins Sans Frontières, Operational Center Brussels, Bujumbura, Burundi
| | - Irene Mulombwe Musambi
- Médecins Sans Frontières, Operational Center Paris, Bangui, Central African Republic, Baghdad, Iraq
| | - Delphine Rougeon
- Médecins Sans Frontières, Operational Center Paris, Bangui, Central African Republic, Baghdad, Iraq
| | | | | | | | - Eric Weerts
- Humanity & Inclusion, Rehabilitation Technical Direction, Brussels, Belgium
| | - The AIM-T Study Group
- Médecins Sans Frontières, Operational Center Brussels, Brussels, Belgium
- Médecins Sans Frontières, Operational Center Geneva, YaoundeYaounde, Cameroon
- Médecins Sans Frontières, Operational Center Brussels, Bujumbura, Burundi
- Médecins Sans Frontières, Operational Center Paris, Bangui, Central African Republic, Baghdad, Iraq
- Médecins Sans Frontières, Operational Center Paris, Baghdad, Iraq
- Médecins Sans Frontières, Operational Center Paris, France
| | - Nina Brodin
- Department of Neurobiology, Division of Physiotherapy, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopaedics, Danderyd Hospital Corp., Division of Physiotherapy, Danderyd, Sweden
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Robinson Y, Ragazzoni L, Della Corte F, von Schreeb J. Teaching extent and military service improve undergraduate self-assessed knowledge in disaster medicine: An online survey study among Swedish medical and nursing students. Front Public Health 2023; 11:1161114. [PMID: 37064676 PMCID: PMC10102457 DOI: 10.3389/fpubh.2023.1161114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundThe purpose of this study was to identify the possible needs for undergraduate disaster medicine education in Sweden and to make informed recommendations for the implementation of disaster medicine content in medical and nursing schools in Sweden.MethodsAn online survey was distributed to undergraduate medical and nursing students through the directors of all medical and nursing programs at Swedish universities. The survey contained demographic questions, as well as questions about the amount of disaster medical education and previous experience with rescue, police, or military services. The final survey page contained self-assessments of disaster medical knowledge. Comparative statistics were applied between nursing and medical students, those with previous military service, and those without, as well as between universities.ResultsA total of 500 medical and 408 nursing students participated in this study. A median of 2 h of disaster medicine education was provided to senior medical students and 4 h was provided to senior nursing students. Senior medical students scored their disaster medical knowledge lower than nursing students (t-test, p < 0.001). A proportion of 1% had served in rescue services or police, and 7% of the participants had a history of military service, of which 67% served in a medical role. Those who had served in rescue services, police, or the armed forces had a higher self-assessed disaster medical knowledge base than those who had not (p < 0.007 and p < 0.001, respectively).ConclusionMost medical and nursing students in this study rated their disaster medical knowledge as insufficient. The correlation between the amount of disaster medical education and self-assessed disaster medical knowledge should influence and help direct Swedish educational policies.
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Affiliation(s)
- Yohan Robinson
- Institute for Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- *Correspondence: Yohan Robinson,
| | - Luca Ragazzoni
- CRIMEDIM—Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Francesco Della Corte
- CRIMEDIM—Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Johan von Schreeb
- Department of Global Public Health, Center for Research on Health Care in Disasters, Karolinska Institute, Stockholm, Sweden
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Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, El Hamid Qaradaya A, Mafuko JM, Al-Abbasi O, Cherestal S, Fernandes L, Da Silva Frois A, Weerts E, Brodin N. Monitoring independence in daily life activities after trauma in humanitarian settings: Item reduction and assessment of content validity of the Activity Independence Measure-Trauma (AIM-T). PLOS Glob Public Health 2022; 2:e0001334. [PMID: 36962914 PMCID: PMC10021394 DOI: 10.1371/journal.pgph.0001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022]
Abstract
A standardized set of measures to assess functioning after trauma in humanitarian settings has been called for. The Activity Independence Measure for Trauma (AIM-T) is a clinician-rated measure of independence in 20 daily activities among patients after trauma. Designed in Afghanistan, it has since been used in other contexts. Before recommending the AIM-T for wider use, its measurement properties required confirmation. This study aims at item reduction followed by content validity assessment of the AIM-T. Using a two-step revision process, first, routinely collected data from 635 patients at five facilities managing patients after trauma in Haiti, Burundi, Yemen, and Iraq were used for item reduction. This was performed by analyzing inter-item redundancy and distribution of the first version of the AIM-T (AIM-T1) item scores, resulting in a shortened version (AIM-T2). Second, content validity of the AIM-T2 was assessed by item content validity indices (I-CVI, 0-1) based on structured interviews with 23 health care professionals and 60 patients in Haiti, Burundi, and Iraq. Through the analyses, nine pairs of redundant items (r≥0.90) were identified in the AIM-T1, leading to the removal of nine items, and resulting in AIM-T2. All remaining items were judged highly relevant, appropriate, clear, feasible and representative by most of participants (I-CVI>0.5). Ten items with I-CVI 0.5-0.85 were revised to improve their cultural relevance or appropriateness and one item was added, resulting in the AIM-T3. In conclusion, the proposed 12-item AIM-T3 is overall relevant, clear, and representative of independence in daily activity after trauma and it includes items appropriate and feasible to be observed by clinicians across different humanitarian settings. While some additional measurement properties remain to be evaluated, the present version already has the potential to serve as a routine measure to assess patients after trauma in humanitarian settings.
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Affiliation(s)
- Bérangère Gohy
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Humanity & Inclusion, Rehabilitation technical direction, Brussels, Belgium
| | - Christina H. Opava
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Aude Brus
- Impact & Information Division, Humanity & Inclusion, Innovation, Brussels, Belgium
| | | | - Jean-Marie Mafuko
- Médecins Sans Frontières, Operational Center Brussels, Bujumbura, Burundi
| | - Omar Al-Abbasi
- Médecins Sans Frontières, Operational Center Brussels, Erbil, Iraq
| | - Sophia Cherestal
- Médecins Sans Frontières, Operational Center Brussels, Port-au-Prince, Haiti
| | - Livia Fernandes
- Médecins Sans Frontières, Operational Center Paris, Baghdad, Iraq
| | | | - Eric Weerts
- Humanity & Inclusion, Rehabilitation technical direction, Brussels, Belgium
| | - The AIM-T Study Group
- Médecins Sans Frontières, Operational Center Brussels, Brussels, Belgium
- Médecins Sans Frontières, Operational Center Paris, Gaza, Palestinian territories
- Médecins Sans Frontières, Operational Center Brussels, Bujumbura, Burundi
- Médecins Sans Frontières, Operational Center Brussels, Port-au-Prince, Haiti
- Médecins Sans Frontières, Operational Center Paris, Baghdad, Iraq
- Médecins Sans Frontières, Operational Center Paris, Paris, France
- Médecins Sans Frontières, Operational Center Paris, Aden, Yemen
- Humanity & Inclusion, Bujumbura, Burundi
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Division of Physiotherapy, Department of Orthopaedics, Danderyd Hospital Corp., Danderyd, Sweden
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Amat Camacho N, von Schreeb J, Della Corte F, Kolokotroni O. Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review. Matern Child Nutr 2022; 19:e13440. [PMID: 36222214 PMCID: PMC9749597 DOI: 10.1111/mcn.13440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022]
Abstract
In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.
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Affiliation(s)
- Nieves Amat Camacho
- Department of Global Public Health, Center for Research on Health Care in DisastersKarolinska InstituteStockholmSweden,Centre for Research and Training in Disaster Medicine,Humanitarian Aid, and Global HealthUniversità del Piemonte OrientaleNovaraItaly
| | - Johan von Schreeb
- Department of Global Public Health, Center for Research on Health Care in DisastersKarolinska InstituteStockholmSweden
| | - Francesco Della Corte
- Centre for Research and Training in Disaster Medicine,Humanitarian Aid, and Global HealthUniversità del Piemonte OrientaleNovaraItaly
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Amirkhani M, Ghaemimood S, von Schreeb J, El-Khatib Z, Yaya S. Extreme weather events and death based on temperature and CO 2 emission - A global retrospective study in 77 low-, middle- and high-income countries from 1999 to 2018. Prev Med Rep 2022; 28:101846. [PMID: 35669858 PMCID: PMC9163583 DOI: 10.1016/j.pmedr.2022.101846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022] Open
Abstract
Summary of reported number of extreme weather events/associated deaths globally. Data from a humanitarian disaster database (77 countries, 425 events, 1999–2018). Number of deaths increased significantly with the repetition of extreme events. Mortality rate in heat season was 7 fold higher than that in cold/severe winter. Consistent reporting measures, is needed, from severe weather-related events.
Due to rising temperatures and CO2 emissions, climate change has become one of the most important global issues. We described the relationship between extreme weather-related events and death, globally, from 1999 through 2018. We used data from the emergency events database of the Université Catholique de Louvain. We also categorized the countries’ income according to the World Bank GDP and we used the CO2 emission levels data from the Carbon Dioxide Information Analysis Center to link the GDP and CO2 emissions to years of extreme weather conditions in each country. We conducted descriptive and Poisson Regression analysis to analyze the data. A total of 77 countries reported 425 extreme weather-related events from1999 through 2018. Mortality related events were highest in middle-income countries due to severe winter conditions (N = 2,020) and cold-waves (N = 70,972). The total number of recorded deaths due to heat waves was highest in high-income countries (N = 84,344). Furthermore, the number of deaths in high-income countries, compared to low-income countries, was five-fold higher (IRR 5.18; 95%CI 4.58; 5.85, p < 0.001). The mortality rate in heat season was almost seven-fold higher than that in cold/severe winter (IRR 33.43; 95%CI 32.85; 34.02, p < 0.001). The number of deaths increased significantly with the repetition of extreme events (IRR 6.82; 95%CI 6.68; 6.96, p < 0.001). We found the number of deaths increased in high-income countries, and this was associated with an increase in the number of times extreme events occurred per year and with heat wave.
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Affiliation(s)
- Maral Amirkhani
- Public Health Graduate Studies, Bahá'i Institute for Higher Education (BIHE), Iran
| | - Shidrokh Ghaemimood
- Public Health Graduate Studies, Bahá'i Institute for Higher Education (BIHE), Iran
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ziad El-Khatib
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Medical University of Vienna, Vienna, Austria.,World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), Québec, Canada
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Canada.,The George Institute for Global Health, Imperial College London, London, UK
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Gustavsson ME, Juth N, Arnberg FK, von Schreeb J. Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders. Confl Health 2022; 16:24. [PMID: 35527276 PMCID: PMC9079207 DOI: 10.1186/s13031-022-00456-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges. Methods Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis. Results We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate. Conclusion The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00456-y.
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13
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Saulnier DD, Thol D, Por I, Hanson C, von Schreeb J, Alvesson HM. 'We have a plan for that': a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia. BMJ Open 2022; 12:e054145. [PMID: 34980624 PMCID: PMC8724583 DOI: 10.1136/bmjopen-2021-054145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods. DESIGN A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework. SETTING Public sector healthcare facilities and health departments in two districts exposed to flooding. PARTICIPANTS Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding. RESULTS The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response. CONCLUSION The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.
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Affiliation(s)
- Dell D Saulnier
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Dawin Thol
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Ir Por
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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14
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Daebes HL, Tounsi LL, Nerlander M, Gerdin Wärnberg M, Jaweed M, Mamozai BA, Nasim M, Trelles M, von Schreeb J. Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015. Emerg Med J 2021; 39:628-633. [PMID: 34759014 PMCID: PMC9304096 DOI: 10.1136/emermed-2020-209470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 10/25/2021] [Indexed: 11/22/2022]
Abstract
Background Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF’s standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings Aim This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC. Method and materials This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes. Results Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red. Conclusion The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.
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Affiliation(s)
- Hadjer Latif Daebes
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Linnea Latifa Tounsi
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian Nerlander
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gerdin Wärnberg
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Momer Jaweed
- Medical Department, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Miguel Trelles
- Medical Department, Operational Centre Brussels, Doctors without Borders, Bruxelles, Belgium
| | - Johan von Schreeb
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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15
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Rowinski A, von Schreeb J. Decontamination of Surgical Instruments for Safe Wound Care Surgeries in Disasters: What are the Options? A Scoping Review. Prehosp Disaster Med 2021; 36:645-650. [PMID: 34550059 PMCID: PMC8459170 DOI: 10.1017/s1049023x2100090x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/23/2021] [Accepted: 07/10/2021] [Indexed: 11/10/2022]
Abstract
International guidelines stipulate that autoclavation is necessary to sterilize surgical equipment. World Health Organization (WHO) guidelines for decontamination of medical devices require four levels of decontamination: cleaning, low- and high-level disinfection, as well as sterilization. Following disasters, there is a substantial need for wound care surgery. This requires prompt availability of a significant volume of instruments that are adequately decontaminated. Ideally, they should be sterilized using an autoclave, but due to the resource-limited field context, this may be impossible. The aim of this study was therefore to identify whether there are portable and less resource-demanding techniques to decontaminate surgical instruments for safe wound care surgery in disasters. A scoping review was chosen, and searches were performed in three scientific databases, grey literature, and included data from organizations and journals. Articles were scanned for decontamination techniques feasible for use in the resource-scarce disaster setting given that: they achieved at least high-level disinfected instruments, were portable, and did not require electricity. A total of 401 articles were reviewed, yielding 13 articles for inclusion. The study identified three techniques: pressure cooking, boiling, and liquid chemical immersion, all achieving either sterilized or high-level disinfected instruments. It was concluded that besides autoclaves, there are less resource-demanding decontamination techniques available for safe wound surgery in disasters. This study provides systematic information to guide optimal standard setting for sterilization of surgical material in resource-limited disaster settings.
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Affiliation(s)
- Anna Rowinski
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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16
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Nerlander MP, Pini A, Trelles M, Majanen H, Al-Abbasi O, Maroof M, Ragazzoni L, von Schreeb J. Epidemiology of Patients Treated at the Emergency Department of a Medcins Sans Frontieres Field Hospital During the Mosul Offensive: Iraq, 2017e. J Emerg Med 2021; 61:774-781. [PMID: 34538676 DOI: 10.1016/j.jemermed.2021.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/17/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. OBJECTIVE This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict. METHODS During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant. RESULTS The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED. CONCLUSIONS The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.
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Affiliation(s)
- Maximilian P Nerlander
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Alessandro Pini
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Miguel Trelles
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Hanna Majanen
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Omar Al-Abbasi
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Mansour Maroof
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Luca Ragazzoni
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Johan von Schreeb
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Muhrbeck M, Osman Z, von Schreeb J, Wladis A, Andersson P. Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study. BMC Emerg Med 2021; 21:94. [PMID: 34380419 PMCID: PMC8359038 DOI: 10.1186/s12873-021-00488-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
Background In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings. Methods A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC’s hospitals in Peshawar, 2009–2012 and Goma, 2012–2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC). Results A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74–0.78) than for KTS (0.53, 95% CI 0.50–0.56) and RTS (0.51, 95% CI 0.48–0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79–0.88) than for KTS (0.71, 95% CI 0.65–0.76) and RTS (0.70, 95% CI 0.63–0.76) for all patients, but not for patients with complete data. Conclusion RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00488-2.
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Affiliation(s)
- Måns Muhrbeck
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden.
| | - Zaher Osman
- International Committee of the Red Cross, Geneva, Switzerland
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Wladis
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
| | - Peter Andersson
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,International Medical Programme, Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
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Älgå A, Haweizy R, Bashaireh K, Wong S, Lundgren KC, von Schreeb J, Malmstedt J. Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial. Lancet Glob Health 2020; 8:e423-e429. [PMID: 32087175 DOI: 10.1016/s2214-109x(19)30547-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. METHODS In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual. FINDINGS Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups. INTERPRETATION NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. FUNDING The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Rawand Haweizy
- College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Khaldoon Bashaireh
- Department of Special Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
| | - Kalle Conneryd Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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19
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Fridell M, Edwin S, von Schreeb J, Saulnier DD. Health System Resilience: What Are We Talking About? A Scoping Review Mapping Characteristics and Keywords. Int J Health Policy Manag 2020; 9:6-16. [PMID: 31902190 PMCID: PMC6943300 DOI: 10.15171/ijhpm.2019.71] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 09/02/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health systems are based on 6 functions that need to work together at all times to effectively deliver safe and quality health services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a shock, it may cease to function or collapse. The concept of resilience has been introduced with the goal of strengthening health systems to avoid disruption or collapse. The concept is new within health systems research, and no common description exists to describe its meaning. The aim of this study is to summarize and characterize the existing descriptions of health system resilience to improve understanding of the concept. Methods and Analysis: A scoping review was undertaken to identify the descriptions and characteristics of health system resilience. Four databases and gray literature were searched using the keywords "health system" and "resilience" for published documents that included descriptions, frameworks or characteristics of health system resilience. Additional documents were identified from reference lists. Four expert consultations were conducted to gain a broader perspective. Descriptions were analysed by studying the frequency of key terms and were characterized by using the World Health Organization (WHO) health system framework. The scoping review identified eleven sources with descriptions and 24 sources that presented characteristics of health system resilience. Frequently used terms that were identified in the literature were shock, adapt, maintain, absorb and respond. Change and learning were also identified when combining the findings from the descriptions, characteristics and expert consultations. Leadership and governance were recognized as the most important building block for creating health system resilience. DISCUSSION No single description of health system resilience was used consistently. A variation was observed on how resilience is described and to what depth it was explained in the existing literature. The descriptions of health system resilience primarily focus on major shocks. Adjustments to long-term changes and the element of learning should be considered for a better understating of health system resilience.
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Affiliation(s)
- My Fridell
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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20
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Nerlander MP, Haweizy RM, Wahab MA, Älgå A, von Schreeb J. Epidemiology of Trauma Patients from the Mosul Offensive, 2016-2017: Results from a Dedicated Trauma Center in Erbil, Iraqi Kurdistan. World J Surg 2019; 43:368-373. [PMID: 30357467 PMCID: PMC6329836 DOI: 10.1007/s00268-018-4817-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Most epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mosul was Emergency Management Center (EMC) in Erbil, 90 km away. The aim of this study was to describe the epidemiology, morbidity, and mortality of civilians and combatants admitted during the ongoing conflict. METHOD This retrospective cohort study utilized routinely collected data on patients with conflict-related injuries who were admitted to EMC between October 16, 2016, and July 10, 2017. Data processing and analysis was carried out using JMP 13. Categorical variables were compared using Fisher's exact test. RESULTS The analysis included 1725 patients, out of which 46% were civilian. Ordnance accounted for most injuries (68%), followed by firearms (18%) and improvised explosive devices (IEDs) (14%). The proportion of IED-related injuries among combatants were almost three times that of civilians. The proportions of abdominal injuries, need for surgery, laparotomies, and amputations were significantly higher among civilians than among combatants. The mortality rate was 0.5%. DISCUSSION The fact that civilians had greater surgical needs than combatants may be explained by several factors including a lack of ballistic protection. The extremely low mortality rate indicates significant gaps in prehospital care and transport. Our results may provide useful information to guide medical preparedness and response during future conflicts. CLINICALTRIALS. GOV ID NCT03358758.
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Affiliation(s)
- Maximilian P Nerlander
- Centre for Research on Health Care in Disasters, Department of Public Health Sciences, Karolinska Institutet, 171 76, Stockholm, Sweden.
| | | | | | - Andreas Älgå
- Centre for Research on Health Care in Disasters, Department of Public Health Sciences, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Johan von Schreeb
- Centre for Research on Health Care in Disasters, Department of Public Health Sciences, Karolinska Institutet, 171 76, Stockholm, Sweden
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Tounsi LL, Daebes HL, Gerdin Wärnberg M, Nerlander M, Jaweed M, Mamozai BA, Nasim M, Drevin G, Trelles M, von Schreeb J. Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan. World J Surg 2019; 43:2123-2130. [PMID: 31065777 DOI: 10.1007/s00268-019-05015-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
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Affiliation(s)
- Linnea Latifa Tounsi
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Hadjer Latif Daebes
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | | | - Maximilian Nerlander
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Momer Jaweed
- Kunduz Trauma Centre, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Kabul Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Gustaf Drevin
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Miguel Trelles
- Medical Department - Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.
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22
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Älgå A, Wong S, Haweizy R, Conneryd Lundgren K, von Schreeb J, Malmstedt J. Negative-Pressure Wound Therapy Versus Standard Treatment of Adult Patients With Conflict-Related Extremity Wounds: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e12334. [PMID: 30478024 PMCID: PMC6288590 DOI: 10.2196/12334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up. Objective The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds. Methods This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat. Results The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019. Conclusions To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies. Trial Registration ClinicalTrials.gov NCT02444598; http://clinicaltrials.gov/ct2/show/NCT02444598 (Archived by WebCite at http://www.webcitation.org/72hjI2XNX) International Registered Report Identifier (IRRID) DERR1-10.2196/12334
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Sidney Wong
- Operational Centre Amsterdam, Médecins Sans Frontières, Amsterdam, Netherlands
| | | | | | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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23
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Bolkan HA, van Duinen A, Samai M, Bash-Taqi DA, Gassama I, Waalewijn B, Wibe A, von Schreeb J. Admissions and surgery as indicators of hospital functions in Sierra Leone during the west-African Ebola outbreak. BMC Health Serv Res 2018; 18:846. [PMID: 30413159 PMCID: PMC6230245 DOI: 10.1186/s12913-018-3666-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/30/2018] [Indexed: 11/23/2022] Open
Abstract
Background In an attempt to assess the effects of the Ebola viral disease (EVD) on hospital functions in Sierra Leone, the aim of this study was to evaluate changes in provisions of surgery and non-Ebola admissions during the first year of the EVD outbreak. Methods All hospitals in Sierra Leone known to perform inpatient surgery were assessed for non-Ebola admissions, volume of surgery, caesarean deliveries and inguinal hernia repairs between January 2014 and May 2015, which was a total of 72 weeks. Accumulated weekly data were gathered from readily available hospital records at bi-weekly visits during the peak of the outbreak from September 2014 to May 2015. The Mann-Whitney U test was used to compare weekly median admissions during the first year of the EVD outbreak, with the 20 weeks before the outbreak, and weekly median volume of surgeries performed during the first year of the EVD outbreak with identical weeks of 2012. The manuscript is prepared according to the STROBE checklist for cross-sectional studies. Results Of the 42 hospitals identified, 40 had available data for 94% (2719/2880) of the weeks. There was a 51% decrease in weekly median non-Ebola admissions and 41% fewer weekly median surgeries performed compared with the 20 weeks before the outbreak (admission) and 2012 (volume of surgery). Governmental hospitals experienced a smaller reduction in non-Ebola admissions (45% versus 60%) and surgeries (31% versus 53%) compared to private non-profit hospitals. Governmental hospitals realized an increased volume of cesarean deliveries by 45% during the EVD outbreak, thereby absorbing the 43% reduction observed in the private non-profit hospitals. Conclusions Both non-Ebola admissions and surgeries were severely reduced during the EVD outbreak. In addition to responding to the EVD outbreak, governmental hospitals were able to maintain certain core health systems functions. Volume of surgery is a promising indicator of hospital functions that should be further explored. Electronic supplementary material The online version of this article (10.1186/s12913-018-3666-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Håkon A Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Box 8905, N-7491, Trondheim, Norway. .,Clinic of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway. .,CapaCare, Norway, Sierra Leone.
| | - Alex van Duinen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Box 8905, N-7491, Trondheim, Norway.,Clinic of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway.,CapaCare, Norway, Sierra Leone
| | - Mohammed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Donald Alpha Bash-Taqi
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Ibrahim Gassama
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | | | - Arne Wibe
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Box 8905, N-7491, Trondheim, Norway.,Clinic of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway
| | - Johan von Schreeb
- Health System and Policy Research Group, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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24
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Haverkamp FJC, Veen H, Hoencamp R, Muhrbeck M, von Schreeb J, Wladis A, Tan ECTH. Prepared for Mission? A Survey of Medical Personnel Training Needs Within the International Committee of the Red Cross. World J Surg 2018; 42:3493-3500. [PMID: 29721638 PMCID: PMC6182760 DOI: 10.1007/s00268-018-4651-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. METHODS All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents' personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. RESULTS The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p < 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). CONCLUSION ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.
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Affiliation(s)
- Frederike J. C. Haverkamp
- Department of Surgery (internal postal code 618), Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harald Veen
- World Health Organization, Geneva, Switzerland
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Medical Centre Leiderdorp, Leiderdorp, The Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Ministry of Defence, Utrecht, The Netherlands
| | - Måns Muhrbeck
- Department of Surgery, Linköping University, Gamla Övägen 25, 603 79 Norrköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Gamla Övägen 25, 603 79 Norrköping, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Andreas Wladis
- International Committee of the Red Cross, 19 Avenue de la paix, 1202 Geneva, Switzerland
- Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Edward C. T. H. Tan
- Department of Surgery (internal postal code 618), Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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25
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Abstract
Background In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. Aim To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. Methods We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. Results In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0–15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0–15 years of age. The estimated unmet need for inguinal hernia repair was 88%. Conclusions The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.
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Affiliation(s)
| | - Håkon Angell Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Lars Hagander
- Surgery and Public Health, Pediatric Surgery, Department of Clinical Sciences in Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan von Schreeb
- Global Health-Health System and Policy Department of Public Health Sciences, Centre for Research on Health Care in Disasters, Stockholm, Sweden
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26
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Älgå A, Wong S, Shoaib M, Lundgren K, Giske CG, von Schreeb J, Malmstedt J. Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan. BMC Infect Dis 2018; 18:233. [PMID: 29788910 PMCID: PMC5964734 DOI: 10.1186/s12879-018-3149-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/15/2018] [Indexed: 11/30/2022] Open
Abstract
Background Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. Methods We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014–2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. Results Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42–4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). Conclusions Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. Trial registration ClinicalTrials.gov (NCT02744144). Registered April 13, 2016. Retrospectively registered.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Kalle Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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27
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Abstract
PURPOSE OF REVIEW Natural disasters have injured more than 2 million people in the last 10 years and led to significant international medical relief deployment. Knowledge of expected injury patterns following these disasters is an important part of planning for type and size of outside surgical assistance. This review aims to summarize what is known about injury patterns following natural sudden-onset disasters (SODs). RECENT FINDINGS Several systematic reviews have concluded that data on injury patterns and surgical needs following natural SODs is scarce. Studies on earthquakes indicate that earthquakes generate large numbers of injured, out of which limb injuries are most common. Tsunamis, floods, storms, and wildfires do not generate a significant burden of injuries in relation to numbers affected. SUMMARY Earthquake may require surgical assistance, especially for limb injuries; therefore, mainly orthopedic and plastic surgeries are priority specialist areas. Major injuries seem to be few in other natural disasters. However, more detailed data is needed on specific injury patterns to determine if additional surgical assistance is needed and to what extent it is needed to cater for normal surgical conditions if existing health care has seized to function.
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Affiliation(s)
- Sofia Bartholdson
- Centre for Research on Health Care in Disasters, Health System and Policy Research, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Johan von Schreeb
- Centre for Research on Health Care in Disasters, Health System and Policy Research, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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28
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Ekström AM, Schreeb JV, Forsberg B, Allebeck P. Hans Rosling. Eur J Public Health 2017. [DOI: 10.1093/eurpub/ckx027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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29
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Burkle FM, Erickson TB, von Schreeb J, Redmond AD, Kayden S, Van Rooyen M. A declaration to the UN on wars in the Middle East. Lancet 2017; 389:699-700. [PMID: 28229875 DOI: 10.1016/s0140-6736(17)30338-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/10/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Frederick M Burkle
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA; Woodrow Wilson International Center for Scholars, Washington, DC, USA
| | - Timothy B Erickson
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard Humanitarian Initiative, 02115 Boston, MA, USA.
| | - Johan von Schreeb
- General Surgeon Centre for Research on Health in Disasters, Health System & Policy, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Anthony D Redmond
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Stephanie Kayden
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard Humanitarian Initiative, 02115 Boston, MA, USA
| | - Michael Van Rooyen
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard Humanitarian Initiative, 02115 Boston, MA, USA
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30
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Roy N, Kizhakke Veetil D, Khajanchi MU, Kumar V, Solomon H, Kamble J, Basak D, Tomson G, von Schreeb J. Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths. BMC Health Serv Res 2017; 17:142. [PMID: 28209192 PMCID: PMC5314603 DOI: 10.1186/s12913-017-2085-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/09/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery. METHODS All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI). RESULTS During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging. CONCLUSION Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.
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Affiliation(s)
- Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | | | | | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Harris Solomon
- Department of Cultural Anthropology and Global Health, Global Health Institute, Duke University, 205 Friedl Building, Box 90091, Durham, 27708 NC USA
| | - Jyoti Kamble
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Debojit Basak
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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31
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Bolkan HA, Hagander L, von Schreeb J, Bash-Taqi D, Kamara TB, Salvesen Ø, Wibe A. The Surgical Workforce and Surgical Provider Productivity in Sierra Leone: A Countrywide Inventory. World J Surg 2017; 40:1344-51. [PMID: 26822155 PMCID: PMC4868859 DOI: 10.1007/s00268-016-3417-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels. Methods Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants. Results The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility’s volume of surgery and the productivity of its surgical providers (rs = 0.642, p < 0.001). Conclusions Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %.
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Affiliation(s)
- Håkon A Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Box 8905, 7491, Trondheim, Norway.
| | - Lars Hagander
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Johan von Schreeb
- Health System and Policy Research Group, Karolinska Institutet, 171 77, Stockholm, Sweden
| | | | - Thaim B Kamara
- Department of Surgery, Connaught Hospital and College of Medicine Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Øyvind Salvesen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Box 8905, 7491, Trondheim, Norway
| | - Arne Wibe
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Box 8905, 7491, Trondheim, Norway
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32
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Roy N, Gerdin M, Schneider E, Kizhakke Veetil DK, Khajanchi M, Kumar V, Saha ML, Dharap S, Gupta A, Tomson G, von Schreeb J. Validation of international trauma scoring systems in urban trauma centres in India. Injury 2016; 47:2459-2464. [PMID: 27667119 DOI: 10.1016/j.injury.2016.09.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian trauma patients. PATIENTS AND METHODS From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of trauma patients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC). RESULTS In a registry of 8791 adult trauma patients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day). CONCLUSION On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.
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Affiliation(s)
- Nobhojit Roy
- Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden; BARC Hospital (Govt of India), HBNI University, Mumbai, India.
| | - Martin Gerdin
- Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.
| | - Eric Schneider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02120, USA.
| | | | - Monty Khajanchi
- BARC Hospital (Govt of India), HBNI University, Mumbai, India.
| | - Vineet Kumar
- Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.
| | - Makhal Lal Saha
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India.
| | - Satish Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai,India.
| | - Amit Gupta
- Department of Surgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Göran Tomson
- Department of Learning, Informatics, Management & Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Johan von Schreeb
- Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.
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Amat Camacho N, Hughes A, Burkle FM, Ingrassia PL, Ragazzoni L, Redmond A, Norton I, von Schreeb J. Education and Training of Emergency Medical Teams: Recommendations for a Global Operational Learning Framework. PLoS Curr 2016; 8. [PMID: 27917306 PMCID: PMC5104687 DOI: 10.1371/currents.dis.292033689209611ad5e4a7a3e61520d0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
An increasing number of international emergency medical teams are deployed to assist disaster-affected populations worldwide. Since Haiti earthquake those teams have been criticised for ill adapted care, lack of preparedness in addition to not coordinating with the affected country healthcare system. The Emergency Medical Teams (EMTs) initiative, as part of the Word Health Organization’s Global Health Emergency Workforce program, aims to address these shortcomings by improved EMT coordination, and mechanisms to ensure quality and accountability of national and international EMTs. An essential component to reach this goal is appropriate education and training. Multiple disaster education and training programs are available. However, most are centred on individuals’ professional development rather than on the EMTs operational performance. Moreover, no common overarching or standardised training frameworks exist. In this report, an expert panel review and discuss the current approaches to disaster education and training and propose a three-step operational learning framework that could be used for EMTs globally. The proposed framework includes the following steps: 1) ensure professional competence and license to practice, 2) support adaptation of technical and non-technical professional capacities into the low-resource and emergency context and 3) prepare for an effective team performance in the field. A combination of training methodologies is also recommended, including individual theory based education, immersive simulations and team training. Agreed curriculum and open access training materials for EMTs need to be further developed, ideally through collaborative efforts between WHO, operational EMT organizations, universities, professional bodies and training agencies. Keywords: disasters; education; emergencies; global health; learning
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Affiliation(s)
| | - Amy Hughes
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Frederick M Burkle
- Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, USA
| | - Pier Luigi Ingrassia
- Research Center in Emergency and Disaster Medicine and Computer Science applied to Medicine (CRIMEDIM); Università del Piemonte Orientale, Novara, Italy
| | - Luca Ragazzoni
- CRIMEDIM - Research Center in Emergency and Disaster Medicine and Computer Science applied to Medical Practice; Università del Piemonte Orientale, Novara, Italy
| | - Anthony Redmond
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Ian Norton
- Emergency Medical Teams (EMT) Project - Policy, Practice and Evaluation Unit, Emergency Risk Management and Humanitarian Response, World Health Organization, Geneva, Switzerland
| | - Johan von Schreeb
- Centre for Research on Health Care in Disasters, Health System and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Brolin Ribacke KJ, Saulnier DD, Eriksson A, von Schreeb J. Effects of the West Africa Ebola Virus Disease on Health-Care Utilization - A Systematic Review. Front Public Health 2016; 4:222. [PMID: 27777926 PMCID: PMC5056406 DOI: 10.3389/fpubh.2016.00222] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022] Open
Abstract
Significant efforts were invested in halting the recent Ebola virus disease outbreak in West Africa. Now, studies are emerging on the magnitude of the indirect health effects of the outbreak in the affected countries, and the aim of this study is to systematically assess the results of these publications. The methodology for this review adhered to the Prisma guidelines for systematic reviews. A total of 3354 articles were identified for screening, and while 117 articles were read in full, 22 studies were included in the final review. Utilization of maternal health services decreased during the outbreak. The number of cesarean sections and facility-based deliveries declined and followed a similar pattern in Guinea, Liberia, and Sierra Leone. A change in the utilization of antenatal and postnatal care and family planning services was also seen, as well as a drop in utilization of children’s health services, especially in terms of vaccination coverage. In addition, the uptake of HIV/AIDS and malaria services, general hospital admissions, and major surgeries decreased as well. Interestingly, it was the uptake of health service provision by the population that decreased, rather than the volume of health service provision. Estimates from the various studies suggest that non-Ebola morbidity and mortality have increased after the onset of the outbreak in Sierra Leone, Guinea, and Liberia. Reproductive, maternal, and child health services were especially affected, and the decrease in facility deliveries, cesarean sections, and volume of antenatal and postnatal care visits might have significant adverse effects on maternal and newborn health. The impact of Ebola stretches far beyond Ebola cases and deaths. This review indicates that indirect health service effects are substantial and both short and long term, and highlights the importance of support to maintain routine health service delivery and the maintenance of vaccination programs as well as preventative and curative malaria programs, both in general but especially in times of a disaster.
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Affiliation(s)
- Kim J Brolin Ribacke
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet , Stockholm , Sweden
| | - Dell D Saulnier
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet , Stockholm , Sweden
| | - Anneli Eriksson
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet , Stockholm , Sweden
| | - Johan von Schreeb
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet , Stockholm , Sweden
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Roy N, Gerdin M, Ghosh SN, Gupta A, Saha ML, Khajanchi M, Dharap SB, Mohd Ismail D, von Schreeb J. The Chennai consensus on in-hospital trauma care for India. J Emerg Trauma Shock 2016; 9:90-2. [PMID: 27162445 PMCID: PMC4843576 DOI: 10.4103/0974-2700.179460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nobhojit Roy
- Department of General Surgery, BARC Hospital, Mumbai, India; Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, Europe E-mail:
| | - Martin Gerdin
- Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, Europe E-mail:
| | - Samarendra Nath Ghosh
- Department of Neurosurgery, Bangur Institute of Neurosciences and IPGMER, SSKM Hospital, Kolkata, West Bengal, India
| | - Amit Gupta
- All India Institute of Medical Sciences, JPN Apex Trauma Centre, New Delhi, India
| | - Makhan Lal Saha
- Department of General Surgery, Institute of PG Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
| | - Monty Khajanchi
- Department of General Surgery, King Edward Memorial Hospital, Mumbai, India
| | - Satish B Dharap
- Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Deen Mohd Ismail
- Department of Orthopaedics, Rajiv Gandhi General Hospital and Madras Medical College, Chennai, Tamil Nadu, India
| | - Johan von Schreeb
- Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, Europe E-mail:
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Roy N, Gerdin M, Ghosh S, Gupta A, Kumar V, Khajanchi M, Schneider EB, Gruen R, Tomson G, von Schreeb J. 30-Day In-hospital Trauma Mortality in Four Urban University Hospitals Using an Indian Trauma Registry. World J Surg 2016; 40:1299-307. [DOI: 10.1007/s00268-016-3452-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gerdin M, Roy N, Khajanchi M, Kumar V, Felländer-Tsai L, Petzold M, Tomson G, von Schreeb J. Validation of a novel prediction model for early mortality in adult trauma patients in three public university hospitals in urban India. BMC Emerg Med 2016; 16:15. [PMID: 26905408 PMCID: PMC4763419 DOI: 10.1186/s12873-016-0079-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/16/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Trauma is one of the top threats to population health globally. Several prediction models have been developed to supplement clinical judgment in trauma care. Whereas most models have been developed in high-income countries the majority of trauma deaths occur in low- and middle-income countries. Almost 20 % of all global trauma deaths occur in India alone. The aim of this study was to validate a basic clinical prediction model for use in urban Indian university hospitals, and to compare it with existing models for use in early trauma care. METHODS We conducted a prospective cohort study in three hospitals across urban India. The model we aimed to validate included systolic blood pressure and Glasgow coma scale. We compared this model with three additional models, which all have been designed for use in bedside trauma care, and two single variable models based on systolic blood pressure and Glasgow coma scale respectively. The outcome was early mortality, defined as death within 24 h from the time when vital signs were first measured. We compared the models in terms of discrimination, calibration, and potential clinical consequences using decision curve analysis. Multiple imputation was used to handle missing data. Performance measures are reported using their median and inter-quartile range (IQR) across imputed datasets. RESULTS We analysed 4440 patients, out of which 1629 were used as an updating sample and 2811 as a validation sample. We found no evidence that the basic model that included only systolic blood pressure and Glasgow coma scale had worse discrimination or potential clinical consequences compared to the other models. A model that also included heart had better calibration. For the model with systolic blood pressure and Glasgow coma scale the discrimination in terms of area under the receiver operating characteristics curve was 0.846 (IQR 0.841-0.849). Calibration measured by estimating a calibration slope was 1.183 (IQR 1.168-1.202). Decision curve analysis revealed that using this model could potentially result in 45 fewer unnecessary surveys per 100 patients. CONCLUSIONS A basic clinical prediction model with only two parameters may prove to be a feasible alternative to more complex models in contexts such as the Indian public university hospitals studied here. We present a colour-coded chart to further simplify the decision making in early trauma care.
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Affiliation(s)
- Martin Gerdin
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
| | - Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
- Tata Institute of Social Sciences, School of Habitat, Mumbai, India.
| | - Monty Khajanchi
- General Surgery, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India.
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.
| | - Li Felländer-Tsai
- Department of Clinical Science Intervention and Technology, Division of Orthopedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden.
| | - Max Petzold
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
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Gerdin M, Roy N, Felländer-Tsai L, Tomson G, von Schreeb J, Petzold M, Gupta A, Jhakal A, Basak D, Mohamed Ismail D, Yabo D, Jegadeesan K, Kamble J, Saha ML, Nitnaware M, Khajanchi M, Jothi R, Ghosh SN, Bhoi S, Mahindrakar S, Dharap S, Rao S, Kamal V, Kumar V, Tirlotkar S. Traumatic transfers: calibration is adversely affected when prediction models are transferred between trauma care contexts in India and the United States. J Clin Epidemiol 2016; 74:177-86. [PMID: 26775627 DOI: 10.1016/j.jclinepi.2016.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/13/2015] [Accepted: 01/04/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We evaluated the transferability of prediction models between trauma care contexts in India and the United States and explored updating methods to adjust such models for new contexts. STUDY DESIGN AND SETTINGS Using a combination of prospective cohort and registry data from 3,728 patients of Towards Improved Trauma Care Outcomes in India (TITCO) and from 18,756 patients of the US National Trauma Data Bank (NTDB), we derived models in one context and validated them in the other, assessing them for discrimination and calibration using systolic blood pressure, heart rate, and Glasgow coma scale as candidate predictors. RESULTS Early mortality was 8% in the TITCO and 1-2% in the NTDB samples. Both models discriminated well, but the TITCO model overestimated the risk of mortality in NTDB patients, and the NTDB model underestimated the risk in TITCO patients. CONCLUSION Transferability was good in terms of discrimination but poor in terms of calibration. It was possible to improve this miscalibration by updating the models' intercept. This updating method could be used in samples with as few as 25 events.
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Affiliation(s)
- Martin Gerdin
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, Maharashtra 400085, India; School of Habitat, Tata Institute of Social Sciences, Chembur, Mumbai, Maharashtra 400088, India
| | - Li Felländer-Tsai
- Division of Orthopedics and Biotechnology, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Alfred Nobels allé 8, SE-141 52 Huddinge, Sweden
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Max Petzold
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, PO Box 414, SE-405 30 Gothenburg, Sweden; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Johannesburg 2193, South Africa
| | | | - Amit Gupta
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Ashish Jhakal
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Debojit Basak
- Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Deen Mohamed Ismail
- Department of Orthopedics, Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Dusu Yabo
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - K Jegadeesan
- Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Jyoti Kamble
- King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Makhan Lal Saha
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Mangesh Nitnaware
- Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Monty Khajanchi
- General Surgery, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Ranganathan Jothi
- Department of Neurosurgery, Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Samarendra Nath Ghosh
- Department of Neurosurgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Sanjeev Bhoi
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Santosh Mahindrakar
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Satish Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Shilpa Rao
- Department of Surgery, King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Veera Kamal
- Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Santosh Tirlotkar
- School of Habitat, Tata Institute of Social Sciences, Chembur, Mumbai, Maharashtra 400088, India
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Eriksson A, Gerdin M, Garfield R, Tylleskar T, von Schreeb J. How Bad Is It? Usefulness of the "7eed Model" for Scoring Severity and Level of Need in Complex Emergencies. PLoS Curr 2016; 8. [PMID: 28503357 PMCID: PMC5419815 DOI: 10.1371/currents.dis.d59e0fa39887031e1c3763851a6e5c2a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Humanitarian assistance is designated to save lives and alleviate suffering among people affected by disasters. In 2014, close to 25 billion USD was allocated to humanitarian assistance, more than 80% of it from governmental donors and EU institutions. Most of these funds are devoted to Complex Emergencies (CE). It is widely accepted that the needs of the affected population should be the main determinant for resource allocations of humanitarian funding. However, to date no common, systematic, and transparent system for needs-based allocations exists. In an earlier paper, an easy-to-use model, “the 7eed model”, based on readily available indicators that distinguished between levels of severity among disaster-affected countries was presented. The aim of this paper is to assess the usefulness of the 7eed model in regards to 1) data availability, 2) variations between CE effected countries and sensitivity to change over time, and 3) reliability in capturing severity and levels of need. Method: We applied the 7eed model to 25 countries with CE using data from 2013 to 2015. Data availability and indicator value variations were assessed using heat maps. To calculate a severity score and a needs score, we applied a standardised mathematical formula, based on the UTSTEIN template. We assessed the model for reliability on previous CEs with a “known” outcome in terms of excess mortality. Results: Most of the required data was available for nearly all countries and indicators, and availability increased over time. The 7eed model was able to discriminate between levels of severity and needs among countries. Comparison with historical complex disasters showed a correlation between excess mortality and severity score. Conclusion: Our study indicates that the proposed 7eed model can serve as a useful tool for setting funding levels for humanitarian assistance according to measurable levels of need. The 7eed model provides national level information but does not take into account local variations or specific contextual factors.
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Affiliation(s)
- Anneli Eriksson
- Department of Public Health Sciences, Health System and Policy, Karolinska Institute, Stockholm, Sweden
| | - Martin Gerdin
- Department of Public Health Sciences, Health System and Policy, Karolinska Institute, Stockholm, Sweden
| | | | | | - Johan von Schreeb
- Department of Public Health Sciences, Health System and Policy, Karolinska Institute, Stockholm, Sweden
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Gerdin M, Roy N, Khajanchi M, Kumar V, Dharap S, Felländer-Tsai L, Petzold M, Bhoi S, Saha ML, von Schreeb J. Correction: Predicting Early Mortality in Adult Trauma Patients Admitted to Three Public University Hospitals in Urban India: A Prospective Multicentre Cohort Study. PLoS One 2015; 10:e0144886. [PMID: 26673911 PMCID: PMC4684508 DOI: 10.1371/journal.pone.0144886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Eriksson A, Ohlsén YK, Garfield R, von Schreeb J. Who Is Worst Off? Developing a Severity-scoring Model of Complex Emergency Affected Countries in Order to Ensure Needs Based Funding. PLoS Curr 2015; 7:ecurrents.dis.8e7fb95c7df19c5a9ba56584d6aa2c59. [PMID: 26635996 PMCID: PMC4648580 DOI: 10.1371/currents.dis.8e7fb95c7df19c5a9ba56584d6aa2c59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Disasters affect close to 400 million people each year. Complex Emergencies (CE) are a category of disaster that affects nearly half of the 400 million and often last for several years. To support the people affected by CE, humanitarian assistance is provided with the aim of saving lives and alleviating suffering. It is widely agreed that funding for this assistance should be needs-based. However, to date, there is no model or set of indicators that quantify and compare needs from one CE to another. In an effort to support needs-based and transparent funding of humanitarian assistance, the aim of this study is to develop a model that distinguishes between levels of severity among countries affected by CE. METHODS In this study, severity serves as a predictor for level of need. The study focuses on two components of severity: vulnerability and exposure. In a literature and Internet search we identified indicators that characterize vulnerability and exposure to CE. Among the more than 100 indicators identified, a core set of six was selected in an expert ratings exercise. Selection was made based on indicator availability and their ability to characterize preexisting or underlying vulnerabilities (four indicators) or to quantify exposure to a CE (two indicators). CE from 50 countries were then scored using a 3-tiered score (Low-Moderate, High, Critical). RESULTS The developed model builds on the logic of the Utstein template. It scores severity based on the readily available value of four vulnerability and four exposure indicators. These are 1) GNI per capita, PPP, 2) Under-five mortality rate, per 1 000 live births, 3) Adult literacy rate, % of people ages 15 and above, 4) Underweight, % of population under 5 years, and 5) number of persons and proportion of population affected, and 6) number of uprooted persons and proportion of population uprooted. CONCLUSION The model can be used to derive support for transparent, needs-based funding of humanitarian assistance. Further research is needed to determine its validity, the robustness of indicators and to what extent levels of scoring relate to CE outcome.
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Affiliation(s)
- Anneli Eriksson
- Public Health Science, Centre for Research on HealthCare in Disasters, Health Systems and Policy Research Group, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Johan von Schreeb
- Department of Public Health Sciences, Health System and Policy, Karolinska Institute, Stockholm, Sweden
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Bjerring AW, Lier ME, Rød SM, Vestby PF, Melf K, Endreseth BH, Salvesen Ø, von Schreeb J, Wibe A, Kamara TB, Bolkan HA. Assessing cesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed in Sierra Leone in 2012. Surgery 2015; 157:836-42. [PMID: 25934020 DOI: 10.1016/j.surg.2014.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/08/2014] [Accepted: 12/18/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND The traditional tools to assess surgical capacity in low-income countries require significant amounts of time and resources, and have thus not been utilized systematically in this context. Proxy indicators have been suggested as a simpler tool to estimate surgical volume. The aim of this study was to assess caesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed per capita in a given region of sub-Saharan Africa. METHODS Surgical data was compiled from 58 health institutions (96.7%) that performed major surgery in Sierra Leone in 2012. In total, 24,152 operative procedures were included in the study. Validity of proxy indicators was tested by logistic regression analyses with the rate of caesarean sections compared with total operations (%CS), hernia repairs (%HR) or both (%CS&HR) as dependent variables and the operations per 100,000 capita as the covariate. RESULTS There was significant correlation for each of the proxy indicators, with the estimated odds ratio for %CS being 0.675 (95% CI, 0.520-0.876; P < .01), the estimated odds ratio for %HR being 0.822 (95% CI, 0.688-0.983; P < .05), and the estimated odds ratio for %CS&HR being 0.838 (95% CI, 0.731-0.962; P < .05). CONCLUSION The unmet need for surgical services in a region of sub-Saharan Africa can be estimated by using any of the 3 proxy indicators. However, it seems that %CS is more sensitive for small changes in operations per 100,000 capita, compared with the %HR. There is no obvious added benefit for using the combined proxy indicator.
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Affiliation(s)
- Anders W Bjerring
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Marius E Lier
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Malene Rød
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pia Fiskaa Vestby
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Klaus Melf
- The State Medical Department, Troms, Norway
| | - Birger H Endreseth
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Øyvind Salvesen
- Institute of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Arne Wibe
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thaim Buim Kamara
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Rydberg H, Marrone G, Strömdahl S, von Schreeb J. A Promising Tool to Assess Long Term Public Health Effects of Natural Disasters: Combining Routine Health Survey Data and Geographic Information Systems to Assess Stunting after the 2001 Earthquake in Peru. PLoS One 2015; 10:e0130889. [PMID: 26090999 PMCID: PMC4475001 DOI: 10.1371/journal.pone.0130889] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 05/26/2015] [Indexed: 11/21/2022] Open
Abstract
Background Research on long-term health effects of earthquakes is scarce, especially in low- and middle-income countries, which are disproportionately affected by disasters. To date, progress in this area has been hampered by the lack of tools to accurately measure these effects. Here, we explored whether long-term public health effects of earthquakes can be assessed using a combination of readily available data sources on public health and geographic distribution of seismic activity. Methods We used childhood stunting as a proxy for public health effects. Data on stunting were attained from Demographic and Health Surveys. Earthquake data were obtained from U.S. Geological Survey’s ShakeMaps, geographic information system-based maps that divide earthquake affected areas into different shaking intensity zones. We combined these two data sources to categorize the surveyed children into different earthquake exposure groups, based on how much their area of residence was affected by the earthquake. We assessed the feasibility of the approach using a real earthquake case – an 8.4 magnitude earthquake that hit southern Peru in 2001. Results and conclusions Our results indicate that the combination of health survey data and disaster data may offer a readily accessible and accurate method for determining the long-term public health consequences of a natural disaster. Our work allowed us to make pre- and post- earthquake comparisons of stunting, an important indicator of the well-being of a society, as well as comparisons between populations with different levels of exposure to the earthquake. Furthermore, the detailed GIS based data provided a precise and objective definition of earthquake exposure. Our approach should be considered in future public health and disaster research exploring the long-term effects of earthquakes and potentially other natural disasters.
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Affiliation(s)
- Henny Rydberg
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Gaetano Marrone
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Strömdahl
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Abstract
BACKGROUND Foreign medical teams (FMT) are international medical teams sent to provide assistance in the aftermath of a disaster. In the last decade, there has been an increase in FMTs deployed following disasters. Despite the potential benefit FMTs might have in substituting the collapsed health care and caring for excess morbidity after large-scale disasters, several studies have demonstrated the difficulties in determining the quality of the response, mainly due to lack of reliable data. In order to bridge the knowledge gap on functioning of FMTs, the aim of this study is to assess the timing, capacities and activities of FMTs deployed to the Philippines after typhoon Haiyan. METHODS This is a retrospective, descriptive study. Data on characteristics of FMTs present in the Philippines after typhoon Haiyan was provided by the World Health Organization (WHO) and compiled into a single database. Additional data was collected through a web survey, email correspondence and internet searches. RESULTS A total of 108 FMTs were identified as arriving to the Philippines within the first month following typhoon Haiyan. None of these were operational in the affected areas within the first 72 h and the average time between arriving and being on-site operational was three days. Of the 108 FMTs, 70% were FMT type 1, 11% were FMT type 2 and 3% were FMT type 3. 16% of FMTs had unknown status. The total number of staff within all these FMTs were 2121, of which 210 were medical doctors, 250 nurses and 6 midwifes. Compared to previous sudden onset disasters, this study found no improvement in data sharing.
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Affiliation(s)
- Kim Brolin
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Omar Hawajri
- Centre for Research on Healthcare in Disasters, Health System and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Health system and policy, Karolinska Institute, Stockholm, Sweden
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Bolkan HA, von Schreeb J, Samai MM, Bash-Taqi DA, Kamara TB, Salvesen Ø, Ystgaard B, Wibe A. Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey. Lancet 2015; 385 Suppl 2:S19. [PMID: 26313065 DOI: 10.1016/s0140-6736(15)60814-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical services are essential components of health-care systems. Monitoring of surgical activity is important, but resource demanding. Simpler tools to estimate surgical volume, particularly in low-income countries, are needed. Previous work hypothesises that the relative frequency of caesarean sections, expressed as a proportion of total operative procedures, could serve as a proxy measure of surgical capacity. We aimed to establish nationwide and district-wide rates of surgery and caesarean sections, and to explore correlations between districts rates for caesarean sections and corresponding rates for total volume of surgery in Sierra Leone in 2012. METHODS A nationwide, exhaustive, retrospective, facility-based study of all surgical providers and surgical procedures was performed in Sierra Leone. Between Jan 14, and May 20, 2013, four teams of 12 medical students collected data on the characteristics of the institutions and of the surgeries performed in 2012. Data were retrieved from operation, anaesthesia, and delivery logbooks. FINDINGS Of 60 facilities performing surgery, complete annual data for 2012 was collected from 58 (97%) institutions. 24 152 surgical procedures identified, gave a national rate of 400 surgeries per 100 000 inhabitants (district range 32-909 per 100 000 [IQR 95-502 per 100 000]). National caesarean section rate was 2·1% (district range 0·3-4·0% [IQR 0·8-2·1]). District caesarean sections rate significantly correlated with the rate of total surgical procedures per 100 000 population (p<0·01). With known caesarean section rate, total volume of surgeries per 100 000 can be calculated with the equation: -9·8 + 4·68 × caesarean sections per 100 000. INTERPRETATION The close correlation between rate of caesarean section and population rates of total volume of surgery at district level in Sierra Leone indicates that rate of caesarean section should be further explored as a proxy indicator for overall surgical volume in low performing settings. By collecting data from three sources, missing procedures was considered less likely. FUNDING Norwegian University of Science and Technology.
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Affiliation(s)
- Håkon A Bolkan
- CapaCare, Trondheim, Norway; Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Johan von Schreeb
- Department of Public Health Sciences, Health system and Policy, Karolinska Institute, Stockholm, Sweden
| | - Mohamed M Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | | | - Thaim B Kamara
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Øyvind Salvesen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Brynjulf Ystgaard
- CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Arne Wibe
- CapaCare, Trondheim, Norway; Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Bjerring AW, Lier ME, Roed SM, Vestby PF, Endreseth BH, Salvesen Ø, von Schreeb J, Wibe A, Kamara TB, Bolkan HA. Assessment of caesarean section and inguinal hernia repair as proxy indicators of total number of surgeries. Lancet 2015; 385 Suppl 2:S21. [PMID: 26313068 DOI: 10.1016/s0140-6736(15)60816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The traditional instruments used to assess surgical capacity in low-income countries require substantial amounts of time and resources, and have thus not been systematically used in this context. Proxy indicators have been suggested as a simpler method to estimate surgical volume. The aim of this study was to assess caesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed per capita in a given region in Sierra Leone in sub-Saharan Africa. METHODS Avaliable handwritten surgical data were compiled from 58 (96·7%) health institutions that performed WHO defined major surgery in Sierra Leone in 2012 (from Jan 1, to Dec 31). 24 152 surgical procedures were included in the study. Validity of proxy indicators was tested by logistic regression analyses with the rate of caesarean sections compared with total operations (% CS), hernia repairs (% HR), or both (% CS plus HR) as dependent variables and the operations per 100 000 capita as the covariate. FINDINGS The number of operations per 100 000 capita for the 13 districts of Sierra Leone varied from 909 in the urban Western District to 32 in the rural district of Moyamba. There was a significant negative correlation between each of the proxy indicators and the number of operations per 100 000 capita. For changes in the operations per 100 000 capita of 100, we obtained an estimated odds ratio for the % CS proxy indicator of 0·675 (95% CI 0·520-0·876; p<0·01), % HR being 0·822 (0·688-0·983; p<0·05), and for % CS plus HR being 0·838 (0·731-0·962; p<0·05). INTERPRETATION The unmet need for surgical services in Sierra Leone can be estimated by either of the three proxy indicators. However, it seems that % CS is more sensitive to small changes in operations per 100 000 capita compared with the % HR. There is no obvious added benefit of use of the combined proxy indicator. Although this study shows that proxy indicators are a promising method to evaluate surgical activity, this is a cross-sectional study and can thus only show correlation. Longitudinal studies would strengthen these findings. FUNDING Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway, and CapaCare.
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Affiliation(s)
| | - Marius E Lier
- Vestre Viken HF, Drammen Sykehus, Welhavens Gate 1, Drammen, Norway
| | - Siri M Roed
- Vestre Viken HF, Drammen Sykehus, Welhavens Gate 1, Drammen, Norway
| | | | | | | | | | - Arne Wibe
- NTNU, Høgskoleringen 1, Trondheim, Norway
| | - T B Kamara
- University of Sierra Leone, Freetown, Sierra Leone
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Bolkan HA, Hagander L, von Schreeb J, Bash-Taqi D, Kamara TB, Salvesen Ø, Wibe A. Who is performing surgery in low-income settings: a countrywide inventory of the surgical workforce distribution and scope of practice in Sierra Leone. Lancet 2015; 385 Suppl 2:S44. [PMID: 26313093 DOI: 10.1016/s0140-6736(15)60839-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Scope of practice and in-country distribution of surgical providers in low-income countries remains insufficiently described. Through a nationwide comprehensive inventory of surgical procedures and providers in Sierra Leone, we aimed to present the geographic distribution, medical training, and productivity of surgical providers in a low-income country. METHODS Following exhaustive sampling, a total of 60 facilities performing surgery in Sierra Leone 2012 was identified. Annual surgical activity was obtained from 58 (97%) facilities, while institution and workforce data was retrieved from 56 (93%). Characteristics of patients, facilities, procedures, and surgical providers were collected retrospectively from operation theatre logbooks and by interviewing facility directors. FINDINGS In 2012, 164 full-time positions of surgical providers performed 24 152 surgeries in Sierra Leone. Of those, 58 (35·6%) were consultant surgeons, obstetricians, or gynaecologists (population density: 0·97 per 100 000 inhabitants). 86 (52·9%) were medical doctors (1·42 per 100 000), whereas the 14 (8·4%) associate clinicians and six (3·8%) nurses represented a density of 0·23 and 0·10 per 100 000 inhabitants, respectively. Almost half of the districts (46%), representing more than 2 million people (34% of the population), had less than one fully trained consultant. Density of consultant and medical doctors were 27 and six times higher in urban areas compared with rural areas, respectively. The surgical providers performed 144 surgeries per position in 2012 (2·8 surgeries per week). Nurses performed 6·6% and associate clinicians 6·8% of the total national volume of surgeries. Districts with lower surgical rates had a significant lower productivity per surgical provider (Rho=0·650, p=0·022). We noted a significant positive correlation between the facility volume of surgery and the productivity of each surgical provider (p<0·001). INTERPRETATION Surgical providers with higher qualifications seem to have a preference for urban settlements. Increasing the output of the existing workforce can contribute to expansion of surgical services. FUNDING Norwegian University of Science and Technology.
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Affiliation(s)
- Håkon A Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Lars Hagander
- Department of Clinical Sciences, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Children's Hospital, Lund, Sweden
| | - Johan von Schreeb
- Health System and Policy Research Group, Karolinska Institutet, Stockholm, Sweden
| | | | - Thaim B Kamara
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Øyvind Salvesen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Wibe
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Frielingsdorf H, Bushayija E, Nordström A, Nyberg F, Rosling H, von Schreeb J, Peterson SS, Nilsson K, Nordenstedt H. [Challenges and opportunities for the next generation in global health]. Lakartidningen 2014; 111:2012-2013. [PMID: 25650454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Gerdin M, Chataigner P, Tax L, Kubai A, von Schreeb J. Does need matter? Needs assessments and decision-making among major humanitarian health agencies. Disasters 2014; 38:451-464. [PMID: 24905705 DOI: 10.1111/disa.12065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Disasters of physical origin, including earthquakes, floods, landslides, tidal waves, tropical storms, tsunamis, and volcanic eruptions, have affected millions of people globally over the past 100 years. Proportionately, there is far greater likelihood of being affected by such disasters in low-income countries than in high-income countries. Furthermore, low-income countries are in need of international assistance following disasters more often than high-income countries. The funding of international humanitarian assistance has increased from USD 12.9 billion in 2006 to an estimated USD 16.7 billion in 2010. The majority of this funding is channelled through humanitarian agencies and is supposed to be distributed based on the need of those affected, as assessed using needs assessments. Such needs assessments may be used to inform decisions internally, to influence others, to justify response decisions, and to obtain funding. Little is known about the quality of needs assessments in practical applications. Consequently, this paper reports on and analyses the views of operational decision-makers in major health-related humanitarian agencies on needs assessments.
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Affiliation(s)
- Martin Gerdin
- PhD student at the Centre for Research on Health Care in Disasters, Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Sweden
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Olin E, von Schreeb J. Funding based on needs? A study on the use of needs assessment data by a major humanitarian health assistance donor in its decisions to allocate funds. PLoS Curr 2014; 6. [PMID: 24894417 PMCID: PMC4032382 DOI: 10.1371/currents.dis.d05f908b179343c8b4705cf44c15dbe9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: International humanitarian assistance is essential for disaster-affected populations, particularly in resource scarce settings. To target such assistance, needs assessments are required. According to internationally endorsed principles, donor governments should provide funding for humanitarian assistance based on need.
Aim: The aim of this study is to explore a major donor’s use of needs assessment data in decision-making for allocations of funds for health-related humanitarian assistance contributions.
Setting: This is a case study of the Swedish International Development Cooperation Agency (Sida), a major and respected international donor of humanitarian assistance.
Methods: To explore Sida’s use of needs assessment data in practice for needs-based allocations, we reviewed all decision documents and assessment memoranda for humanitarian assistance contributions for 2012 using content analysis; this was followed by interviews with key personnel at Sida.
Results: Our document analysis found that needs assessment data was not systematically included in Sida’s assessment memoranda and decision documents. In the interviews, we observed various descriptions of the concept of needs assessments, the importance of contextual influences as well as previous collaborations with implementing humanitarian assistance organizations. Our findings indicate that policies guiding funding decisions on humanitarian assistance need to be matched with available needs assessment data and that terminologies and concepts have to be clearly defined.
Conclusion: Based on the document analysis and the interviews, it is unclear how well Sida used needs assessment data for decisions to allocate funds. However, although our observations show that needs assessments are seldom used in decision making, Sida’s use of needs assessments has improved compared to a previous study. To improve project funds allocations based on needs assessment data, it will be critical to develop distinct frameworks for allocation distributions based on needs assessment and clear definitions, measurements and interpretations of needs.
Key words: Needs assessment, humanitarian assistance, disasters, donor decision-making
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Affiliation(s)
- Emma Olin
- Global Health/IHCAR, Department of Public Health, Karolinska Institute, Stockholm, Sweden
| | - Johan von Schreeb
- Centre for research on health care in disasters, Department of Public Health, Karolinska Institute, Stockholm, Sweden
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