Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey.

INTRODUCTION: We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India. METHODS: A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant. RESULTS: Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas. CONCLUSIONS: Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

Community health workers to reduce unmet surgical needs in an urban slum in India: an implementation study.

BACKGROUND: The Surgical Accredited & Trained Healthcare Initiative (SATHI) project demonstrates how community healthcare workers (CHWs) with merely 8 y of formal schooling and training for a short period can reduce unmet surgical needs. METHODS: A pilot study was carried out in the slums of a metropolitan city in India to know the effectiveness of a SATHI in reducing the burden of unmet surgical needs. In total, 12 730 people from 3000 households were included in the study for a duration of 6 months. RESULTS: We found 10% surgical needs (n=293) out of which 57% had unmet surgical needs. Out of total surgical needs, about half of the needs were cataract and abdominal, followed by extremities and chest conditions. SATHIs were able to convert 99 patients (60%) from unmet to met needs, who underwent surgery/treatment. The conversion from unmet to met among all surgery needs was highest for abdominal conditions (29%) followed by cataracts (17%). CONCLUSIONS: SATHIs with short training can reduce the burden of unmet surgical needs. SATHIs were able to convert a significant proportion of unmet to met needs by trust building, facilitating access to healthcare and ensuring post-operative adherence. Scaling up could help in the achievement of equitable healthcare across India.

Reimagining diaspora diplomacy during the COVID-19 crisis in India.

Diasporas are organized groups motivated by common cultural, ideological, political and religious values and common concerns for their countries of origin. Diaspora diplomacy has gained prominence worldwide, particularly in India, spurred by harrowing images of deaths and devastation due to the COVID-19 pandemic. A new generation of diaspora professionals modeled as social entrepreneurs uses collaborative and non-profit models to establish relationships with their counterparts to facilitate medical services and research. Teleradiology and telepsychiatry facilitate communication between diaspora members and their counterparts. We propose a common telehealth platform to standardize advice given by the Indian diaspora in the Global North as protocols change rapidly in acute pandemics. Consideration should be given to the well-known digital divide in India and other low- and middle-income countries. We advocate for diaspora members to train themselves in the art of global health diplomacy, to promote transparency and accountability in the collection of funds and a mandatory provision of outcome measurement by independent monitors rather than through social media. In the long run, Indian-Americans should play an active role in strengthening the domain of public health, which has historically been neglected in India, by focusing on the country's long-term infrastructure needs. The lessons learned from various diaspora efforts should be independently evaluated and recorded as best practice for future pandemics and humanitarian crises.

Trust Deficit in Surgical Systems in an Urban Slum in India Under Universal Health Coverage: A Mixed Method Study.

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India. Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion. Results: Responses from the 2 groups for "the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting" scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree (p = 0.076). Results between 2 groups regarding "Patient perceptions of quality" did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed (p = 0.064). Similar observations were made in the in depth interviews and focus group. Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Unconditional cash transfer to reduce the burden of unmet surgical needs.

Recent years have seen scandals involving international humanitarian organizations. Short term surgical missions from high to low- and middle-income countries have been criticized as 'parachute' missions. There are significant surgical unmet needs in low- and middle-income countries. Universal health coverage has been underutilized in low- and middle-income countries for surgical conditions. We suggest a two-fold solution: first, restructuring of aid organizations by splitting them into smaller units to make them transparent and responsive to local needs. Secondly, unconditional cash transfer directly to beneficiaries giving them a choice to select physician and hospital for surgical treatment.

Could global surgery overcome a decline in surgical cases?

•There have been three distinct landmarks for the US surgical trainees leading to a decline in surgical volume and in open number of cases.•Global surgery experiences have been adopted to expose trainees to surgical problems not routinely seen in the Global North.•Global Surgery also exposes trainees to empathic and collaborative approaches.•Benefits of global surgery to compensate for the decline in volume, variety and open surgical cases need to be studied through an academic, ethical, and economic lens.•LMICs trainees could travel to HIC for research and clinical training in exchange for the skills and case volume that HIC trainees would obtain in LMICs.

Effectiveness of Health Promotion Curriculum in Enhancing Non-communicable Diseases Health Literacy in Indian Youth.

Background There is a theory-praxis gap related to health literacy interventions focused on non-communicable diseases (NCDs) among young people. We designed an NCD curriculum and investigated its' effect on health literacy in non-medical, non-nursing college students in India. We deliberately selected non-medical and non-nursing college students (age 17 to 22 years) as we hypothesized, they would have a minimum baseline knowledge of NCDs. Methods We initially carried out a pilot study on 85 students in a four-day-long workshop (32 teaching hours) using empirically developed health literacy instrument. We administered the curriculum to 120 randomly selected students in four colleges, while 50 students were assigned to the comparison group. The curriculum was given over four days for a total of 32 hours. Approval was sought to give four credits for completion of the course. Each lecture comprised didactics, followed by discussion, and skills testing of measuring blood pressure and blood sugar. Health literacy was measured using a specifically designed tool at baseline and endline. The difference in health literacy scores between the two time-points (timepoint 1: before delivering the curriculum, time-point 2: at the end of four days of training) was analyzed using the t-test. Multiple linear and Poisson regression models were used to account for covariates. Results The average difference between the intervention and the control group in baseline scores was 0.05% points (unpaired t-test statistics: -1.36, degrees of freedom 103.15, p>0.05). The same at endline was 20.59% points (unpaired t-test statistics: -11.31, degrees of freedom 138.14, p<0.001). The endline to baseline difference in health literacy scores was 18.54% points higher in the intervention group versus the control group (unpaired t-test statistics: -10.88, degrees of freedom 161.32, p<0.001). The difference-in-difference scores remained significant after accounting for college setting and baseline score (Multivariable linear regression model, ß: 19.62% points, p<0.001). None of the socio-economic characteristics were significantly associated with the difference in the difference scores, independent of the intervention effect. The proportion of participants scoring 40% or above on the health literacy measure at endline was significantly higher in the intervention versus the control group (p<0.001). Conclusions We provide empirical data to support the incorporation of NCDs as a credit course in college curricula in low- and middle-income countries. Our findings showed that a theory-driven skills-focused curriculum may be a tool for enhancing NCD health literacy in Indian youth from diverse academic and socio-economic backgrounds.

Global health diplomacy: Provision of specialist medical services in the Republic of Botswana.

Global Health Diplomacy (GHD) can be defined as the convergence between public health and international affairs. The following case report demonstrates the impact of "brain drain" on provision of specialist medical services in Botswana, a middle-income country in Southern Africa and how GHD is being used to address the challenge. Botswana's priorities include the attainment of Sustainable Development Goals (SDGs) by 2030 which are embedded within the Ministry of Health and Wellness (MOHW) strategy. MOHW strategies include access to health services, reduction in the cost of referral of specialist services, and strengthening primary health care (PHC), which is the vehicle for attaining Universal Health Coverage (UHC). Botswana has, in the past tried to bridge this gap through strategic partnerships with private institutions and bilateral treaties with other states such as the Republic of Cuba and the People's Republic of China. In the private sector, the Ministry has partnered with Indus Medical Group, and a range of private medical institutions both in-country and outside the country. However, challenges experienced with previous partnerships were that the objectives were more service-driven than capacity building, which proved to be unsustainable. The case report outlines the negotiation process between the Government of Botswana represented by MOHW, and St. Paul Medical Missions, a religion-based NGO from Egypt. It demonstrated the importance of all actors and countries being clear on their health priorities at the start of negotiations. GHD is a relatively new concept that can be explored by countries in forming durable partnerships.

Liver Function Enzymes are Potential Predictive Markers for Kidney Allograft Dysfunction.

INTRODUCTION: Biopsy of the allograft is the gold standard for assessing kidney allograft dysfunction. The aim of our pilot study was to identify serum biomarkers that could obviate the need for biopsy. MATERIALS AND METHODS: We conducted a study to identify the biomarkers in the serum from different groups of chronic kidney disease (CKD) patients and kidney transplanted patients vs. healthy individuals. The four groups (n=25 in each group) were as follows: 1) Patients with unstable kidney allograft transplants requiring biopsy for cause, 2) Patients with stable kidney allograft transplants, 3) Patients with CKD not on immunosuppressive therapy and, 4) healthy subjects. We measured the activity and level of serum alkaline phosphatase (ALP) and other liver enzymes (alanine transaminase (ALT) and aspartate transaminase (AST)) as potential serum biomarkers in acute allograft dysfunction. RESULTS: We found that ALP correlated with allograft biopsy findings, liver function, and clinical outcomes and possibly graft survival. Additionally, AST and ALT were higher in patients with graft rejection compared to non-rejected and stable kidney transplants. Moreover, the low Pearson correlations (r- values) between ALP level with age (r=0.179), gender, body mass index (r=0.236), creatinine (r=0.044) or estimated glomerular filtration rate (r=0.048) suggest that ALP may be an independent biomarker which is relatively unaffected by other individual-level variables. CONCLUSION: ALP may be a putative biomarker to predict kidney allograft function and rejection. Data also indicated that liver function plays an important role for the overall success of kidney transplantation.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study.

INTRODUCTION: We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India. METHODS: A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field. RESULTS: Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care. CONCLUSIONS AND RELEVANCE: Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

The burgeoning role of global health diplomacy to alleviate suffering of cancer patients in low- and middle-income countries.

The science of global health diplomacy (GHD) consists of cross-disciplinary, multistakeholder credentials comprised of national security, public health, international affairs, management, law, economics and trade policy. GHD is well placed to bring about better and improved multilateral stakeholder leverage and outcomes in the prevention and control of cancer. It is important to create an evidence base that provides clear and specific guidance for health practitioners in low- and middle-income countries (LMICs) through involvement of all stakeholders. GHD can assist LMICs to negotiate across multilateral stakeholders to integrate prevention, treatment and palliative care of cancer into their commercial and trade policies.

Teaching Human Rights in Surgical Curriculum.

The relatively new academic discipline of health and human rights builds upon international efforts to support universal human rights education. I propose that teaching of human rights, both in domestic and international situations, could be part of a structured curriculum along with medical ethics, professionalism, role-modeling, and mentoring for surgeons in training. I suggest a pilot course of human rights be taught to global and humanitarian surgeons as an initial step before widespread inclusion for all surgeons.