Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature.

Task sharing, the involvement of non-specialists (non-physician clinicians or non-specialist physicians) in performing tasks originally reserved for surgeons and anesthesiologists, can be a potent strategy in bridging the vast human resource gap in surgery and anesthesia and bringing needed surgical care to the district level especially in low-resource countries. Although a common practice, the idea of assigning advanced tasks to less-specialized workers remains a subject of controversy. In order to optimize its benefits, it is helpful to understand the current task sharing landscape, its challenges, and its promise. We performed a literature review of PubMed, EMBASE, and gray literature sources for articles published between January 1, 1996, and August 1, 2016, written in English, with a focus on task sharing in surgery or anesthesia in low-resource countries. Gray literature sources are defined as articles produced outside of a peer-reviewed journal. We sought data on the nature and forms of task sharing (non-specialist cadres involved, surgical/anesthesia procedures shared, approaches to training and supervision, and regulatory and other efforts to create a supportive environment), impact of task sharing on delivery of surgical services (effect on access, acceptability, cost, safety, and quality), and challenges to successful implementation. We identified 40 published articles describing task sharing in surgery and anesthesia in 39 low-resource countries in Africa and Asia. All countries had a cadre of non-specialists providing anesthesia services, while 13 had cadres providing surgical services. Six countries had non-specialists performing major procedures, including Cesarean sections and open abdominal surgeries. While most cadres were recognized by their governments as service providers, very few had scopes of practice that included task sharing of surgery or anesthesia. Key challenges to effective task sharing include specialists' concern about safety, weak training strategies, poor or unclear career pathways, regulatory constraints, and service underutilization. Concrete recommendations are offered.

Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

BACKGROUND: The World Health Organisation recommends that services accompany wheelchair distribution. This study examined the relationship of wheelchair service provision in Kenya and the Philippines and wheelchair-use-related outcomes. METHOD: We surveyed 852 adult basic manual wheelchair users. Participants who had received services and those who had not were sought in equal numbers from wheelchair-distribution entities. Outcomes assessed were daily wheelchair use, falls, unassisted outdoor use and performance of activities of daily living (ADL). Descriptive, bivariate and multivariable regression model results are presented. RESULTS: Conditions that led to the need for a basic wheelchair were mainly spinal cord injury, polio/post-polio, and congenital conditions. Most Kenyans reported high daily wheelchair use (60%) and ADL performance (80%), while these practices were less frequent in the Philippine sample (42% and 74%, respectively). Having the wheelchair fit assessed while the user propelled the wheelchair was associated with greater odds of high ADL performance in Kenya (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1) and the Philippines (OR 2.8, 95% CI 1.8, 4.5). Wheelchair-related training was associated with high ADL performance in Kenya (OR 3.2, 95% CI 1.3, 8.4). In the Philippines, training was associated with greater odds of high versus no daily wheelchair use but also odds of serious versus no falls (OR 2.5, 95% CI 1.4, 4.5). CONCLUSION: Select services that were associated with some better wheelchair use outcomes and should be emphasised in service delivery. Service providers should be aware that increased mobility may lead to serious falls.

Use of a design challenge to develop postural support devices for intermediate wheelchair users.

The provision of an appropriate wheelchair, one that provides proper fit and postural support, promotes wheelchair users' physical health and quality of life. Many wheelchair users have postural difficulties, requiring supplemental postural support devices for added trunk support. However, in many low- and middle-income settings, postural support devices are inaccessible, inappropriate or unaffordable. This article describes the use of the design challenge model, informed by a design thinking approach, to catalyse the development of an affordable, simple and robust postural support device for low- and middle-income countries. The article also illustrates how not-for-profit organisations can utilise design thinking and, in particular, the design challenge model to successfully support the development of innovative solutions to product or process challenges.

Perspectives of basic wheelchair users on improving their access to wheelchair services in Kenya and Philippines: a qualitative study.

BACKGROUND: The United Nations has called for countries to improve access to mobility devices when needed. The World Health Organization has published guidelines on the provision of manual wheelchairs in less-resourced settings. Yet little is known about the extent to which appropriate wheelchairs are available and provided according to international guidelines. This study's purpose was to describe wheelchair users' experiences receiving services and acquiring wheelchair skills in urban and peri-urban areas of Kenya and the Philippines. METHODS: Local researchers in Nairobi and Manila interviewed 48 adult basic wheelchair users, with even distribution of those who had and had not received wheelchair services along with their wheelchair. Recordings were transcribed in the local language and translated into English. The study team coded transcripts for predetermined and emergent themes, using Atlas-ti software. A qualitative content analysis approach was taken with the WHO service delivery process as an organizing framework. RESULTS: Wheelchair users frequently described past experiences with ill-fitting wheelchairs and little formal training to use wheelchairs effectively. Through exposure to multiple wheelchairs and self-advocacy, they learned to select wheelchairs suitable for their needs. Maintenance and repair services were often in short supply. Participants attributed shorter duration of wheelchair use to lack of repair. Peer support networks emerged as an important source of knowledge, resources and emotional support. Most participants acknowledged that they received wheelchairs that would have been difficult or impossible for them to pay for, and despite challenges, they were grateful to have some means of mobility. Four themes emerged as critical for understanding the implementation of wheelchair services: barriers in the physical environment, the need for having multiple chairs to improve access, perceived social stigma, and the importance of peer support. CONCLUSIONS: Interventions are needed to provide wheelchairs services efficiently, at scale, in an environment facilitating physical access and peer support, and reduced social stigma. TRIAL REGISTRATION: Not applicable since this was a descriptive study.

Erratum: Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

[This corrects the article DOI: 10.4102/ajod.v6i0.318.].

Intimate partner violence associated with poor health outcomes in U.S. South Asian women.

To assess the associations between Intimate Partner Violence (IPV) victimization and health outcomes of South Asian women in Greater Boston. To explore the nature of the health experiences of victimized women in this population. Cross-sectional surveys with a community-based sample of women in relationships with males (n = 208) assessed demographics, IPV history, and health. In-depth interviews were conducted with a separate sample of women with a history of IPV (n = 23). Quantitative data were assessed by logistic regression, qualitative data by a grounded theory approach. Twenty-one percent of the quantitative sample reported IPV in the current relationship. Abused women were significantly more likely than those with no history of IPV in their current relationship to report poor physical health (95% CI = 1.3-12.0), depression (95% CI = 1.8-9.3), anxiety (95% CI = 1.3-6.4), and suicidal ideation (95% CI = 1.9-25.1). Qualitative subjects described how victimization resulted in injury and chronic health concerns and how IPV-induced depression and anxiety affected their sleep, appetite, energy, and wellbeing. Experiences of IPV are related to increased poor health among South Asian women. This elevated risk demands intervention. Healthcare providers should be trained to screen and refer South Asian patients for partner violence.