Research Articles (Centre for Global Surgery)


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    The collateral damage of the COVID-19 pandemic on surgical health care in sub-Saharan Africa
    (Edinburgh University Global Health Society, 2020-12) Chu, Kathryn; Reddy, Ché L; Makasa, Emmanuel
    The COVID-19 pandemic has swept across the globe at an unprecedented pace. The first COVID-19 case arrived in Sub-Saharan Africa (SSA) on February 28, 2020, and there are over 600 000 cases spread across the continent [1]. The World Health Organisation has predicted up to a quarter of a billion infections on the continent [2]. In preparation, SSA countries have sharply downscaled non-COVID-19 health services, including emergency and essential surgical health care (EESC). However, surgical conditions contribute up to a third of the global burden of disease [3].
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    Unmet need for hypercholesterolemia care in 35 low- and middle-income countries : a cross-sectional study of nationally representative surveys
    (Public Library of Science, 2021-10) Marcus, Maja E.; Ebert, Cara; Geldsetzer, Pascal; Theilmann, Michaela; Bicaba, Brice Wilfried; Andall-Brereton, Glennis; Bovet, Pascal; Farzadfar, Farshad; Gurung, Mongal Singh; Houehanou, Corine; Malekpour, Mohammad-Reza; Martins, Joao S.; Moghaddam, Sahar Saeedi; Mohammadi, Esmaeil; Norov, Bolormaa; Quesnel-Crooks, Sarah; Wong-McClure, Roy; Davies, Justine I.; Hlatky, Mark A.; Atun, Rifat; Barnighausen, Till W.; Jaacks, Lindsay M.; Manne-Goehler, Jennifer; Vollmer, Sebastian
    Background: As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. Methods and findings: We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. Conclusions: Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs—calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.
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    Establishing a South African national framework for COVID-19 surgical prioritisation
    (Health & Medical Publishing Group, 2021-03-23) Chu, K. M.; Owolabi, E. O.; Smith, M.; Hardcastle, T. C.; Maswime, S.; Geduld, H.; Gopalan, P. D.; Marco, J.; Mendelson, M.; Biccard, B. M.; Cairncross, L.
    Background. Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. Objectives. To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculator for operative care. Methods. The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. Results. A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. Conclusions. This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.
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    A geospatial analysis of two-hour surgical access to district hospitals in South Africa
    (BMC (part of Springer Nature), 2020-08-13) Chu, Kathryn M.; Dell, Angela J.; Moultrie, Harry; Day, Candy; Naidoo, Megan; Van Straten, Stephanie; Rayne, Sarah
    Background: In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa. Methods: All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods. Results: Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities. Conclusion: Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.
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    Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone : protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project
    (BioMed Central, 2021-01-27) Brima, Nataliya; Sevdalis, Nick; Daoh, K.; Deen, B.; Kamara, T. B.; Wurie, Haja; Davies, Justine; Leather, Andrew J. M.
    Background: There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods: This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) preimplementation( project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting. Discussion: We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone.