Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Perceptions of Global Health Engagements in Relation to the COVID-19 Pandemic Among Kenyan Health Care Workers and Administrators in Western Kenya: Protocol for Multi-stage Qualitative Study

BACKGROUND

There has been significant interest in global health in low- and middle-income countries (LMICs) among individuals living in high-income countries (HICs) over the past 30 years. Much of the literature on global health engagements (GHEs) has been presented from the perspective of individuals from HIC participants. Local stakeholders such as health care workers and health care administrators represent critical constituencies for global health activities, yet their perspectives are under-represented in the literature. The purpose of this study is to examine local health worker and administrator experiences with GHEs in Kenya. We will explore the perceived role GHEs play in preparing the health system to address a public health crisis, as well as their role in pandemic recovery and its aftermath.

OBJECTIVE

The aim of this study is to 1) examine how Kenyan health care workers and administrators interpret experiences with global health engagements as having advantaged or hindered them and the local health system to provide care during an acute public health crisis and 2) to explore recommendations to reimagine GHEs in a post-pandemic Kenya.

METHODS

This study will be conducted at a large teaching and referral hospital in western Kenya, with a long history of hosting GHEs in support of its tripartite mission of providing care, training, and research. This qualitative study will be conducted in three phases. In Phase 1, in-depth interviews (IDIs) will be conducted to capture participants' lived experience in relation to their unique understandings of the pandemic, GHEs, and the local health system. In Phase 2, group discussions, using nominal group technique (NGTs) will be conducted to determine potential priority areas to reimagine future GHEs. In Phase 3, IDIs will be conducted to explore these priority areas in greater detail to explore potential recommendations for potential strategies, policies, and other actions that might be employed to achieve the priorities determined to be of highest importance.

RESULTS

Study activities will commence late summer 2022, with findings to be published in 2023. It is anticipated that findings from this study will provide insight into the role GHEs play in a local health system in Kenya, and provide critical stakeholder and partner input, from persons hitherto ignored in the design, implementation, and management of GHEs.

CONCLUSIONS

This qualitative study will examine perspectives of global health engagements in relation to the COVID-19 pandemic among Kenyan health care workers and health care administrators in western Kenya using a multi-stage protocol. Using a combination of in-depth interviews and nominal group techniques this study aims to shed light on the roles global health activities are perceived to play in preparing health care professionals and the health system to address an acute public health crisis.

CLINICALTRIAL

INTERNATIONAL REGISTERED REPORT

PRR1-10.2196/41836.

Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission

OBJECTIVE

To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention.

DESIGN

Prospective study with all participants receiving an educational intervention.

SETTING

Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020.

PARTICIPANTS

A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery.

INTERVENTION

Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points.

MAIN OUTCOME MEASURE

Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up.

RESULTS

Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based.

CONCLUSIONS

In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries

BACKGROUND

The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries.

METHOD

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach.

RESULTS

Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers.

CONCLUSION

Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study

OBJECTIVE

To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians.

SUMMARY BACKGROUND DATA

STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians.

METHODS

Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence.

RESULTS

We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM.

CONCLUSIONS

While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.

Gratitude in Health Care: A Meta-narrative Review

Research into gratitude as a significant sociological and psychological phenomenon has proliferated in the past two decades. However, there is little consensus on how it should be conceptualized or investigated empirically. We present a meta-narrative review that focuses on gratitude in health care, with an emphasis on research exploring interpersonal experiences in the context of care provision. Six meta-narratives from literatures across the humanities, sciences, and medicine are identified, contextualized, and discussed: gratitude as social capital; gifts; care ethics; benefits of gratitude; gratitude and staff well-being; and gratitude as an indicator of quality of care. Meta-narrative review was a valuable framework for making sense of theoretical antecedents and findings in this developing area of research. We conclude that greater attention needs to be given to what constitutes "evidence" in gratitude research and call for qualitative studies to better understand and shape the role and implications of gratitude in health care.

Short-term surgical trips: local collaboration and its effects on complications and patient satisfaction

PURPOSE

Short-term surgical missions can provide communities in need with desired expertise; however, it is uncertain who will manage the complications after visiting experts leave. Poor outcomes, decreased patient satisfaction, and tension on the healthcare system develop when local providers, often excluded from the initial patient care, are unable to cope with subsequent morbidity.

METHODS

Two-year retrospective review of pediatric general, plastic, and reconstructive surgery, and urology cases performed by a relief organization in the developing world. Case complexity and postoperative complications were analyzed. Phone interviews conducted with patients/families to quantify postoperative outcomes and satisfaction.

RESULTS

474 surgeries were performed on pediatric patients with 60% response rate. Respondents stratified into three levels of complexity: 159 simple, 72 intermediate, and 54 advanced surgeries. Six (2.1%) high-level complications occurred. No association between the complexity of the surgery and the occurrence of a complications. 83.5% were satisfied with outcomes and > 92% were happy with the provided support.

CONCLUSION

Facilitating visiting and local surgeons performing cases together increases the expertise of local providers, strengthens infrastructure, and establishes clear follow-up. Despite complications, patients and families continued to recommend care to family and friends by the relief organization and were happy with support from local providers. Engaging local providers is the gold-standard for short-term trips.

Lasting impact: a qualitative study of perspectives on surgery by adult recipients of free mission-based surgical care in Benin

OBJECTIVES

This study aimed to explore how adult patients who received free mission-based elective surgery experienced surgery and its outcomes, in order to provide recommendations for improved service delivery, measurement of impact and future quality initiatives for the humanitarian organisation Mercy Ships and other mission-based surgical platforms.

SETTING

Data were collected in June 2017 in Cotonou, Benin, where the participants had previously received free mission-based elective surgery aboard the Africa Mercy, a non-governmental hospital ship.

PARTICIPANTS

Sixteen patients (seven male, nine female, age range 22-71, mean age 43.25) who had previously received surgical care aboard the Africa Mercy hospital ship between September 2016 and May 2017 participated in the study.

METHODS

Using a qualitative design, 16 individual semistructured interviews were conducted with the assistance of two interpreters. Participants were recruited using purposive sampling from the Mercy Ships patient database. Interview data were coded and organised into themes and subthemes using thematic content analysis in an interpretivist approach.

FINDINGS

Analysis of interview data revealed three main themes: barriers to surgery, experiences with Mercy Ships and changes in perspectives of surgery after their experiences. Key findings included barriers to local surgical provision such as cost, a noteworthy amount of fear and distrust of local surgical teams, exceptional positive experiences with the care at Mercy Ships, and impactful surgery, resulting in high levels of trust in foreign surgical teams.

CONCLUSIONS

While foreign surgical teams are meeting an immediate need for surgical care, the potential enduring legacy is one of trusting only foreigners for surgery. Patients are a critical component to a well-functioning surgical system, and mission-based surgical providers must formulate strategies to mitigate this legacy while strengthening the local surgical system.