Impact of conflict on medical education: a cross-sectional survey of students and institutions in Iraq

Dental education amid armed conflict in Sudan: Unveiling the impact on training

The ongoing conflict in Sudan has severely disrupted the health professions education, notably in dentistry. This study aims to explore the impact of the armed conflict on dental education and training. A mixed-method cross-sectional study encompassed 29 dental schools in Khartoum, Darfur, Kordofan States, and Merowe City. Five key informants from the Sudanese Medical Specialization Board, the Human Resource Development Administration, and a university offering clinical dental master's programs were interviewed. Quantitative data on attacks against dental schools were collected through a structured Google form, and qualitative data on postgraduate training were obtained through semi-structured key informant interviews. Findings reveal that 79.3% of dental schools faced military assaults, with 73.9% experiencing looting and 60.9% repurposed as military bases. Notably, 44.8% of schools shifted to online education,3.4% collaborated with other universities, and 27.6% adopted a combined approach. Key informants' interviews unveiled disruptions in specialty training and housemanship, limiting access to crucial training facilities. The primary proposed solution was overseas training. Recurrently emphasized strategies to enhance the resilience of the training system included establishing dental centers in all states, collaborating with external training bodies, and anticipating and preparing for potential disasters. The adverse effects of the conflict on both undergraduate and postgraduate dental education are discernible, manifested through resource limitations, a shortage of dental materials and supplies within training facilities, and direct disruptions to clinical training due to attacks on healthcare institutions. The imperative need for urgent interventions is underscored to alleviate these consequences and safeguard the continuity of educational and training efforts.

War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023

BACKGROUND

War results in widespread destruction of a country's infrastructure, healthcare facilities, and educational institutions. This study aims to assess the attacks on medical schools amidst the ongoing conflict in Sudan.

METHODS

A descriptive cross-sectional study was conducted across 58 medical schools located in the states of Khartoum, Darfur, and Kordofan. Data on attacks between April 15, 2023, and July 15th 2023, were collected using online data collection form.

RESULTS

All medical schools in conflict areas were included in the study. More than half (58.6%) of these medical schools were attacked. Private schools, constituting the majority of the study sample, were the most frequently attacked (70.6%). Of these, 52.9% were located in Khartoum city. More than one form of attack was reported in 64.7% of the affected schools. Looting occurred in 73.5% of the attacked faculties, while 67.6% of them were converted into military bases. Despite these challenges, 60.3% of the schools in the conflict zone managed to restore the educational process through online learning and collaboration with other institutions.

CONCLUSION

During a three-month period of warfare, most medical schools within conflict zones were attacked. This emphasizes the vulnerability of medical education institutions during war and highlights the urgent need of the Ministry of Higher Education interventions to provide leadership, support, and oversight for the educational process in medical schools across the country.

Medical education in times of war: a mixed-methods needs analysis at Ukrainian medical schools

BACKGROUND

As Ukraine struggles with the education of healthcare professionals due to the war, we aimed to identify the specific effects of the war on medical education, the resulting needs, and the expected consequences for schools, faculty, staff, students, and the healthcare system.

METHODS

In October and November 2022, we performed a survey of students, faculty, and staff of medical schools in Ukraine and conducted semi-structured interviews with faculty leaders (i.e., rectors, vice-rectors). We conducted a descriptive analysis of the survey's closed-ended questions. The survey and the interviews included open-ended questions about war-related restrictions to teaching and learning, resulting needs, and expected consequences, for which we applied a thematic analysis.

RESULTS

We received 239 survey responses (N = 49 faculty and staff, N = 190 students) and conducted nine interviews with faculty leaders across Ukraine. Most survey participants indicated that they had experienced restrictions or changes to their work or study due to the war (86% of faculty and staff, 69% of students). From the thematic analysis of the survey and interviews, we identified eight themes: disruption of teaching, increased workload, mental stress, financial restrictions, non-war related needs, international cooperation, quality of education, and prospects of future professionals. The quality of healthcare education in Ukraine was threatened, and schools, faculty, staff, and students were under great strain. While already established international cooperation has been supportive, some needs have still not been addressed.

CONCLUSIONS

We hope that our findings will help researchers and educators from abroad contribute to meeting Ukraine's needs in medical education.

COVID-lateral Damage: Impact of the Post-COVID-19 Era on Procedural Training in Emergency Medicine Residency

Introduction: Hospitalizations during the coronavirus 2019 (COVID-19) pandemic peaked in New York in March-April 2020. In the months following, emergency department (ED) volumes declined. Our objective in this study was to examine the effect of this decline on the procedural experience of emergency medicine (EM) residents compared to the pre-pandemic period. Methods: We conducted this multicenter, retrospective cohort study of patients seen and key procedures performed by EM residents at hospitals spanning three Accreditation Committee for Graduate Medical Education-approved EM residencies in New York City and Nassau County, NY. We obtained numbers of procedures performed during May-July 2020 and compared them to the same time period for 2019 and 2018. We a priori classified critical care procedures-cardioversion, central lines, chest tubes, procedural sedation, and endotracheal intubation. We also studied "fast-track" procedures-fracture/joint reduction, incision and drainage (I&D), laceration repairs, and splints. Results: Total number of critical care procedures in the months following the COVID-19 peak decreased from 694 to 606 (-12.7%, 95% confidence interval [CI] 10.3-15.4%), compared to an increase from 642 to 694 (+8.1%, 95% CI 6.1-10.5%) the previous year (difference -9.3%). Total number of fast-track procedures decreased from 5,253 to 3,369 (-35.9%, 95% CI 34.6-37.2%), compared to a decrease from 5,333 to 5,253 (-1.5%, 95% CI 1.2-1.9%) the year before (difference -36.3%). Specific critical care procedures performed in 2020 compared to the mean of 2019 and 2018 as follows: cardioversion -33.3%; central lines +19.0%; chest tubes -27.9%; procedural sedation -30.8%; endotracheal intubation -13.8%. Specific fast-track procedures: reductions +33.3%; I&D -48.6%; laceration repair -17.3%; and splint application -49.8%. Conclusion: Emergency medicine residents' critical and fast-track procedural experience at five hospitals was reduced during the months following the COVID-19 peak in comparison to a similar period in the two years prior. Training programs may consider increasing simulation-lab and cadaver-lab experiences, as well as ED and critical care rotations for their residents to offset this trend.

Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022

BACKGROUND

Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS).

METHODS

A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework.

RESULTS

Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base.

CONCLUSION

While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.

Academic productivity of Iraqi medical students in the field of neurosurgery: A literature review

Background

The interest in clinical research is growing worldwide, and the involvement of medical students in academic and clinical research is increasing. Medical students in Iraq have started to focus on academic activities. However, this trend is in its infancy due to limited resources and the war burden. Their interest in the field of Neurosurgery has been evolving recently. This is the first paper that aims to assess the status of the academic productivity of Iraqi medical students within the neurosurgical field.

Methods

We searched the PubMed Medline database and Google scholar between January 2020 and December 2022 with a different combination of keywords. Additional results were obtained by individually searching for all the medical universities in Iraq that participated in the neurosurgical literature.

Results

Between January 2020 and December 2022, 60 neurosurgical publications included Iraqi medical students. 47 Iraqi medical students from 9 universities (the University of Baghdad 28 students, followed by 6 students from the University of Al-Nahrain, and others) were involved in these 60 neurosurgery publications. The topics of these publications are "vascular neurosurgery" (n = 36) followed by "neurotrauma" (n = 11).

Conclusion

Academic productivity of Iraqi medical students in the field of Neurosurgery has surged in the last 3 years. In the past 3 years, 47 Iraqi medical students from nine different Iraqi universities contributed to sixty international neurosurgical publications. However, there are challenges that are required to be tackled to establish a research-friendly environment despite wars and restrained resources.

Impact of war on foreign students’ satisfaction with quality of dental and medical education in Ukraine

The objective of this study was to evaluate the changes in foreign students' satisfaction with the quality of dental and medical education considering the impact of the war in Ukraine. The present study was organized in the form of a questionnaire-based survey among 300 foreign students of Medical Faculty and Faculty of Dentistry in Ukraine. The questionnaire was ad mistered via Google form in a multiple-choice, closed-ended format. Students' satisfaction with environment safety and comfort (p < 0.05) and with the collaborative learning offered (p < 0.05) statistically decreased during the war. Sixty percent of the variability in the mean of students' satisfaction with the quality of education during the war could be explained by the satisfaction rate before the war. The need of migration from Ukraine had a stronger inverse correlation with education quality (r = -0.58) than the fact of the war itself (r = -0.32). The war in Ukraine has had a negative impact on the educational process of foreign medical and dental students, even though the quality of education was considered by students to be as high as before and during the war. The personal effort of professors, the quality of study materials, and adequate technical support could potentially overcome the negative impact of the war on student satisfaction with the quality of medical and dental education by the online mode, if the academic medium could be protected from the direct impact of the war or if the influence of the war within the university community could be minimized.

COVID-19 and medical educator perceptions: Sense-making during times of crisis

Background. Although crises are generally considered uncommon, health professions education (HPE) literature gives evidence of repeated and ongoing crises. This has been most recently demonstrated by the global impact of COVID-19. Crisis management literature proposes that such recurrent crises are opportune moments for learning. While there has been much literature published that describes changes made to the format of HPE amid COVID-19, there has been little attention given to the perceptions of medical educators. Medical educators’ experiences may serve as a resource to uncover lessons that may have been learnt during this period. Objective. To address the gap in the literature, by analysing the perceptions of medical educators at the University of Cape Town (UCT) during the COVID-19 pandemic of 2020-2021.Methods. A qualitative case-study approach was adopted. Rich data were collected from four medical educators using semi-structured interviews and a focus group discussion, and then analysed using a reflexive thematic approach. Results. The data indicated that educators grappled with a multitude of struggles during the COVID-19 pandemic. These were analysed thematically as: tensions with technology, balancing expectations, and the distribution of support. However, surface-level challenges faced by educators seem to belie a much deeper personal struggle. Conclusion. The data suggest that whether any learning occurs and what is learnt are embedded within the process of sense-making. If institutions of higher education aim to adopt proactive responses to crises, then further research – as well as support for these sense-making processes during crises – should form a critical part of overall institutional preparedness.

Social, political and legal determinants of kidney health: Perspectives from lower- and middle-income countries with a focus on India

The social determinants of health (SDoH) are the non-medical factors that influence kidney health outcomes directly or indirectly in a substantial manner and include conditions in which people are born, grow, work, live, and age. Many such challenges in lower- and middle- income countries have an unfavourable impact on kidney health. These conditions potentially influence economic policies and systems, development agendas, social norms, social policies, and political systems. In addition, many political and legal factors also determine and modify the ultimate outcome in patients with kidney disease. Legal factors that ensure universal health care, promote gender and racial equality, prevent malpractices and regulate strict laws in the field of kidney transplantation are the paramount determinants for the provision of necessary kidney care. Converging lines of evidence have supported the impact of social variables such as socioeconomic resources, social inclusion, housing conditions, educational attainment, and financial status on kidney health, particularly affect vulnerable and disadvantaged groups and result in challenges in kidney care delivery. Furthermore, the climate is an important SDoH that plays a crucial role in the occurrence, prevalence, and progression of kidney diseases as highlighted by the presence of higher prevalence of chronic kidney disease in hot tropical countries. The rising incidence of water and vector-borne diseases causing acute kidney injury is another consequence of disruptive environmental and climate change which is detrimental to kidney health. Political risk factors such as conflict also have a devastating influence on kidney health. The relationship between SDoH and kidney health outcomes requires more clarity. Gaps in the current knowledge need to be identified to inform the development of appropriate interventions to address upstream socio-economic risk factors for kidney disease.

Maintaining health professional education during war: A scoping review

PURPOSE

War negatively impacts health professional education when health care is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarise the research.

METHODS

We conducted a scoping review between 20 June 2018 and 2 August 2018. The search was restricted to English publications including peer-reviewed publications without date ranges involving war and health professional education (medical school, residency training and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences.

RESULTS

Screening identified 3271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 17 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified five categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era.

CONCLUSIONS

There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.

Basic life support knowledge in a war-torn country: a survey of nurses in Yemen

Background

Successful implementation of Basic life support (BLS) is critical to improving survival rates and outcomes, especially among healthcare workers. To our knowledge, there is no available literature pertaining to the level of BLS knowledge of health care professionals in Yemen.

Methods

Data was collected for this cross-sectional descriptive study from June to August 2020, using a 10-item questionnaire related to cardiopulmonary resuscitation (CPR) and BLS, along with questions on socio-demographic characteristics. Participants were nurses in public and private hospitals located in Al-Rahida and Al-dimna cities, Taiz governance and Hodeidah city, Hodeidah governance in Yemen.

Results

Out of 220 distributed questionnaires, 200 were returned with a response rate of 90.9%. More than a half (53.65%) of answer choices for BLS knowledge were correct. There was a significant difference in knowledge score based on level of education where those who had Bachelor degree had more knowledge (P = 0.000). Those who said they had received training in CPR or received information about CPR had significantly higher scores than those who did not receive (P = 0.000).

Conclusions

BLS knowledge among nurses in Yemen is below an acceptable level to ensure maximum survival in the event of cardiac arrest. Disseminating BLS information and training in a cost effective and efficient manner will provide a large benefit in terms of lives saved with minimal costs.

Forming the Hematology-Oncology Collaborative Videoconferencing (CO-VID) Learning Initiative: Experiential Lessons Learned From a Novel Trainee-Led Multidisciplinary Virtual Learning Platform

PURPOSE

COVID-19 challenged medical practice and graduate medical education. Building on previous initiatives, we describe and reflect on the formative process and goals of the Hematology-Oncology Collaborative Videoconferencing Learning Initiative, a trainee-led multi-institutional virtual COVID-19 learning model.

METHODS

Clinical fellows and faculty from 13 US training institutions developed consensus needs, goals, and objectives, recruited presenters, and generated a multidisciplinary COVID-19 curriculum. Weekly Zoom conferences consisted of two trainee-led instructional segments and a trainee-moderated faculty Q&A panel. Hematology-oncology training program faculty and trainees were the targeted audience. Leadership evaluations consisted of anonymized baseline and concluding mixed methods surveys. Presenter evaluations consisted of session debriefs and two structured focus groups. Conference evaluations consisted of attendance, demographics, and pre- or postmultiple-choice questions on topic learning objectives.

RESULTS

In 6 weeks, the initiative produced five conferences: antivirals, anticoagulation, pulmonology, provider resilience, and resource scarcity ethics. The average attendance was 100 (range 57-185). Among attendees providing both pre- and postconference data, group-level knowledge appeared to increase: antiviral (n = 46) pre-/postcorrect 82.6%/97.8% and incorrect 10.9%/2.2%, anticoagulation (n = 60) pre-/postcorrect 75%/93.3% and incorrect 15%/6.7%, and pulmonary (n = 21) pre-/postcorrect 66.7%/95.2% and incorrect 33.3%/4.8%. Although pulmonary management comfort appeared to increase, comfort managing of antivirals and anticoagulation was unchanged. At the conclusion of the pilot, leadership trainees reported improved self-confidence organizing multi-institutional collaborations, median (interquartile range) 58.5 (50-64) compared with baseline 34 (26-39), but did not report improved confidence in other educational or leadership skills.

CONCLUSION

During crisis, trainees built a multi-institutional virtual education platform for the purposes of sharing pandemic experiences and knowledge. Accomplishment of initiative goals was mixed. Lessons learned from the process and goals may improve future disaster educational initiatives.

When disruption strikes the curriculum: Towards a crisis-curriculum analysis framework

INTRODUCTION

COVID-19 has severely disrupted health professions training globally. This pandemic has been preceded by several other interferences on a smaller scale, setting the scene for crises in perpetuity. With a reactive stance adopted, these crises may result in rapid shifts to curricula, minimizing the opportunity for thorough planning and critical analyses.

GUIDANCE FROM THE LITERATURE

Recognizing the limited frameworks available to provide structure to such curricular crises responses, we drew on the literature to develop a crisis-curriculum analysis framework. The work of the SPICES model by Harden et al., the four-dimensional framework by Steketee et al., and Deverell's crisis-induced learning, was used to develop the framework.

CRISIS-CURRICULUM ANALYSIS FRAMEWORK

The framework provides a structured approach to curriculum analysis in the face of disruption. It is designed to meet the needs of the global health professions education community, currently in the midst of a crisis. Accompanied by a step-wise guideline, this framework is suitable for educators requiring a practically-orientated approach to curriculum analysis.

CONCLUSION

Recognizing that curriculum analysis is but one part of crisis-management, we argue that this crisis-curriculum analysis framework may align well with strengthening institutional readiness as educators seek to refine and entrench curricular practices adopted during COVID-19.

Challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west Syria

Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.

The prevalence of burnout syndrome among resident physicians in Syria

INTRODUCTION

Burnout syndrome is a work-related chronic stress that is described as emotional exhaustion, a decreased sense of personal accomplishment, and depersonalization. it has been considered an important problem especially among workers in the health sector.

OBJECTIVES

The aim of this research was to study the prevalence of burnout among Syrian residents during the Syrian crisis, which started 9 years ago, and to assess the factors related to burnout syndrome.

METHODS

A cross-sectional study was conducted to assess the levels of burnout syndrome; data were collected from residents doing their residency in 12 different hospitals spread over 8 governorates in Syria. A web-based Arabic version of Maslach Burnout Inventory questionnaire was used. The final sample size was 3350 residents from different specialties. SPSS V.22 was used to analyses the data using descriptive and inferential statistics.

RESULTS

(93.75%) had a high level in at least one of the three domains of the burnout index, and (19.3%) of the residents had a high level of burnout in all three domains. Significant relation was found between gender, age group and affiliated authority variables and the levels of burnout. However no significant relation was found between burnout and the specialties or geographic variables. Males, residents in Ministry of Defense, and emergency medicine residents had the highest levels of burnout.

CONCLUSION

High levels of burnout was found among residents during the Syrian crisis in comparison with other studies, which highlights the role of the current situation in raising workload on the Syrian residents.

Academic Medicine and Science Diplomacy: Medical Education in Iraq

Physicians are infrequently selected to serve in the yearlong role of Jefferson Science Fellow (JSF) as senior science advisor for the U.S. Department of State or the United States Agency for International Development. The authors discuss the role of a JSF in promoting "science diplomacy" from the perspective of one alumnus, who sites examples of ongoing, long-term collaborative projects including one focusing on medical education reform in Iraq that would not have been possible without the JSF program. More than 3 decades of political and social unrest, terrorism, the internal displacement of millions of Iraqi citizens, the arrival of Syrian refugees, international sanctions, and the effect of fluctuating oil prices that fund education in Iraq have all led to a standstill in modernizing educational systems and the need for reform. In 2016, new opportunities for international collaboration and travel allowed faculty from the Al Kindy College of Medicine, University of Baghdad, Iraq, to visit the United States, explore U.S. medical school teaching methods, interact with U.S. faculty and students, and then implement their vision of a revised medical curriculum. These faculty members shared their observations with the Iraqi Council of Deans, which represents all 30 Iraqi medical schools. Structural changes in curriculum content and teaching methods have been implemented with the goal of restoring quantifiable excellence in education and health care in Iraq. The authors close with lessons learned to encourage other physicians to participate in the JSF program, which offers a unique opportunity to influence foreign policy through science diplomacy.

Contemporary global perspectives of medical students on research during undergraduate medical education: a systematic literature review

BACKGROUND

The need for increased expertise in evidence-based medicine and concerns about the decreasing numbers of physician-scientists have underscored the need for promoting and encouraging research in medical education. The critical shortage of physician-scientists has assumed a dimension demanding a coordinated global response. This systematic review examined the perceptions of medical students regarding research during undergraduate medical school from a global perspective.

METHODS

Articles for this review were searched using PubMed, SCOPUS and Cochrane. Studies published within the last 10 years of the start date of the study that met specified criteria were included. Identified articles were initially screened by title as well as keywords and their abstracts were further screened to determine relevance. Full-text of screened articles were read for validation prior to inclusion.

RESULTS

A total of 26 articles from the literature met the set criteria for final inclusion. Contents of the abstracts and corresponding full-text articles were analyzed for themes on the research perspectives of medical students. The themes derived comprised: research interest, physician-scientist decline and shortage, responses to physician-scientist shortage, curriculum issues, skills (motivation and self-efficacy), research needs, socioeconomic and cultural issues, and barriers.

CONCLUSION

Despite the wide variations in medical education systems worldwide, the perspectives of medical students on research in undergraduate medical education shared many common themes. Globally, medical students underscored the necessity and importance of research in medical education as reflected by many students reporting positive attitudes and interest in research endeavors. Moreover, a worldwide consensus emerged regarding the decline in the numbers of physician-scientists and the necessity for a reversal of that trend. Various barriers to research engagement and participation were highlighted.

Emergency health education in a conflict stricken environment: A situational analysis

Introduction

Bosasso General Hospital is located in Puntland Somalia, an area affected by prolonged civil conflict, terrorism, clan fighting and piracy. International evidence highlights that staff skills and competence may have a significant impact on patient outcomes however there has been little research on emergency education in such an austere and volatile environment. The purpose of this study therefore was to identify current practices and gaps in delivering emergency medicine education in this resource-deprived environment.

Methods

A mixed methods approach was adopted to inform convergent parallel data collection techniques including questionnaire (n = 16), key informant (n = 5) and focus group interviews (n = 16). Data analysis, following data triangulation, produced descriptive quantitative statistics of themes such as emergency care, educational provision, enablers and barriers.

Results

The research showed that among health care staff at the hospital, 19% of the nurses felt that visiting nurses offer some knowledge on emergency care, while 38% of knowledge was gained from visiting doctors. Regarding knowledge of emergency medicine, 88.9% of the nurses felt that emergency medicine is basically first aid.

Discussion

Emergency care was perceived by the majority as essentially ‘first aid’. Many indicated that they received little or no regular or formal training on emergency care and related essential topics. In terms of challenges faced in delivering emergency care education demonstrated a common factor in the limited resources available which included lack of teaching materials, reading materials, online resources, health care professionals, equipment and mentors. Conclusions drawn suggest that the knowledge of emergency medicine by front line professionals is limited. Therefore, the development of field curricula, practical and theoretical training by visiting practitioners, provision of additional teaching aids, tools and equipment, integration of multiple disciplines in training and financial resource mobilisation would be beneficial in improving knowledge, attitudes and practices of emergency care.

Health Care Workers in the setting of the "Arab Spring": a scoping review for the Lancet-AUB Commission on Syria

Background

"Health Care Workers in Conflict Areas" emerged as one of the priority themes for a Lancet Commission addressing health in conflict. The objective of our study was to conduct a scoping review on health workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration.

Methods

Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the "Arab Spring". We electronically searched six electronic databases. We conducted descriptive analysis of the general characteristics of the included papers. We also used the results of this scoping review to build an evidence gap map.

Results

Out of the 11 165 identified citations, 136 met our eligibility criteria. The majority of the articles tackled the issue of violence against health care workers (63%) followed by practicing in conflict setting (19%), migration (17%) and education (10%). Countries in focus of most articles were: Syria (35%), Iraq (33%), and Bahrain (29%). News, editorials, commentaries and opinion pieces made up 81% of all included papers, while primary studies made up only 9%. All the primary studies identified in this review were conducted on Iraq. Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. The first and corresponding authors were most frequently affiliated with institutions from non-Arab countries (79% and 79% respectively).

Conclusions

Research evidence on health care workers in the setting of the "Arab Spring" is scarce. This review and the gap map can inform the research agendas of funders and researchers working in the field of health care workers in conflict setting. More well-designed primary studies are needed to inform the decisions of policymakers and other interested parties.

Perceptions, experiences and expectations of Iraqi medical students

BACKGROUND

The environment for medical education in Iraq has been difficult for many years. The 2003 invasion of Iraq accelerated a steady emigration of faculty and graduates. Kidnappings and deaths of doctors became commonplace. To understand current career plans, expectations and perceptions of medical students, three Baghdad medical schools were surveyed.

METHODS

Written questionnaires were completed by 418 medical students variously in their 4th, 5th and 6th (final)years of training. We asked about perceptions of the quality of their medical education, the quality of health services in Iraq generally, and about deaths, injuries and migration of faculty, classmates and family.

RESULTS

The average age of students was 22 years, with 59% women. Most students (90%) were originally from Baghdad. Although there were some positive responses, many students (59%) rated the overall quality of their medical education as fair or poor. Three-fourths of students believed the quality of hospital care in Iraq to be only fair or poor. A majority of students (57%) stated they were thinking frequently or all the time about leaving Iraq after graduation. Reasons given for leaving included the desire for further education, seeking a better lifestyle and fleeing conflict. Leading reasons for staying included the pull of friends and family, familiarity with the health system, and a sense of responsibility to the country. Nearly one in five (18%) students reported the death of a family member attributable to intentional violence, and 15% reported the violent death of a medical school classmate or faculty member since the 2003 invasion. Half the students reported at least one school faculty members had left Iraq because of the war.

CONCLUSION

Medical students hold a mediocre view of the quality of their medical education and of Iraq's health system. Many of their faculty members have left the country. The majority of students may leave Iraq after graduation, afforded the opportunity. This poses a significant problem for staffing an already demoralized and stressed health system. Current circumstances suggest the situation will continue to deteriorate.