The unmet surgical needs of global refugee populations: A perspective review

The current state of pediatric gastroenterology in under-resourced nations

Background

Pediatric gastroenterology (GI) care in low- and middle-income countries (LMICs) faces substantial challenges due to limited healthcare infrastructure, inadequate resources, and a shortage of specialized healthcare professionals. These challenges lead to delayed diagnoses and treatment, exacerbating the morbidity and mortality associated with pediatric GI diseases, which include both infectious conditions like diarrhea and chronic conditions such as inflammatory bowel disease (IBD) and liver diseases.

Aim

The aim of this review is to examine the current state of pediatric GI care in LMICs, identify the key challenges these regions face, and propose strategies to improve healthcare outcomes for children affected by GI disorders.

Methods

This review synthesizes existing literature from a range of LMICs, analyzing factors such as the economic burden of healthcare, barriers to access, the availability of diagnostic and therapeutic services, and the state of pediatric hepatology and endoscopy. Studies included in the review were sourced from countries in sub-Saharan Africa, South Asia, and other LMIC regions, focusing on pediatric GI disorders and healthcare delivery.

Results

Economic burden: Families in LMICs face significant economic barriers in accessing pediatric GI care, with treatment costs often exceeding household income, especially in private healthcare settings. Healthcare access: Limited access to healthcare facilities, especially in rural areas, coupled with the shortage of trained pediatric gastroenterologists and necessary medical equipment, leads to delayed diagnoses and inadequate care for conditions like Helicobacter pylori infections and chronic liver diseases. Sanitation and infectious diseases: Poor sanitation and lack of access to clean water contribute to the high prevalence of diarrheal diseases, which can be reduced through better hygiene practices and improved infrastructure. Training gaps: The shortage of trained healthcare workers, particularly pediatric specialists, hinders effective care delivery, with healthcare workers often overburdened due to workforce migration and low salaries. Hepatology and endoscopy: Pediatric hepatology, especially in the context of viral hepatitis, and the availability of pediatric GI endoscopy are severely limited in LMICs, further complicating the management of liver diseases and GI conditions in children.

Conclusion

Improving pediatric GI care in LMICs requires addressing systemic challenges such as inadequate healthcare infrastructure, limited financial resources, and a shortage of trained professionals. Prevention strategies like vaccination, sanitation improvements, and public health education campaigns are crucial for reducing the prevalence of pediatric GI diseases. In addition, enhancing access to specialized training, healthcare services, and diagnostic tools will improve outcomes for children in resource-limited settings. Continued international collaboration and investment in local healthcare systems are essential for creating sustainable solutions and bridging the gap in pediatric GI care.

Innovative strategies and implementation science approaches for health delivery among migrants in humanitarian settings: A scoping review

INTRODUCTION

Over 100 million displaced people rely on health services in humanitarian contexts, defined as unstable or transitory settings created in response to complex emergencies. While services are often described, there is a dearth of evidence on best practices for successful implementation to guide efforts to optimize health delivery. Implementation science is a promising but underutilized tool to address this gap. This scoping review evaluates implementation science in health services for forced migrants in humanitarian settings.

METHODS

We conducted a scoping review according to JBI methodologies. A search of eight databases yielded 7,795 articles, after removal of duplicates, that were screened using PRISMA-ScR guidelines. Data extraction assessed study descriptors, implementation objects, barriers, facilitators, implementation strategies, and use of implementation frameworks in service delivery.

RESULTS

Data from 116 studies represented 37 countries and 11 topic areas. Methods were mainly cross-sectional with low-medium evidence rigor. Mental health programs (25%) and vaccination services (16%) were the most common objects of implementation. Thirty-eight unique barriers were identified including resource limitations (30%), health worker shortages (24%), and security risks (24%). Among 29 facilitators, the most common were health worker availability (25%), pre-existing partnerships (25%), and positive perceptions towards the intervention (20%). More than 90% of studies collectively identified 35 implementation strategies, the most common being capacity building (44%), stakeholder engagement (35%), information dissemination (38%), and feedback mechanisms (25%). Only 10 studies used formal implementation models, with RE-AIM (n = 3) and Intervention mapping (n = 2) being most frequent.

CONCLUSIONS

In this scoping review, we found similar barriers, facilitators, and implementation strategies across diverse humanitarian migrant settings and services. However, the use of rigorous methods and formal implementation models was rare. Frameworks included RE-AIM, CFIR, and Precede-Proceed. Increased use of implementation science frameworks and methods will help humanitarians more rigorously and systematically evaluate and develop best practices for implementation of health services for migrants in humanitarian settings.

A Scoping Review of Limited English Proficiency and Immigration in Pediatric Surgery

INTRODUCTION

With increasing globalization and diversity, the intersection of immigration and language barriers can impact patient outcomes. This scope review aims to summarize current evidence on immigration and language barriers on pediatric surgical outcomes.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases were searched with Medical Subject Heading terms describing pediatric surgery, immigration, limited English proficiency (LEP), and refugees between 2000-2023. Four independent reviewers screened and analyzed texts for final inclusion.

RESULTS

Thirty-three studies were included. Ten studies described disease incidence and severity, finding that LEP, immigrant, and refugee patients were more likely to present with severe disease in appendicitis and traumatic injuries. five studies described pain management, finding patients with LEP received fewer pain assessments, waited longer for analgesia, and had more discrepancies in pain scores. Seventeen studies investigated treatment receipt and delay, finding that immigrants and patients with LEP had longer time to and reduced rates of treatment. Seventeen studies described surgical outcomes, finding that patients with LEP have longer length of stay and more postoperative emergency department visits but fewer follow-up appointments. In kidney transplants, patients with LEP and immigrants had worse outcomes, but these trends are not seen in immigrants from Europe. Overall, immigrants and refugees have higher rates of complications and mortality.

CONCLUSIONS

Immigrants and patients with LEP and are more likely to present with advanced disease and severe injuries, receive inadequate pain management, experience delays in surgery, and suffer more complications. There is continued need to assess the impact of LEP and immigration on pediatric surgery outcomes.

Examining Barriers to Rehabilitation and Addressing Rehabilitation Needs Among Persons With Forced Migration Experiences: Interdisciplinary Perspectives

Globally, human displacement is at a record high. According to the United Nations High Commissioner for Refugees, 110 million people have been forcibly displaced worldwide owing to persecution, mass conflict, or human rights violations. Conflicts continue to rage in different parts of the world such as Ukraine, Palestine, Sudan, and Tigray. Large-scale political upheaval is also on the rise in many countries such as Haiti, Venezuela, and Iran. Natural disasters fueled by climate change will further contribute to large-scale forced migration. Persons with forced migration experiences (PFMEs) tend to have significant rehabilitation needs because of high risk of physical injuries, mental trauma, and exacerbation of pre-existing health problems during displacement. Rehabilitation practitioners in host countries must be well equipped to address the complex needs of this population. However, there is currently limited literature to guide best practice. In this article, a group of interdisciplinary professionals examine rehabilitation needs among PFMEs, provide examples of established and emerging rehabilitation interventions with PFMEs in the context of asylum and resettlement, identify barriers to accessing rehabilitation services in host countries, and propose avenues for professional advocacy in this area.