Care In Low-resource Settings Research Articles

Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies.

The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi.

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

Pediatric Emergency Care in Low-Resource Settings

Pediatric Emergency Care in Low-Resource Settings

Future Fertility Among Pediatric Cancer Patients: Experiences and Perspectives of Health Workers in a Low-Resource Setting.

Purpose:Although fertility preservation for patients with childhood and adolescent cancer is considered standard of care in the high-resource settings, it is rarely offered in low-resource settings. This study explores the experiences and perspectives of oncology health care professionals in Uganda to identify contextual barriers and facilitators to addressing oncofertility in low-resource settings. Methods: Using ground theory, we conducted in-depth face-to-face interviews of health care professionals managing pediatric patients at the Uganda Cancer Institute (UCI). Using a systematic, semi-structured interview guide, participants were asked open-ended questions about their understanding of fertility preservation and their perspectives on implementing this care at their institution. Although all the eligible health care providers were interviewed, interview transcripts were uploaded into NVivo version 12 and openly coded as per theoretical requirements. Codes were refined into categories and later into structured themes. Results: Twelve health care professionals were interviewed. Most participants identified as female (n = 9). Their role in the medical team varied from nurses (n = 6), medical officers (n = 3), pediatric oncologists (n = 2), and pediatric oncology fellow (n = 1). Six themes were noted as follows: (1) importance of information, (2) importance of future fertility, (3) inadequate consideration to future fertility, (4) communication barriers, (5) inadequate knowledge, and (6) resource barriers. Conclusion: Although health care providers at the UCI face contextual barriers to addressing future fertility among patients with pediatric cancer, they value preserving fertility in this population. Future initiatives that aim to introduce oncofertility care in low-resource settings should prioritize educating providers and building capacity to meet the oncofertility needs in this setting.

Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer

BackgroundThis case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes.MethodsProyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level.ResultsThis approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy.ConclusionsProyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.

Development of a LAMP-Based Diagnostic for the Detection of Multiple HIV-1 Strains.

Since its first appearance in 1981, HIV-1 has remained a global concern. Current methods for diagnosing HIV-1, while effective, are mostly specific to a given subtype of HIV-1 and often require expensive equipment and highly trained individuals to collect and process the sample. It is necessary to develop a sensitive diagnostic method that can be administered with minimal equipment to provide better care in low-resource settings. Loop-mediated isothermal amplification is a rapid and sensitive method for detecting the presence of specific nucleic acid sequences. Herein we report the development and comparison of two different HIV LAMP assays, integrase and VPR, as well as the comparison between TRIZol and magnetic beads RNA extraction methods for each assay. Our analysis shows that the integrase assay was able to detect the virus from multiple subtypes in under 30 min with a variable limit of detection (LOD) that was dependent on the HIV-1 subtype.

Facilitators and constraints to family integrated care in low-resource settings informed the adaptation in Uganda.

Family Integrated Care (FICare) was developed in high-income countries and has not been tested in resource-poor settings. We aimed to identify the facilitators and constraints that informed the adaptation of FICare to a neonatal hospital unit in Uganda. Maternal focus groups and healthcare provider interviews were conducted at Uganda's Jinja Regional Referral Hospital in 2020. Transcripts were analysed using inductive content analysis. An adaptation team developed Uganda FICare based on the identified facilitators and constraints. Participants included 10 mothers (median age 28 years) and eight healthcare providers (seven female, median age 41 years). Reducing healthcare provider workload, improving neonatal outcomes and empowering mothers were identified as facilitators. Maternal stress, maternal difficulties in learning new skills and mistrust of mothers by healthcare providers were cited as constraints. Uganda FICare focused on task-shifting important but neglected patient care tasks from healthcare providers to mothers. Healthcare providers learned how to respond to maternal concerns. Intervention material was adapted to prioritise images over text. Mothers familiar with FICare provided peer-to-peer support to other mothers. Uganda FICare shares the core values of FICare but was adapted to be feasible in low-resource settings.

Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial

Although evidence-based treatments for depression in low-resource settings are established, implementation strategies to scale up these treatments remain poorly defined. We aimed to compare two implementation strategies in achieving high-quality integration of depression care into chronic medical care and improving mental health outcomes in patients with hypertension and diabetes. We conducted a parallel, cluster-randomised, controlled, implementation trial in ten health facilities across Malawi. Facilities were randomised (1:1) by covariate-constrained randomisation to either an internal champion alone (ie, basic strategy group) or an internal champion plus external supervision with audit and feedback (ie, enhanced strategy group). Champions integrated a three-element, evidence-based intervention into clinical care: universal depression screening; peer-delivered psychosocial counselling; and algorithm-guided, non-specialist antidepressant management. External supervision involved structured facility visits by Ministry officials and clinical experts to assess quality of care and provide supportive feedback approximately every 4 months. Eligible participants were adults (aged 18-65 years) seeking hypertension and diabetes care with signs of depression (Patient Health Questionnaire-9 score ≥5). Primary implementation outcomes were depression screening fidelity, treatment initiation fidelity, and follow-up treatment fidelity over the first 3 months of treatment, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03711786, and is complete. Five (50%) facilities were randomised to the basic strategy and five (50%) to the enhanced strategy. Between Oct 1, 2019, and Nov 30, 2021, in the basic group, 587 patients were assessed for eligibility, of whom 301 were enrolled; in the enhanced group, 539 patients were assessed, of whom 288 were enrolled. All clinics integrated the evidence-based intervention and were included in the analyses. Of 60 774 screening-eligible visits, screening fidelity was moderate (58% in the enhanced group vs 53% in the basic group; probability difference 5% [95% CI -38% to 47%]; p=0·84) and treatment initiation fidelity was high (99% vs 98%; 0% [-3% to 3%]; p=0·89) in both groups. However, treatment follow-up fidelity was substantially higher in the enhanced group than in the basic group (82% vs 20%; 62% [36% to 89%]; p=0·0020). Depression remission was higher in the enhanced group than in the basic group (55% vs 36%; 19% [3% to 34%]; p=0·045). Serious adverse events were nine deaths (five in the basic group and four in the enhanced group) and 26 hospitalisations (20 in the basic group and six in the enhanced group); none were treatment-related. The enhanced implementation strategy led to an increase in fidelity in providers' follow-up treatment actions and in rates of depression remission, consistent with the literature that follow-up decisions are crucial to improving depression outcomes in integrated care models. These findings suggest that external supervision combined with an internal champion could offer an important advance in integrating depression treatment into general medical care in low-resource settings. The National Institute of Mental Health.

Identifying critically ill children in Malawi: A modified qSOFA score for low-resource settings.

In low-resource settings, a reliable bedside score for timely identification of children at risk of dying, could help focus resources and improve survival. The rapid bedside Liverpool quick Sequential Organ Failure Assessment (LqSOFA) uses clinical parameters only and performed well in United Kingdom cohorts. A similarly quick clinical assessment-only score has however not yet been developed for paediatric populations in sub-Saharan Africa. In a development cohort of critically ill children in Malawi, we calculated the LqSOFA scores using age-adjusted heart rate and respiratory rate, capillary refill time and Blantyre Coma Scale, and evaluated its prognostic performance for mortality. An improved score, the Blantyre qSOFA (BqSOFA), was developed (omitting heart rate, adjusting respiratory rate cut-off values and adding pallor), subsequently validated in a second cohort of Malawian children, and compared with an existing score (FEAST-PET). Prognostic performance for mortality was evaluated using area under the receiver operating characteristic curve (AUC). Mortality was 15.4% in the development (N = 493) and 22.0% in the validation cohort (N = 377). In the development cohort, discriminative ability (AUC) of the LqSOFA to predict mortality was 0.68 (95%-CI: 0.60-0.76). The BqSOFA and FEAST-PET yielded AUCs of 0.84 (95%-CI:0.79-0.89) and 0.83 (95%-CI:0.77-0.89) in the development cohort, and 0.74 (95%-CI:0.68-0.79) and 0.76 (95%-CI:0.70-0.82) in the validation cohort, respectively. We developed a simple prognostic score for Malawian children based on four clinical parameters which performed as well as a more complex score. The BqSOFA might be used to promptly identify critically ill children at risk of dying and prioritize hospital care in low-resource settings.

Towards an integrated type 1 diabetes management in low-resource settings: barriers faced by patients and their caregivers in healthcare facilities in Ghana

Background In Low-Middle-Income Countries (LMICs), young people living with Type 1 Diabetes Mellitus (T1DM) face structural barriers which undermine adequate T1DM management and lead to poor health outcomes. However, research on the barriers faced by young people living with T1DM have mostly focused on patient factors, neglecting concerns regarding plausible barriers that may exist at the point of healthcare service delivery.Objective This study sought to explore barriers faced by young people living with T1DM and their caregivers at the point of healthcare service delivery.MethodsData were drawn from a qualitative research in southern Ghana. The research was underpinned by a phenomenological study design. Data were collected from 28 young people living with T1DM, 12 caregivers, and six healthcare providers using semi-structured interview guides. The data were collected at home, hospital, and support group centres via face-to-face interviews, telephone interviews, and videoconferencing. Thematic and framework analyses were done using CAQDAS (QSR NVivo 14).ResultsEight key barriers were identified. These were: shortage of insulin and management logistics; healthcare provider knowledge gaps; lack of T1DM care continuity; poor healthcare provider-caregiver interactions; lack of specialists’ care; sharing of physical space with adult patients; long waiting time; and outdated treatment plans. The multiple barriers identified suggest the need for an integrated model of T1DM to improve its care delivery in low-resource settings. We adapted the Chronic Care Model (CCM) to develop an Integrated Healthcare for T1DM management in low-resource settings.ConclusionYoung people living with T1DM, and their caregivers encountered multiple healthcare barriers in both in-patient and outpatient healthcare facilities. The results highlight important intervention areas which must be addressed/improved to optimise T1DM care, as well as call for the implementation of a proposed integrated approach to T1DM care in low-resource settings.

Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa.

This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

Caregiver Enablement Training to Support Homecare: A Study from India

AbstractHomecare is the prevalent model of dementia care in India and ‘attendants,’ who are non‐trained lay workers are often employed in Indian households to assist with personal care, ADL and other support which the family may need. Providing training to these attendants can support continued dementia care at home. We present initial data from a caregiver enablement program (CEP) being provided in India.MethodsThe (CEP) consists of a minimum of 6‐8 individually tailored sessions beginning with a clinical evaluation. Using a collaborative approach, challenging areas of caregiving are identified and prioritized. Across the sessions, information about what may be contributing to these challenges and tips for providing care are provided by a dementia trained specialist. Attendants and family members are encouraged to use these approaches and feedback was discussed in an iterative manner to improve the caregiving process and address emerging issues.ResultsTen families availed the caregiver enablement program, out of those 2 patients were living with their 24 hours attendant and 8 patients were living with family and attendants. The caregiver enablement program was conducted online, offline and in hybrid mode, 5 of them were online sessions, 4 offline sessions and one hybrid session (session conducted at home and online). Patients had moderate to severe stage dementia (Hindi MMSE Mn = 13.3, SD = 5.7; Caregiver burden: Zarit burden interview Mn = 29.8 SD = 19.6).Key areas where enablement was required were basic understanding of dementia, acceptance of the illness by the family and that they need external support, how to manage challenging behaviours like toileting, bathing, dressing, incontinence, transferring and feeding, how to engage the patient in meaningful activities and the need for environment modifications to improve safety and managing challenging behaviours. Psycho educational skill building, multi component intervention was found to be effective in the present study to combat the concerns shared by the attendants/family members.ConclusionThis study demonstrates how up‐skilling lay workers through training on dementia and management of challenging behaviours can support home care. Supporting the informal care system with specialised training can be an effective way of providing dementia care in low resource settings.

Abstract B130: Social determinants associated with HPV disparities among people with HIV infection in Puerto Rico

Abstract Background: People with HIV (PWH) have a higher risk of acquiring oral HPV infection when compared to people without HIV, which can lead to the high prevalence of oropharyngeal cancers in PWH. Puerto Rico (PR), a US jurisdiction, is on the top 10 in terms of HIV prevalence and cumulative AIDS cases among the US and have a significant burden and disparity of HPV-related malignancies. Additionally, PR has socio-economic disadvantages, which is a social determinant of oral health disparities, and can potentially affect oral HPV. The relationship of these social determinants with HPV have not been investigated in PWH in PR. Hence, in this study, we evaluated the relationship between socio-economic, behavioral, and oral health factors with oral HPV among PWH. Methods: We evaluated 117 sexually active PWH (102 males and 15 females) from a community clinic in San Juan, PR. Oral rinse samples were collected and analyzed for HPV infection and genotype using the DNA ELISA kit HPV SPF10 and RHA kit HPV SPF10-LiPA25. We collected sociodemographic characteristics (age, marital status, employment, income) as well as lifestyle variables (smoking habits, alcohol consumption, sexual practices) through an administered questionnaire. Participants also underwent a clinical full-mouth periodontal assessment following the CDC/AAP guidelines. Statistical analyses in relation to HPV were performed in R statistical software. Findings: There was a prevalence of oral HPV infection of 29.9% in PWH in PR, which 70% were high-risk genotypes, with HPV-18 being the most abundant genotype (27.5%). There were 33.3% of males who had oral HPV while only 20% of females had oral HPV. Also, oral HPV infection was significantly associated with periodontitis (p<0.05). In men, oral HPV positivity trended to be frequent with no HPV vaccination (p=0.08). No HPV vaccination was associated with lower income (p<0.05). There was no association between HPV status and sociodemographic and lifestyle variables. Interpretation: The prevalence in high-risk HPV genotypes among PWH was higher than what has previously been observed in PR. We also found a higher prevalence of HPV-18, which may explain clinical disparities concerning oropharyngeal cancer in PR’s population. Additionally, our findings highlight the importance of access to medical care in low-resource settings. Low income can be a surrogate of lack of access of care, which can impact early diagnosis, risk, and prevention of oral HPV. Therefore, targeting social determinants, may help lower the risk of infection and oral cancer in underserved populations. While our findings contribute to understanding the impact of social determinants in oral cancer, more studies are still needed that investigate the relationship between other sociodemographic factors that affect oral health in PWH. Citation Format: Carlos A. Solá-Morlá, Yabdiel Ramos-Valerio, Coral Martes-Villalobos, María M. Sánchez-Vázquez, Ramón F. Gonzalez-García, Ana P. Ortiz, Magaly Martinez-Ferrer, Josué Pérez-Santiago. Social determinants associated with HPV disparities among people with HIV infection in Puerto Rico [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B130.

Innovation in cancer policy & health systems education during hematology-oncology (HO) fellowship training: Single center experience.

446 Background: Cancer care delivery and outcomes in the US are influenced by a complex health system and regulatory environment. To our knowledge, a structured approach to education on these topics during HO training is lacking. We sought to evaluate baseline knowledge and establish a longitudinal curriculum aimed at educating HO trainees on cancer policy. Methods: First year HO trainees at Johns Hopkins were surveyed on their prior education related to affordability, social determinants of health, and oncologic drug development. Based on these results, a longitudinal curriculum with 10 didactic sessions led by invited content experts was developed and implemented into the 2022-23 academic year schedule. Impact of curriculum was evaluated through anonymous surveys at the beginning and end of each teaching session. Results: Pre-curricular intervention survey was completed by 12 fellows (100% response rate; 58% female, 41.6% White; 16.6% IMGs). All had treated patients that were uninsured (100%, n = 12), unable to afford care (100%, n = 12), or lacked stable housing, transportation, food and employment (100%, n = 12). Smaller number had counseled patients on clinical trial enrollment (50%, n = 6) or discussed trial endpoints (33%, n = 4). Systems education prior to fellowship varied by topic: social determinants of health (33%, n = 4), critical appraisal of clinical trials (33%, n = 4), oncologic care in low-resource settings (41.6%, n = 5), high-value care (66%, n = 8), health insurance (91%, n = 11). Pre and post-surveys demonstrated each teaching session was associated with a significant improvement in fellows’ confidence in understanding pre-set lecture objectives (Table; cumulative mean improvement 1.14 from “neutral” pre-intervention, to “agree” or “strongly agree” post-intervention). Conclusions: We demonstrate lack of education on practice-relevant systems topics in HO trainees at time of subspecialty education initiation. Our longitudinal systems education curriculum improved trainee awareness and understanding of these complex topics. Future efforts will build on this scalable curriculum utilizing trainee feedback and departmental buy-in with the goal of training an oncologic workforce better equipped to counsel patients, navigate structural barriers, and appraise evidence.[Table: see text]

The role of high-income countries in the establishment and development of modern critical care in low resource settings: A Slovenian model.

Critical care medicine is a young branch of medicine, of which the development was much faster in High Income Countries (HICs) than in Low Resources Settings (LRS). Slovenia, as one of the successor states of former Yugoslavia, passed the process of transition and joined the European Union successfully. On the contrary, Bosnia and Herzegovina (B&H) went through the extremely difficult process of transition (four years of civil war), which left a deep scar to the healthcare system, including critical care medicine. To examine the impact of HICs on the development of critical care in LRS. This review examined the process of growing up the first modern Medical Intensive Care Unit (MICU) in the Republic of Srpska. The five-year process of transferring critical care knowledge from Slovenia to the health care system of Republic of Srpska has contributed to the existence of modern and state of the art MICU with tremendous social effects. The model of using the impact of HICs for improving critical care in LRS can be extrapolated to other similar settings.

Cancer Care During the COVID-19 Pandemic: The African Narrative and Prospects.

The COVID-19 pandemic has had a significant impact on healthcare services globally. Whilst it has been particularly disruptive for cancer care in low-resource settings, a few African countries have been able to adapt strategies to enable continued delivery of medical care to persons with cancer. This study seeks to highlight how much effect the coronavirus pandemic has had on oncological care in Africa and to indicate the way forward. For this narrative review, PubMed and Google Scholar were used to search for literature addressing the effect of the coronavirus pandemic on the care of patients with cancer in Africa with ensuing coping strategies. Selection criteria were manuscripts published since the onset of the pandemic in 2019 and written in the English language with Africa being the focus. In total, 52 research papers involving up to 21 African nations were found and reviewed. Across the board, the COVID-19 pandemic resulted in the deferral of oncological screening programs and a halt in immunization activities routinely scheduled for preventable cancers. It caused a colossal shortage in the availability of appropriately trained medical personnel, reduced frequency and duration of outpatient consultations, and a delay in cancer investigations and diagnosis. It also stirred up the substandard modification of chemotherapy regimens and radiotherapy due to the scarcity of anticancer medications and radioisotopes and engendered the cancellation of cancer surgical procedures. Palliative care for patients with locally advanced and metastatic disease was in many cases interrupted and cancer research activities were abruptly deferred. Ultimately, these led to poor patient outcomes and increased cancer-related fatalities. However, a few African countries - Rwanda, Ghana, and Tunisia - have continued to adapt telemedicine, small unmanned aircraft systems (sUAS), and home therapy to facilitate cancer care. To date, there is a paucity of data concerning the successesand cost-effectiveness of these relatively new methods recently adapted to cater to the medical needs of cancer patients in Africa. The pandemic has presented the African communityan opportunity to advance her healthcare systems, especially as it pertains to the delivery of medical care to persons with cancer. The need of the hour is to study further the alternative cancer care delivery systems initiated during the pandemic in order to determine their sustainability in Africa at large.

Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study.

The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

A Delphi Study to Prioritize Evidence-Based Strategies for Cardiovascular Disease Care in India.

The online version contains supplementary material available at 10.1007/s43477-023-00087-2.

SERVANT HEARTS: VILLAGE CADRES’ PUBLIC SERVICE MOTIVATION IN INDONESIA’S MENTAL HEALTH CARE

Background: Despite the growing interest in public service motivation (PSM) research, there is a lack of studies that specifically examine the PSM of individuals in nontraditional roles, such as village cadres, in the context of mental health care in low-resource settings. Aims: This study aimed to fill this knowledge gap by exploring how PSM influences the actions and choices of village cadres in providing care for people with mental illness in Indonesia. Methods: An instrumental case study approach was employed to gather data through in-depth interviews with 14 village actors across five regencies in East Java Province, Indonesia. Results: The study’s findings reveal the crucial role of PSM in inspiring village cadres to provide mental health care by showcasing their sense of duty toward the community, program dedication, and compassion for patients, highlighting the correlation between PSM and callings that focuses on serving others. Conclusion: This study provides empirical insights into the intricate ways PSM influences the behavior of village cadres toward people with mental illness in Indonesia, offering valuable knowledge about the motivations of this particular group of public service providers and informing policy decisions and future research in the field of public administration. Keywords: callings, Indonesia, mental health care, public service motivation, village cadres

SERVANT HEARTS: VILLAGE CADRES’ PUBLIC SERVICE MOTIVATION IN INDONESIA’S MENTAL HEALTH CARE

Background: Despite the growing interest in public service motivation (PSM) research, there is a lack of studies that specifically examine the PSM of individuals in nontraditional roles, such as village cadres, in the context of mental health care in low-resource settings. Aims: This study aimed to fill this knowledge gap by exploring how PSM influences the actions and choices of village cadres in providing care for people with mental illness in Indonesia. Methods: An instrumental case study approach was employed to gather data through in-depth interviews with 14 village actors across five regencies in East Java Province, Indonesia. Results: The study’s findings reveal the crucial role of PSM in inspiring village cadres to provide mental health care by showcasing their sense of duty toward the community, program dedication, and compassion for patients, highlighting the correlation between PSM and callings that focuses on serving others. Conclusion: This study provides empirical insights into the intricate ways PSM influences the behavior of village cadres toward people with mental illness in Indonesia, offering valuable knowledge about the motivations of this particular group of public service providers and informing policy decisions and future research in the field of public administration. Keywords: callings, Indonesia, mental health care, public service motivation, village cadres