Implementation science in humanitarian assistance: applying a novel approach for humanitarian care optimization.

Humanitarian assistance is hindered by a lack of strategies to optimize care delivery through research and organized networks. Distinct from global health, humanitarian assistance struggles to address its multifaceted challenges, including duplicative resources, uncoordinated communication, unregulated staff expertise and safety, financial waste, and poor-quality metrics and care delivery. Implementation science provides an exciting and underutilized approach that can be applied to address these challenges, by studying how to effectively design, implement, optimize, and scale evidence-based interventions. Though successful in well-resourced and global health systems, implementation science approaches are rare in humanitarian assistance. Adopting implementation science approaches including identifying determinants, creating accessible evidence-based intervention bundles, adapting study methodologies for the humanitarian context, and partnering with implementation experts could make these promising approaches more accessible for thousands of humanitarian actors delivering healthcare for millions of vulnerable patients worldwide.

Evidence supporting performance measures of laparoscopic appendectomy through a novel surgical proficiency assessment tool and low-cost laparoscopic training system.

BACKGROUND: Laparoscopic training remains inaccessible for surgeons in low- and middle-income countries, limiting its widespread adoption. We developed a novel tool for assessment of laparoscopic appendectomy skills through ALL-SAFE, a low-cost laparoscopy training system. METHODS: This pilot study in Ethiopia, Cameroon, and the USA assessed appendectomy skills using the ALL-SAFE training system. Performance measures were captured using the ALL-SAFE verification of proficiency tool (APPY-VOP), consisting of a checklist, modified Objective Structured Assessment of Technical Skills (m-OSATS), and final rating. Twenty participants, including novice (n = 11), intermediate (n = 8), and expert (n = 1), completed an online module covering appendicitis management and psychomotor skills in laparoscopic appendectomy. After viewing an expert skills demonstration video, participants recorded their performance within ALL-SAFE. Using the APPY-VOP, participants rated their own and three peer videos. We used the Kruskal-Wallis test and a Many-Facet Rasch Model to evaluate (i) capacity of APPY-VOP to differentiate performance levels, (ii) correlation among three APPY-VOP components, and (iii) rating differences across groups. RESULTS: Checklist scores increased from novice (M = 21.02) to intermediate (M = 23.64) and expert (M = 28.25), with differentiation between experts and novices, P = 0.005. All five m-OSATS domains and global summed, total summed, and final rating discriminated across all performance levels (P < 0.001). APPY-VOP final ratings adequately discriminated Competent (M = 2.0), Borderline (N = 1.8), and Not Competent (M = 1.4) performances, Χ2 (2,85) = 32.3, P = 0.001. There was a positive correlation between ALL-SAFE checklist and m-OSATS summed scores, r(83) = 0.63, P < 0.001. Comparison of ratings suggested no differences across expertise levels (P = 0.69) or location (P = 0.66). CONCLUSION: APPY-VOP effectively discriminated between novice and expert performance in laparoscopic appendectomy skills in a simulated setting. Scoring alignment across raters suggests consistent evaluation, independent of expertise. These results support the use of APPY-VOP among all skill levels inside a peer rating system. Future studies will focus on correlating proficiency to clinical practice and scaling ALL-SAFE to other settings.

Ten Questions to Guide Learners Seeking Equitable Global Health Experiences Abroad.

"Global health experiences," clinical and research learning opportunities where learners from high-income country (HIC) institutions travel to low- and middle-income countries (LMICs), are becoming increasingly popular and prolific in the health sciences. Increased interest has been well documented among medical, pharmacy, and nursing learners who are driving these agendas at their institutions. Although such opportunities have potential to mutually benefit the learner and host, in practice they can be exploitative, benefiting HIC learners without reciprocity for LMIC hosts. Given these and other pervasive ethical concerns in global health, efforts to decolonize global health and emphasize equity are being made at the institutional level. Despite progress toward global health equity from institutions, most learners lack the resources and education needed to critically evaluate the numerous global health opportunities or equitably codesign these experiences for themselves. This article offers 10 guiding questions that learners should answer before selecting or codesigning a global health opportunity through a lens of global health equity. These prompts encompass values including motivations, reciprocity, accountability, sustainability, financial implications, self-reflection, bidirectional communication, and mitigating burden and power dynamics. The authors provide tips, pitfalls to avoid, and pragmatic examples for learners working to actualize partnerships and opportunities aligned with the movement of global health equity. With these guiding questions and accompanying reflection tool, learners, faculty members, and their LMIC partners should be better equipped to engage in mutually beneficial partnership through the framework of global health equity.

Challenges and Effects of the COVID-19 Pandemic on Asylum Seeker Health at the U.S.-Mexico Border.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic presents health care challenges to asylum seekers living in congregate encampments, including those along the U.S.-Mexico border. It is necessary to understand the impact of the pandemic among this population to address health care needs, reduce transmission, and diminish COVID-19-related morbidity. Methods: Thirty interviews were conducted with asylum seekers and health care professionals in a temporary camp in Matamoros, Mexico to determine challenges, perceptions, and effects of the COVID-19 pandemic. Interviews were coded in NVivo12 by using a team-based approach. Results: The pandemic caused significant mental health burdens but no perceived adverse physical effects, with the U.S. border closure and health care access barriers as more pressing concerns. Participants reported access to information about COVID-19 but had varied levels of knowledge and adherence to disease reduction strategies due to camp conditions. Most participants believed that they had special protection from COVID-19, including strong immune systems or from God. The nongovernmental organizations providing health care and sanitation faced multiple challenges to implement new policies to manage COVID-19. The institution of required temperature checks and quarantine of COVID-19 positive patients led to distrust, decreased seeking of health care services among asylum seekers, and possible underreporting of COVID-19 cases. Conclusion: Our findings among asylum seekers in a Matamoros camp highlight the challenges to implementing disease reduction policies in low-resource congregate camps. Policies to address disease outbreaks focusing on the social determinants of health, health care access barriers, and community engagement may be more acceptable to asylum seekers, suggesting the need for effective strategies to provide prevention information that complements such measures.

Healthcare access barriers for FARC ex-combatants in Colombia: qualitative perspectives from healthcare providers and FARC health promoters.

BACKGROUND: Following the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs-Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services. METHODS: Semi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk's Domains of Healthcare Access framework. RESULTS: Among 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system. CONCLUSIONS: FARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.