Geospatial availability of breast cancer treatment modalities and hypothetical access improvement in Ghana: A nationwide survey.

Breast cancer in Ghana is a growing public health problem with increasing incidence and poor outcomes. Lack of access to comprehensive treatment in Ghana may be a contributing factor to its high mortality. The purpose of this study was to evaluate the availability of treatments nationwide and systematically identify high yield areas for targeted expansion. We conducted a cross-sectional, nationwide hospital-based survey from November 2020-October 2021. Surveys were conducted in person with trained research assistants and described hospital availability of all breast cancer treatments and personnel. All individual treatment services were reported, and hospitals were further stratified into levels of multi-modal treatment modeled after the National Comprehensive Cancer Network (NCCN) Framework treatment recommendations for low-resource settings. Level 3 included Tamoxifen and surgery (mastectomy with axillary lymph node sampling); Level 2 included Level 3 plus radiation, aromatase inhibitors, lumpectomy, and sentinel lymph node biopsy; Level 1 included Level 2 plus Her2 therapy and breast reconstruction. Hospitals were identified that could expand to these service levels based on existing services, location and personnel. The distance of the total population from treatment services before and after hypothetical expansion was determined with a geospatial analysis. Of the 328 participating hospitals (95% response rate), 9 hospitals had Level 3 care, 0 had Level 2, and 2 had Level 1. Twelve hospitals could expand to Level 3, 1 could expand to Level 2, and 1 could expand to Level 1. With expansion, the population percentage within 75km of Level 1, 2 and 3 care would increase from 42% to 50%, 0 to 6% and 44% to 67%, respectively. Multi-modal breast cancer treatment is available in Ghana, but it is not accessible to most of the population. Leveraging the knowledge of current resources and population proximity provides an opportunity to identify high-yield areas for targeted expansion.

Analysis of the Perinatal Care System in a Remote and Mountainous District of Nepal.

INTRODUCTION: Despite significant improvements in recent years, maternal and neonatal health outcomes remain poor in many regions of the world. One such area is in the remote mountainous regions of Nepal. The purpose of this study is to describe the current antenatal care practices and delivery support in a mountainous district of Nepal. METHODS: This study took place in Solukhumbu District between December 2015 and February 2018. A household survey was created using evidence-based maternal and neonatal care indicators. Women who had delivered within the previous two years were surveyed regarding antenatal and delivery care they received. A standardized health facility survey was used to evaluate the operational status of health facilities. The study was approved by the Nepal Ministry of Health and the University of Utah IRB. RESULTS: A total of 487 households and 19 facilities were surveyed. 35.7% (174/487) of deliveries occurred in a health facility (hospital, primary health care center or birthing center). 35.2% (171/486) of deliveries were attended by a skilled birth attendant. 52.8% (47/89) of women who did not deliver in a facility noted that transportation issues and not having sufficient time to travel during labor prevented them from delivering in a facility. No health posts had staff trained in obstetric and neonatal emergencies. DISCUSSION: The majority of women in Solukhumbu District do not receive high quality antenatal and delivery care. An intervention that would make antenatal care and delivery support more accessible could improve maternal and infant outcomes in this district and other similar regions.

Drivers of Moral Distress in Surgical Intensive Care Providers: A Mixed Methods Study.

BACKGROUND: Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. MATERIALS AND METHODS: This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. RESULTS: 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. CONCLUSIONS: Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.