Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

The Local Heroes Project: a youth-led pan-India hyperlocal crisis relief model during the COVID-19 pandemic.

Introduction: There was shortage of essential diagnostic and therapeutic supplies in public hospitals during the second wave of COVID-19 in India. Materials and methods: The Local Heroes Project, a hyperlocal project initiated by the World Youth Heart Federation (WYHF). Pilot project was conducted in six cities, and a nationwide project was scaled up to 58 city groups with 438 volunteers. Three-step model of needs assessment, fundraising, and establishment of the supply chain was undertaken. A national team was formed consisting of representatives from multiple international organizations and stakeholders. Local Volunteers were recruited and empowered in each city to conduct donation drives. The Qualitative Comparative Analysis (QCA) model was used to assess the impact of the intervention. Results: 48.2% of the city groups completed needs assessment and 37.9% completed their donations. Factors such as team strength more than 4, local needs assessment, regular reporting during monthly meeting, receptive local administration, donation to more than 2 health centers and donation of supplies worth >= Rs 5,000 in each city (raw coverage 0.44, consistency 1) were more important contributors for success of the outcome. Supplies worth INR 2.45 million were donated. Conclusion: Hyperlocal projects can effectively address essential supply shortages. A three-step model of needs assessment, fundraising, and supply chain establishment can be an effective approach. Community involvement and donations are crucial for the success and sustainability of such projects.

Peer mentorship to build research capacity among members of the International Student Surgical Network (InciSioN): a proof of concept study.

BACKGROUND: International Student Surgical Network (InciSioN) is the largest student and trainee global surgery interest group worldwide and its members have contributed significantly to global surgery research. The InciSioN Research Capacity-Building (IReCaB) program aimed to enhance the research skills and confidence of participants via a peer mentorship model. METHODS: After an open call to members of InciSioN to enroll, participants' knowledge of research methods and the process was evaluated through a test to assign mentor and mentee roles, with mentors being those who scored ≥ 20/25. Mentors then delivered a series of four webinars to help disseminate research methodology to mentees. Finally, mentees were tested on their knowledge of research and their satisfaction with the program was also evaluated. RESULTS: Fifty-two participants, mostly from LMICs (n = 23/52, 44.2%) were enrolled, and 36 completed the program. There was a significant improvement in the proportion of questions answered correctly on the post-program test (R = 0.755, p < 0.001). Post-IReCaB test scores were greater than pre-IReCaB scores (p < 0.001). The difference in confidence after the course was also significant (p < 0.001). IReCaB participants successfully designed, implemented, and published an international cross-sectional study. CONCLUSION: This study showed improvements in participants' understanding of theoretical components of scientific research. We offer a model for research capacity building that can be implemented, modeled, and further refined by similar organizations with academic research goals.

TRUE-Bolivia: Trauma Responders Unifying to Empower Communities in Santa Cruz, Bolivia.

BACKGROUND: The aim of this study is to assess the efficacy of the TRUE-Bolivia (Trauma Responders Unifying to Empower Communities Bolivia) trauma first responder course at improving participant confidence in first responder abilities and increasing knowledge of trauma response skills. METHODS: Participants attended the 4-h TRUE-Bolivia course at the municipal department of urban transportation and universities and medical schools in Santa Cruz, Bolivia and completed a demographic survey and pre- and post-course knowledge assessments. All participants who attended the full course and completed both knowledge assessments were included in the study, with 453 people attending at least one portion of the course and 329 completing the full course and assessments. RESULTS: A majority of participants were men, had completed high school or attended university, and worked or trained in the fields of transportation or medicine. Participant ratings of confidence on a 5-point Likert scale improved from a median of 3 (interquartile range [IQR] 2) before the course to 5 (IQR 1) after the course (P < 0.01). The median number of correct answers on the pre-course nine-question knowledge assessment was 3 (IQR 3), improving to 7 (IQR 3) on the post-course assessment (P < 0.01). All demographic groups demonstrated improvements in scores from the pre- to post-test. Female gender, higher education level, a background in medicine, and prior training in first aid were associated with higher pre- and post-test scores. CONCLUSIONS: The TRUE-Bolivia course increased knowledge of first responder skills and improved confidence in these abilities in participants from a variety of backgrounds. Further study is needed to determine the long-term skill utilization by participants and the course's impact on local trauma morbidity and mortality.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Evaluation of a First Responders Course in Rural North India.

BACKGROUND: Most mortality in trauma occurs in prehospital settings when the golden hour is spent accessing healthcare facilities rather than resuscitating and stabilizing. Assessments performed in the rural community of Nanakpur, India demonstrated a significant paucity of, and limited access to healthcare facilities. To address deficiencies in prehospital care, the All-India Institute of Medical Sciences (AIIMS) constructed the Basic Emergency Care Course (BECC). This study evaluated the BECCs efficacy in Nanakpur. METHODS: The first responder courses took place in 2017 in Nanakpur. Local community health workers, known as Accredited Social Health Activists (ASHAs) were recruited as participants. Participants completed both a pre- and post-course evaluation to assess baseline knowledge and improvement. Participants then took a one-year post-course assessment to evaluate retention. RESULTS: The course included 204 individuals, and over half (109/204) were ASHAs. Pre- and post-course test results were available for 70 participants and demonstrated a significant improvement in knowledge (P < 0.0001). The one-year knowledge retention assessment was completed by 48.6% (n = 53/109) of the original ASHAs. Comparisons between both the pre- and post-course assessment tests with the 12-mo retention assessment revealed a significant decay in knowledge (P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of utilizing BECC to train ASHAs in Nanakpur as first responders. Participants demonstrated a significant improvement in knowledge immediately after the course. After one year, there was a significant loss in knowledge, highlighting the need for refresher courses. These data suggest potential for the use of BECC for training ASHAs countrywide to strengthen India's prehospital care system.

Surgical and Trauma Capacity Assessment in Rural Haryana, India.

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified. Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools. Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively. Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures. Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.

The Bolivian trauma patient's experience: A qualitative needs assessment.

BACKGROUND: Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. METHODS: Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. RESULTS: Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. CONCLUSIONS: This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.

Closing the Gender Gap in Global Surgery: Trends at the Academic Surgical Congress.

INTRODUCTION: Female researchers are underrepresented in academic surgery. While they are increasingly producing original research, they lag male researchers in productivity. This disparity is not well understood within the nascent field of global surgery. The following study examines gender parity in global surgery research presented at the Academic Surgical Congress and within subsequent publications. METHODS: Abstracts presented at the Academic Surgical Congress (ASC) between 2015 and 2019 in "Global Surgery" sessions were reviewed to obtain title, the first author (FA) and senior author (SA). The authors were classified by gender. The Scopus database was queried by two reviewers for abstracts with corresponding publications, citations, and journal impact factors. Statistical analysis was conducted using chi-square analysis and t-tests where appropriate. RESULTS: Of a total of 6635 abstracts, 218 global surgery abstracts over a 5-year period were identified. Of these abstracts, 96 (44%) had female FAs, while 56 (26%) had female SAs. When comparing gender, female (44%) FAs and male (56%) FAs were equally represented. While SAs were significantly less likely to be female (26% versus 74%, P < 0.0001), female senior authorship increased significantly within the study period. Output with respect to publications, citations, and journal impact factors were equal by gender. CONCLUSIONS: This study presents 5 y of gender trends in global surgery scholarly work presented at the ASC. Despite an overall predominance of male senior authors, the paradigm is shifting with a recent trend to gender parity. Male and female authors have equal output and are equally impactful. Findings of gender equity in academic global surgery are encouraging, and further study of other disciplines are warranted.

What is trauma? Qualitatively assessing stakeholder perceptions in Santa Cruz de la Sierra, Bolivia.

Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.

Gender-Specific Conferences and Symposia: A Putative Support Structure for Female Physicians.

Objective: To determine the impact of gender-specific conferences or symposia as it relates to medical professional development. Materials and Methods: An online survey instrument was distributed nationally through social media and shared by respondents. The survey assessed participants' demographics, attendance at gender-specific conferences or symposia, motivations or barriers to attendance, and perceived benefits of attendance. Results: Of 792 respondents, 34% had attended a conference or symposia for women in medicine, whereas 66% had not. Attendees were significantly more likely to hold a leadership position (68% vs. 43%, p < 0.0001), an academic faculty position (74% vs. 56%, p < 0.0001), and have received a professional accolade within the past year (42% vs. 28%, p < 0.0001). Nonattendees were significantly more likely to be the primary caregiver for children or seniors (64% vs. 56%, p = 0.042). Respondents indicated that an interest in discussion topics, a sense of community, and growth of professional network were key motivators in attendance. The majority of respondents indicated that attendance improved their self-advocacy, self-image, and leadership skills. Of those who did not attend, 51% were unaware of such conferences or symposia. Those who were aware, but unable to attend, cited lack of time as the major barrier to participation. Conclusions: The results of this study provide preliminary data surrounding gender-specific conferences or symposia for women in medicine and highlight opportunities for increased engagement. While not causative, attendees share attributes of professional success and report personal and professional benefits. Lack of awareness and access to child/family care are likely major barriers to participation, which can be addressed through strategic initiatives.

Geriatric Trauma in Santa Cruz, Bolivia.

BACKGROUND: The population of Latin America is aging. Research from high-income countries demonstrates geriatric trauma is associated with higher morbidity and mortality. Very little research exists on geriatric patient (GP) injury prevalence in low-resource settings, like Bolivia. METHODS: Data were collected prospectively for 34 mo in the emergency departments of six trauma registry hospitals in Santa Cruz, Bolivia. Data were analyzed with Stata v14. Comparisons were made between GPs, defined as age greater than 65 y, and younger patients (YPs), with ages 18-64 y. RESULTS: Of n = 8796 trauma registry patients, 10.1% (n = 797) were aged 65 y or above, and n = 4989 (63.1%) were aged 18-64 y. The majority of GPs suffered falls (n = 543, 69.6%) versus 30.9% (n = 1541) of YPs (P < 0.001). Frequently, GPs had isolated injuries of the pelvis/hip (15.9% versus 1.4% YP, P < 0.0001) or upper extremity (15.8% versus 18.5% YP, P = 0.07), while YPs had a higher incidence of multiple injuries (YP 14.8% versus GP 8.4%, P < 0.001). While the majority of patients were discharged home (GP 43.0% versus YP 48.1%, P = 0.008), GPs were more likely to be admitted to the hospital (32.3% versus 22.3%, P < 0.001). CONCLUSIONS: As life expectancy improves, the incidence of geriatric trauma will continue to increase. Understanding the characteristics associated with trauma in GP can allow for effective prevention methods, resource distribution, and discharge planning.

Empowering Bystanders to Intervene: Trauma Responders Unify to Empower (TRUE) Communities.

BACKGROUND: Timely and effective bystander first aid can improve outcomes for trauma victims. Bystanders are present at most traumas and are more likely to assist with prior training. MATERIALS AND METHODS: An evidence-based course was created for the general public in high-risk Chicago neighborhoods focused on basic traumatic first aid, including scene management, hemorrhage control, and mitigating the psychological impact of trauma to overcome the bystander effect. Prospectively, participants completed knowledge-based and self-efficacy assessments precourse, postcourse, and 6 mo follow-up. The change in self-efficacy and knowledge scores was analyzed. RESULTS: Over 32 courses, 503 participants were taught; 474 and 460 participants completed precourse and postcourse surveys, respectively, whereas 60 of 327 who consented for follow-up completed the 6-mo survey. Postcourse, participants were more likely to assist trauma victims and felt more confident in the quality of care they could provide; the effect remained significant at 6 mo (all P < 0.001). All seven self-efficacy empowerment-based questions individually demonstrated improvement from precourse to postcourse (P < 0.001), with an overall mean (SD) increase of 2.8 (2.1, P < 0.001); six maintained significance at follow-up with an overall mean increase of 2.8 (1.9, P < 0.001). Knowledge scores improved from 6.2 of 10 to 7.2 postcourse and 7.7 at follow-up (P < 0.001). Most improved were the ability to render first aid and apply tourniquets. CONCLUSIONS: The TFRC increased self-efficacy, successfully teaching initial trauma care, particularly hemorrhage control and scene safety, suggesting that a grassroots approach to trauma care may improve outcomes in communities that experience high violence rates.

SOSAS Study in Rural India: Using Accredited Social Health Activists as Enumerators.

BACKGROUND: Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators. MATERIAL AND METHODS: Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care. RESULTS: One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%). CONCLUSIONS: This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.

Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.