Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey.

INTRODUCTION: We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India. METHODS: A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant. RESULTS: Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas. CONCLUSIONS: Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

Reimagining diaspora diplomacy during the COVID-19 crisis in India.

Diasporas are organized groups motivated by common cultural, ideological, political and religious values and common concerns for their countries of origin. Diaspora diplomacy has gained prominence worldwide, particularly in India, spurred by harrowing images of deaths and devastation due to the COVID-19 pandemic. A new generation of diaspora professionals modeled as social entrepreneurs uses collaborative and non-profit models to establish relationships with their counterparts to facilitate medical services and research. Teleradiology and telepsychiatry facilitate communication between diaspora members and their counterparts. We propose a common telehealth platform to standardize advice given by the Indian diaspora in the Global North as protocols change rapidly in acute pandemics. Consideration should be given to the well-known digital divide in India and other low- and middle-income countries. We advocate for diaspora members to train themselves in the art of global health diplomacy, to promote transparency and accountability in the collection of funds and a mandatory provision of outcome measurement by independent monitors rather than through social media. In the long run, Indian-Americans should play an active role in strengthening the domain of public health, which has historically been neglected in India, by focusing on the country's long-term infrastructure needs. The lessons learned from various diaspora efforts should be independently evaluated and recorded as best practice for future pandemics and humanitarian crises.

Trust Deficit in Surgical Systems in an Urban Slum in India Under Universal Health Coverage: A Mixed Method Study.

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India. Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion. Results: Responses from the 2 groups for "the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting" scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree (p = 0.076). Results between 2 groups regarding "Patient perceptions of quality" did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed (p = 0.064). Similar observations were made in the in depth interviews and focus group. Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Global health diplomacy: Provision of specialist medical services in the Republic of Botswana.

Global Health Diplomacy (GHD) can be defined as the convergence between public health and international affairs. The following case report demonstrates the impact of "brain drain" on provision of specialist medical services in Botswana, a middle-income country in Southern Africa and how GHD is being used to address the challenge. Botswana's priorities include the attainment of Sustainable Development Goals (SDGs) by 2030 which are embedded within the Ministry of Health and Wellness (MOHW) strategy. MOHW strategies include access to health services, reduction in the cost of referral of specialist services, and strengthening primary health care (PHC), which is the vehicle for attaining Universal Health Coverage (UHC). Botswana has, in the past tried to bridge this gap through strategic partnerships with private institutions and bilateral treaties with other states such as the Republic of Cuba and the People's Republic of China. In the private sector, the Ministry has partnered with Indus Medical Group, and a range of private medical institutions both in-country and outside the country. However, challenges experienced with previous partnerships were that the objectives were more service-driven than capacity building, which proved to be unsustainable. The case report outlines the negotiation process between the Government of Botswana represented by MOHW, and St. Paul Medical Missions, a religion-based NGO from Egypt. It demonstrated the importance of all actors and countries being clear on their health priorities at the start of negotiations. GHD is a relatively new concept that can be explored by countries in forming durable partnerships.

The burgeoning role of global health diplomacy to alleviate suffering of cancer patients in low- and middle-income countries.

The science of global health diplomacy (GHD) consists of cross-disciplinary, multistakeholder credentials comprised of national security, public health, international affairs, management, law, economics and trade policy. GHD is well placed to bring about better and improved multilateral stakeholder leverage and outcomes in the prevention and control of cancer. It is important to create an evidence base that provides clear and specific guidance for health practitioners in low- and middle-income countries (LMICs) through involvement of all stakeholders. GHD can assist LMICs to negotiate across multilateral stakeholders to integrate prevention, treatment and palliative care of cancer into their commercial and trade policies.

Commercialization of kidney transplants: a systematic review of outcomes in recipients and donors.

In this study we systematically reviewed outcomes in recipients and donors of commercial kidney transplants. Inherent in a study of this nature is the possibility of center and country bias, in particular there are no publications from China and South America. Publications also tended to report poor outcomes which may reflect bias on the part of the authors or to highlight the ethical issues in this area. We were unable to perform a meta-analysis due to variability in studies making it impossible to synthesize the data other than descriptive. Furthermore, these studies were not large or well conducted. We found that patient and graft survival was generally inferior to the data obtained from the UNOS (United Network for Organ Sharing). Some studies did achieve good outcomes, however, due to lack of details, it was not possible to infer if the donor hospital, surgical technique or immunosuppressive regimen was a factor. There was a higher incidence of unconventional and life-threatening infections such as malaria, invasive fungal infections, pneumonia, HIV and hepatitis. There was also a markedly increased incidence of postoperative surgical interventions in recipients. We suggest the establishment of a database for both recipients and donors to identify unique surgical, medical, infectious and immunosuppressive protocols for the recipients and donors in these hospitals. This could lead to better liaison between the recipient and donor hospitals so that modern surgical and medical practices can be implemented. There should also be improved emotional and psychological support to both the recipient and the donor. However, these steps could be seen as condoning the reprehensible practice of commercialization of human body parts.

The dynamics of recipient-donor relationships in living kidney transplantation.

Psychosocial issues in kidney transplant donors and recipients are a cause for concern. We reviewed studies that investigated psychosocial issues in donors and recipients of living kidney transplants. A variety of instruments were used for this purpose. However, there was a lack of consensus regarding the structure and method of psychosocial assessment in living kidney donors. We found that only a few centers currently carry out a systematic psychosocial follow-up of recipients and their donors. The majority of psychosocial studies were of living kidney donors, indicating a preference of researchers to study psychosocial issues in live kidney donors. We believe living kidney transplant recipients are also an important group, and more studies should be done to better understand the psychosocial issues in this group. The majority of studies were retrospective in nature. We also discuss relationships, interactions, and communication patterns that characterize living kidney donation. We place emphasis on understanding the relational history of donors and recipients to provide supportive intervention and enable the potential donor make an informed decision about surgery. We recommend comprehensive psychosocial screening before and after transplantation and donation. This may decrease psychological problems and increase satisfaction with the transplantation process. Furthermore, the transplant community will need to address the type of instruments, duration of follow-up, and funding sources to carry out our recommendations.

Kidney transplantation and gender disparity.

Gender inequity in access to hemodialysis and kidney transplantation has created a public health crisis in the US. Women have a lower chance of receiving hemodialysis and kidney transplant than men, but they constitute the majority of living kidney donors. Research has shown that economic factors such as greater income of men may encourage females to be donors; while gender-bias on part of physicians or institutions, lack of social support networks and differences in health-seeking behaviors compared to men are cited as reasons for this imbalance. We suggest various strategies to improve participation of women in the transplant process by education; raising awareness by publishing gender-specific data for dialysis and transplant centers; education and workshops to eliminate gender-bias within institutions and health-care providers and establishment of gender-specific support groups. Transplant teams that are more sensitive to the social complexities of women's lives may lead to increased understanding of the effects of renal disease and indicate measures that need to be in place in order to address this gender disparity in the treatment of renal failure. Research needs to be done to elucidate the underlying medical, societal or psychological processes that lead to gender bias in the field of kidney transplantation.

Psychosocial profiling: a holistic management tool for non-compliance.

We introduce a new concept of psychosocial profiling as a tool that provides the transplant team with a psychosocial framework for identification, intervention and management of non-compliance. This will also increase our understanding of emotional problems experienced by patients before transplant, as a result of living with the uncertainty and medical side effects of chronic illness. Psychosocial profiling is adaptable throughout the transplant process and gives every patient an opportunity of psychosocial support to help him or her into a position of emotional stability and compliance with their medications and postoperative care. Implementation of this strategy will move health care professionals from being gatekeepers to managers and facilitators of holistic care in recipients of transplants.

Prospective randomized study of individual and group psychotherapy versus controls in recipients of renal transplants.

BACKGROUND: Recipients of kidney transplant have been shown to develop emotional problems. These have been associated with medical noncompliance, compromised quality of life, and difficulty integrating the newly acquired transplant into their sense of self. In general, group psychotherapy has been shown to be more cost effective than individual therapy. We have compared the efficacy of two modalities of therapy in recipients of kidney transplants with control patients who did not receive therapy. METHODS: Recipients of first cadaver kidney transplants were randomized into two groups to receive a 12-week course of group or individual psychotherapy. The control arm of the study was composed of 37 consecutive patients who had received a first cadaver kidney. Recipients of live kidney transplants, and patients who received more than one kidney transplant, were excluded because these patients have different emotional issues. The Beck Depression Inventory (BDI) was used as a measure of change in emotional state, pretherapy, at 3, 6, 9, and 12 months. A higher score on BDI was suggestive of psychologic dysfunction. RESULTS: We recruited 89 recipients of first cadaver kidney transplants into the study. They were randomly allocated into the two study groups, 49 for individual therapy, and 40 for group therapy. Of these, 82 patients completed 12 weeks of therapy (45 patients from the individual treatment arm, and 37 from the group therapy arm). Fifty-five patients completed one-year follow-up (33 in individual therapy, and 32 in the group therapy). The mean score was 26.3 +/- 7.9 before and 18.9 +/- 9.0 after therapy in the individual treatment group (P= 0.001). This was in comparison with a mean score of 30.2 +/- 3.8 before and 26.0 +/- 4.2 after therapy for the group therapy arm (P= 0.01). Improvement appeared to be more significant in the individual therapy compared with group therapy (P= 0.01). Lowering of scores was progressive and sustained (P= 0.01). In the control arm, mean score was 9.4 +/- 5.4 before and 20.5 +/- 5.5 at the end of the first year (P= 0.005), suggesting a significant worsening of BDI scores. Multivariate analysis of age, gender, employment status, duration of dialysis, etiology of kidney failure, diabetes mellitus, and psychotherapy received at any time before transplantation did not affect results. CONCLUSION: We conclude that both individual and group psychotherapy were beneficial to our patients; however, individual therapy was found to result in lower BDI scores versus group therapy at the end of treatment period.

Quality of life after kidney and pancreas transplantation: a review.

There is an increasing amount of data on quality of life (QOL) in most chronic illnesses; some of the instruments used are generic, but recently, there is a tendency to use disease-specific instruments. We propose that recipients of organ transplants be assessed routinely for QOL by means of the 36-Item Short-Form Health Survey or a disease-specific instrument; for compliance, by means of the Long-Term Medication Behavior Self-Efficacy Scale; and for psychological status, by means of the Beck Depression Inventory Brief Symptom Inventory or the Symptom Checklist. The widespread use of QOL data in recipients of organ transplants will increase accountability of service providers and eventually increase patient satisfaction because these instruments are patient reported.