Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon.

INTRODUCTION: Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon. METHODS: This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach. RESULTS: The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted. CONCLUSION: Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon.

INTRODUCTION: Equitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills. METHODS: In-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants. RESULTS: Living in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts. CONCLUSIONS: The experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review.

Background: The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population. Materials and methods: A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation. Results: Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group. Conclusions: Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.

Availability and Use of Essential Opioid Analgesics in Sub-Saharan Africa: A Scoping Review Protocol.

Introduction: The treatment of acute, peri-operative, and chronic pain by healthcare practitioners and health systems requires appropriate access to and availability of essential opioid medications. While opioids are often oversupplied and overprescribed in high-income countries, there are significant inequities as many low- and middle-income countries (LMICs) experience severe shortages. In fact, while the richest 10% in the world reside in countries receiving almost 90% of all available opioids, 50% of the poorest in the world reside in countries receiving just 1% of all available opioids.Understanding the social, economic, cultural, and regulatory barriers to access essential opioid analgesics in LMICs is critical in delineating and prioritizing appropriate interventions. We aim to conduct a scoping review on the availability and usage of essential opioid analgesics in LMICs, specifically in sub-Saharan Africa, to identify barriers, themes, and knowledge gaps. Materials and Methods: We will utilize the framework for conducting scoping reviews by Arksey and O'Malley. We will perform the search for articles in 3 electronic databases (i.e., SCOPUS, PubMed, Embase) and relevant gray literature. Only articles in English will be included. There will be no restriction on the publication period. All articles will directly involve either the availability and/or the use of essential opioid analgesics. Studies will be restricted to focus on sub-Saharan Africa. We will use a tailored extraction frame to extract relevant information from published articles that meet our inclusion criteria. We will analyze the data using both descriptive statistics and thematic analysis on the main study questions. Ethics and Dissemination: Since we will not be collecting primary data, formal ethical approval is not required.Our study findings will be disseminated through abstracts, conference presentations, and peer-reviewed publications. Highlights: 50 percent of the poorest in the world reside in countries receiving just 1 percent of all available opioidsThere is a paucity of data analyzing the inequitable distribution of essential opioid analgesics worldwideOur scoping review will identify barriers, themes, and knowledge gaps on the availability and use of essential opioids in SSAIt will identify areas for further research and potential policy initiatives.

A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa.

BACKGROUND: Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA). METHODS: The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training. RESULTS: 6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical. CONCLUSIONS: Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.

Management and outcomes of chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review protocol.

Introduction: Pneumoperitoneum - free air within the peritoneal cavity - is often the result of bowel perforation, though other causes include residual postprocedural or postoperative air and barotrauma. In non-cancer patients, operative intervention is often required. Cancer patients, on the other hand, present a unique set of challenges as they usually have elevated risk of pneumoperitoneum from local radiation therapy, frequent endoscopic procedures, and tumor invasion. Factors such as malnutrition, neutropenia, chemotherapy, and steroid use make emergent surgery tenuous in cancer patients. There is a paucity of published literature on the management of pneumoperitoneum in patients actively undergoing chemotherapy. The main objective of this scoping review is to assess the presentation, management, and subsequent outcomes of this unique patient population. Materials and Methods: The authors will utilize the framework for performing scoping reviews as outlined by Arksey and O'Malley. They will perform the search for articles in three electronic databases (i.e. SCOPUS, PubMed, Embase) and relevant gray literature. Only articles available in English and published between 1999 and 2022 will be included. Inclusion criteria will be a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. Exclusion criteria will be cancer diagnosis at the time of presentation, perforation secondary to cancer itself, and chemotherapy greater than 6 months prior to presentation. A tailored extraction frame to extract relevant information from published articles that meet our inclusion criteria. The data using both descriptive statistics and thematic analysis of the main study questions. Ethics and Dissemination: Since the authors will not be collecting primary data, formal ethical approval is not required. They study findings will be disseminated through abstracts, conference presentations, and peer-reviewed publications.

Examining the Implementation of the Performance-Based Financing Equity Strategy in Improving Access and Utilization of Maternal Health Services in Cameroon: A Qualitative Study.

Performance-based financing (PBF)-a supply-side strategy that incentivizes health providers based on predefined quality and quantity criteria-introduced an innovative approach to reaching the poor by means of using PBF equity instruments. These PBF equity instruments include paying providers more to reach out to poor women, selecting services used by the poor, subsidizing user fees to reduce out-of-pocket expenses, and adding complementary demand-side intervention. Before the implementation of the PBF equity instrument in Cameroon, there were few initiatives/schemes to enable the poor to access maternal health services. Moreover, there is a significant research gap on how the equity elements are defined and implemented across contexts. This study aims to understand (i) how health facilities define and classify the poor and vulnerable in the context of PBF, (ii) how the equity elements are implemented at the community and facility levels, and (iii) the potential impact on access to and the use of maternal health services at the facility level and challenges in the implementation process. We used key informant interviews and focus group discussions (FGDs) based on a grounded theory approach to gain an understanding of the social processes and experiences. Data were collected from three districts in the Southwest region of Cameroon from April 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. The thematic analysis approach/technique was used to analyze data. Key informant interviews and focus groups were conducted with 79 participants, including 28 health professionals and service administrators, 27 pregnant women, and 24 community health workers in three districts. Health facilities employed various subjective approaches to assess and define poor and vulnerable (PAV) persons. Home visits were reported to have an impact in reaching the poor and vulnerable to improve access to maternal services. Meanwhile, a delay in the payment of PBF incentives was reported to be the main challenge that had a negative relationship with the consistent provision of care to the poor and vulnerable, especially in private health facilities. The theory generated from our findings suggests that the impact of the PBF equity elements specific to maternal health depends on (i) a shared understanding of the definition of PAV among different stakeholders, including providers and users, as well as how the PAV is operationalized (structure), and (ii) the appropriate and timely payment of incentives to health facilities and health providers.

Perceptions and practices of community members relating to trachoma in Africa: a qualitative systematic review.

OBJECTIVE: The objective of this review was to synthesize the perceptions and practices of community members relating to trachoma in Africa. INTRODUCTION: Trachoma is the leading cause of blindness worldwide, and Africa is the worst-affected continent. Synthesized evidence relating to the disease has focused on various aspects including epidemiology, control, health education, facial cleanliness, interventions for trachomatous trichiasis, and the burden of trachoma on women. Currently, systematic reviews on perceptions and practices relating to trachoma are lacking despite the existence of primary studies. Filling this knowledge gap is critical for decision-making for effective community uptake of interventions. INCLUSION CRITERIA: Qualitative studies on the perceptions and practices relating to trachoma in both health care and community settings in Africa were considered for inclusion. Studies with participants 14 years or older were considered, regardless of gender, health status, religion, or ethnicity. Perceptions included beliefs, perspectives, views, knowledge, and thoughts relating to trachoma. Practices included regular actions relating to trachoma, such as treatment and prevention behaviors. METHODS: A search for studies in English was conducted in MEDLINE, CINAHL, Embase, PsycINFO, Sociological Abstracts, BioMed Central, Current Contents, Cochrane Library, and Google Scholar in May 2019 and updated in October 2021. Unpublished studies were searched in MedNar, Index to Thesis, ProQuest Dissertations and Theses Global, World Health Organization, and individual governments' commissioned trachoma reports. Two independent reviewers were involved in study selection, critical appraisal, and data extraction using the JBI tools. Data were synthesized using the JBI meta-aggregative approach. RESULTS: Seven studies were included in this review. Participants were people either with or without trachoma. A total of 90 findings were extracted, from which 10 categories were produced and three synthesized findings derived from the categories. The synthesized findings are: understanding and awareness of trachoma influences perceptions of treatment and preventive methods; beliefs and behaviors influence treatment options; economic constraints, socio-cultural beliefs, and risk perceptions influence prevention behaviors and practices. CONCLUSION: Various perceptions and practices relating to trachoma exist among community members in Africa. These perceptions and practices are influenced by knowledge, cultural beliefs, economic factors, and environmental factors. The findings suggest the need for decision-makers in policy and practice to consider and include these perceptions and practices when designing interventions to combat trachoma in endemic countries. However, due to the limited number of included studies and their methodological weaknesses, more high-quality studies are needed to have a deeper and broader view on these perceptions and practices.

Rapid reviews and the methodological rigor of evidence synthesis: a JBI position statement.

ABSTRACT: The demand for rapid reviews has exploded in recent years. A rapid review is an approach to evidence synthesis that provides timely information to decision-makers (eg, health care planners, providers, policymakers, patients) by simplifying the evidence synthesis process. A rapid review is particularly appealing for urgent decisions. JBI is a world-renowned international collaboration for evidence synthesis and implementation methodologies. The principles for JBI evidence synthesis include comprehensiveness, rigor, transparency, and a focus on applicability to clinical practice. As such, JBI has not yet endorsed a specific approach for rapid reviews. In this paper, we compare rapid reviews versus other types of evidence synthesis, provide a range of rapid evidence products, outline how to appraise the quality of rapid reviews, and present the JBI position on rapid reviews. JBI Collaborating Centers conduct rapid reviews for decision-makers in specific circumstances, such as limited time or funding constraints. A standardized approach is not used for these cases;instead, the evidence synthesis methods are tailored to the needs of the decision-maker. The urgent need to deliver timely evidence to decision-makers poses challenges to JBI's mission to produce high-quality, trustworthy evidence. However, JBI recognizes the value of rapid reviews as part of the evidence synthesis ecosystem. As such, it is recommended that rapid reviews be conducted with the same methodological rigor and transparency expected of JBI reviews. Most importantly, transparency is essential, and the rapid review should clearly report where any simplification in the steps of the evidence synthesis process has been taken.

Scoping review protocol to understand the conceptualisation, implementation and practices of health promotion within the context of primary healthcare in Africa.

INTRODUCTION: The ongoing COVID-19 pandemic has highlighted the importance of health promotion in empowering and sustaining communities, as well as the need to build resilient health systems and work collectively with other sectors to protect and promote health. The WHO has mainstreamed health promotion in the Global health agenda. However, the definition and practices of health promotion in Africa are not well understood and documented, with often, an interchangeable use of the concept of health promotion and health prevention. This scoping review is to explore how health promotion is defined and practised in Africa and identify gaps in its implementation within the framework of the Ottawa Charter. METHODS AND ANALYSIS: The scoping review will employ the approach described by Arksey and O'Malley in 2005. The approach consists of five stages: (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data and (5) collating, summarising and reporting the results. This protocol employed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). The review will apply the PRISMA extension for scoping reviews to present the results. The scoping review will adapt the five principles set forth in the Ottawa Charter to categorise the outcomes and uses its strategies to define the interventions. Data bases searched are Ovid Medline, Embase, Cochrane Library, CINAHL, SCOPUS, CABI, JBI Evidence Synthesis and grey literature. The database last searched was January 2021. ETHICS AND DISSEMINATION: This review does not require ethics approval. Our dissemination strategy includes peer review publication, policy brief, presentation at conferences and relevant stakeholders.

Perceptions and practices of community members relating to trachoma in Africa: a qualitative systematic review protocol.

OBJECTIVE: The objective of this systematic review is to synthesize and present the best available evidence on community perceptions and practices relating to trachoma in Africa. INTRODUCTION: Globally, trachoma is the leading cause of blindness and is responsible for about 1.4% of all cases of blindness. The African continent is the worst affected, with about 1.9 million cases of trichiasis (61%). While interventions are currently being implemented to combat the disease in Africa, very little is known by decision makers about community perceptions and practices relating to trachoma, which may hinder successful implementation. INCLUSION CRITERIA: Studies with participants, regardless of their health status, gender, religion and ethnicity, aged 14 and over conducted in any African country, will be considered. Studies on Africans, conducted out of the continent and those involving healthcare professionals, will not be included in this review. METHODS: Qualitative studies, published in English from 1996 onwards. will be considered. Databases to be searched will include, but not be limited to: PubMed, CINAHL, Embase and PsycINFO. Study selection, critical appraisal and data extraction will be conducted by two independent reviewers, using the appropriate JBI methodology and any disagreement will be resolved by discussion or with a third reviewer. Qualitative findings will be synthesized using the appropriate JBI methodology, following the meta-aggregation approach. Where textual pooling is not possible, the findings will be presented in narrative form. The ConQual approach will be used to grade synthesized findings, and these will be presented in a Summary of Findings.