Search

Sexual and gender-based violence (SGBV) leads to severe sequelae for individuals and communities. Lack of cross-sector coordination inhibits effective medical–legal support and justice for survivors. Multisectoral trainings for health, legal, and law enforcement professionals on survivor-centered SGBV care were conducted in Kenya during 2012–2018. Evaluation utilized objective structured clinical examinations, standardized patients, knowledge assessments, and interviews. A total of 446 professionals participated in 18 trainings. Mean knowledge scores increased from 75.6% to 84.7% ( p

Postgraduate clinical global health (GH) training is a rapidly evolving field. To understand and improve training opportunities, we sought the perspectives of current and former trainees related to their advanced clinical training or global health fellowships and the anticipated impact on their careers. Clinical GH fellowships across North America were identified through websites and previous studies. An e-mail was sent to program directors to invite all current and former GH fellows to complete a web-based questionnaire. We contacted 100 GH fellowship programs. Fifty-two fellows from 10 different specialties completed the survey. The median fellowship length was 23.3 months, with an annual median of 4.8 months spent in low-income and middle-income countries, which was less than their reported ideal of 6 months. The majority reported satisfaction, the anticipation of career benefits, and that they would recommend fellowship training to others. Challenges included insufficient funding, mentorship, and formal curricula. Conducting research in high-income countries was a significant negative predictor of fellowship satisfaction. Most fellows (73.1%) were not at all or only a little concerned about the absence of fellowship accreditation, with only 17.3% desiring accreditation. Survey respondents were largely satisfied with their training and valued program flexibility and educational opportunities, including advanced tropical medicine certificates or diplomas. However, to improve fellowship training, improvements are needed in mentorship, standardized curricula, institutional support, and funding. For GH fellowship training to be effective and sustainable, institutions will need to balance the needs of fellows, training programs, and the communities (low-, middle-, and high-income countries) where the fellows serve.

Conflict-related sexual and gender-based violence is common in the eastern Democratic Republic of Congo, but there are few evaluations of multisectoral training interventions in conflict settings. We conducted high-quality, trauma-informed medicolegal trainings amongst multisectoral professionals and sought to describe changes in knowledge after training and perceived training acceptability. Participants were health, law enforcement, and legal professionals who completed training at one of four sites from January 2012 to December 2018. Twelve trainings were randomly selected for evaluation. We conducted pre- and post-training assessments and semi-structured interviews of participants within 12 months of index training. Forty-six trainings of 1,060 individuals were conducted during the study period. Of the randomly selected trainings, 368 questionnaires were included in the analysis (36% health, 31% legal, 12% law enforcement, 21% other). The mean knowledge scores (standard deviation) significantly improved after training: 77.9 (22.9) vs. 70.4 (20.8) (p

A maternal diagnosis of chorioamnionitis, based on maternal peripartum fever of 100.4°F alone, is commonly used as an indication for blood work and antibiotic treatment in newborns. New strategies such as the Kaiser Permanente early-onset sepsis (EOS) calculator have proven effective in identifying high-risk newborns and reducing unnecessary antibiotic administration.Retrospective data from October 2017 to September 2018 from 297 well-appearing newborns ≥35 weeks' gestational age (GA) with maternal chorioamnionitis showed that 93.6% had blood work and 90.2% were treated with antibiotics. This was despite no culture-positive cases of sepsis. Our aim was to reduce by 50% blood work evaluation and antibiotic treatment within a 6-month period.Using plan-do-study-act (PDSA) cycles, we adopted the Kaiser Permanente EOS calculator. We collected longitudinal data to track the outcomes after its implementation.In 423 newborns with maternal chorioamnionitis triaged with the EOS calculator from October 2018 to July 2020, the rates of blood culture and antibiotic treatment decreased from 93.6% to 26.7% and 90.2% to 12.3% (P.0001). In the larger population of 6426 newborns ≥35 weeks' GA, the rate of blood culture and antibiotic treatment decreased from 12.8% to 5.8% and 9.9% to 2.5% (P.0001).The EOS calculator substantially and safely decreases blood work and antibiotic administration in asymptomatic newborns with maternal chorioamnionitis.Our findings provide further evidence for the effectiveness and safety of the EOS calculator.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

Background The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses. Purpose To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey. Methods A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020. Findings A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress. Implications for practice NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses. Implications for research Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.

Objective: Conflict is often destructive to existing services and exacerbates population health inequities and the vulnerabilities of existing healthcare. We undertook a scoping review of the literature concerning delivery of primary healthcare (PHC) in post-conflict settings. Design: We undertook a scoping review of the peer-reviewed and gray literature to identify articles related to the development and delivery of PHC in post-conflict settings. We searched PubMed / Medline, Cochrane Library, Embase / Ovid, CAB abstracts, POPLINE, and WHO.int. between January 1990 through the December end of 2017, for articles in the English language. Two researchers independently assessed each article and applied inclusion criteria: referring to postconflict settings and a range of terms related to PHC or health system development. Search terms were selected by careful review of the World Health Organization ’ s analytical framework for developing a strategy on universal coverage and analysis according to the availability, accessibility, affordability, and acceptability of healthcare and further themes involving demand-side or user-side concerns. Results: Findings were captured to reflect a range of conflict-affected settings and varied priorities and approaches to PHC reconstruction. Integrated immediate and longer-term strategies, involving needs-assessments, effective administration, development of institutions, and cost-efficient investment in human resources, infrastructure, and capacity building are needed to deliver expanded and equitable services, responsive to population health needs, critical to the delivery of equitable PHC. Conclusions: Scoping review of the literature may be formative in the generation of evidence-base to inform delivery of universal PHC, when applied according to context specificity of conflict-affected setting.

Background Due to the COVID-19 pandemic, the 2021 Harvard Medical School course Clinical Topics in Global Health was offered for the first time as a remote class. We sought to understand student and faculty perceptions of the elective and evaluate the perceived effectiveness of teaching global health using an online education platform. Methods Following the course, students and faculty were invited to complete a combined total of three online surveys, which consisted of closed- and open-response questions assessing the strengths and challenges of online learning. Data analyses included traditional descriptive statistics, Net Promoter Score calculation, and inductive thematic analysis of qualitative data. Results Thirty-two students and eighteen guest faculty (including four international faculty) participated in the course. Highly-rated course components included guest lecturers, practical skill sessions, polls, and case studies. The Net Promoter Score for the course was excellent at 92, and students reported a greater likelihood of pursuing a career in global health because of the course. While students and faculty highlighted limitations of the remote learning platform (lack of community and interactivity), they also commented on increased accessibility and faculty diversity. Most faculty and students recommended a hybrid model for future versions of the course and suggested strategies to address current limitations. Conclusions A remote learning platform can effectively deliver global health education, both in the pandemic setting and beyond.

Increasing numbers of residency graduates desire global health (GH) fellowship training. However, the full extent of training options is not clear.To identify clinical GH fellowships in all specialties in the U.S. and Canada and to describe their demographics, innovative features, and challenges.The authors surveyed program directors or designees from GH fellowships with a web-based tool in 2017.The authors identified 85 programs. Fifty-four programs (63.5%) responded confirming 50 fellowships. One- third of fellowships accepted graduates from more than one specialty, and the most common single-specialty programs were Emergency Medicine and Family Medicine. Fellowships most commonly were 24 months in duration with a median size of one fellow per year. Funding and lack of qualified applicants were significant challenges. Most programs were funded through fellow billing for patient care or other self-support.The number of U.S. and Canadian GH fellowship programs has nearly doubled since 2010. Challenges include lack of funding and qualified applicants. Further work is needed to understand how best to identify and disseminate fellowship best practices to meet the diverse needs of international partners, fellows, and the patients they serve and to determine if consensus regarding training requirements would be beneficial.Un nombre croissant de diplômés des programmes de résidence optent pour une formation complémentaire en santé mondiale. Cependant, la pleine mesure des possibilités de formation n’est pas claire.Identifier les formations cliniques complémentaires en santé mondiale pour toutes les spécialités aux États- Unis et au Canada et décrire leur démographie, leurs caractéristiques novatrices, et leurs défis.En 2017, les auteurs ont interrogé les directeurs de programmes de formation complémentaire en santé mondiale ou leur représentant à l’aide d’un outil en ligne.Les auteurs ont identifié 85 programmes. 54 programmes (63,5 %) ont répondu et confirmé 50 programmes de formation. Un tiers des programmes acceptaient des diplômés provenant de plusieurs spécialités, et les programmes offerts à des spécialités uniques étaient plus fréquemment ceux en médecine d’urgence et en médecine familiale. Les programmes étaient généralement d’une durée de 24 mois avec une capacité d’accueil d’un moniteur (fellow) par année. Le financement et le manque de candidats qualifiés étaient des défis de taille. La plupart des programmes étaient financés par la rémunération des moniteurs (fellows) pour les soins qu’ils prodiguaient aux patients ou via d’autres aides financières individuelles.Le nombre de programmes de formation complémentaire en santé mondiale a presque doublé depuis 2010. Les défis sont notamment le manque de financement et de candidats qualifiés. Il est nécessaire de poursuivre le travail pour pouvoir bien identifier et transmettre les meilleures pratiques en matière de formation complémentaire afin de répondre aux divers besoins des partenaires internationaux, des moniteurs (fellows) et des patients qu’ils soignent, et déterminer si un consensus concernant les exigences de formation serait bénéfique.

Introduction: Five of the 7.2 billion people on earth have limited access to emergency and essential surgical procedures. The lack of safe, affordable and timely anaesthesia services are primary barriers to universal surgical coverage. The objective of this study was to assess intraoperative awareness when the ‘Every Second Matters for Emergency and Essential Surgery – Ketamine’ (ESM-Ketamine) package was used to support emergency and essential surgeries and painful procedures in rural Kenya when no anaesthetist was available. Methods: Forty-seven consecutive adult patients that underwent an operative procedure under ESM-Ketamine at Sagam Community Hospital in Luanda, Kenya were enrolled. Participants underwent two semi-structured interviews that explored the patient’s experience with ESM-Ketamine both after the operative procedure and four to six weeks after surgery. Results: Forty-seven participants completed the first interview and 37 (78.7%) the second interview. Thirty-seven (78.7%) cases were procedural sedations and ten were (21.3%) emergency surgeries. Intraoperative awareness occurred in nine (24.3%) participants who underwent procedural sedation and two (20%) who underwent emergency surgery. Twenty-six (55.3%) participants reported dreams during the procedure. Thirty-two (86.5%) participants considered their experience positive, and 35 (95%) would recommend a procedure supported by ketamine to a friend. Discussion: Most patients whose painful procedures and emergency operations were supported by the ESM-Ketamine package when no anaesthetist was available reported favourable experiences. Keywords: Ketamine, Anesthesia, Low-resource settings, Emergency operative procedures, Intraoperative awareness

Introduction: Developed and introduced in 2010, Helping Babies Breathe (HBB) has found great success globally as an easily-implementable neonatal resuscitation training program for healthcare providers working in resource-limited settings. As HBB approaches a decade of in-field use in over 80 countries, this systematic literature review aimed to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming. Methods: A systematic …

Introduction With 70.8 million people displaced worldwide, there is an increasing need for medical professionals to provide medical care to refugees. Insufficient training on refugee health poses a barrier to effective care delivery. Methods This workshop addressed common challenges in providing family-centered pediatric refugee care in community settings as well as barriers related to policy changes. Presentations covered prearrival experiences, medical screening, and trauma-based care. In small groups, participants discussed cases that featured medical, behavioral health, social, and cultural factors impacting the provision of family-centered pediatric care that was culturally respectful and included shared decision-making. After the breakout session, each small group informed the larger group of topics discussed. Facilitators identified themes and reinforced key learning points. At the workshop's conclusion, participants were guided to create their own personalized action plan. Results This workshop was presented at two international conferences to more than 47 participants, including clinicians, nurse practitioners, pediatric residents, and medical students. Evaluations were completed by 34 individuals. Participants' overall comfort level with taking care of refugee patients increased from 3.3 to 4.0 (on a 5-point scale, p = .24) during the 3-hour version of the workshop and from 3.8 to 4.0 (p = .43) in the 1-hour version of the workshop. Mean overall ratings of the 3- and 1-hour workshop versions on conference-administered evaluations were 4.8 and 4.2, respectively, on a 5-point scale. Discussions This workshop was well received and equipped participants with knowledge, tools, and strategies regarding pediatric refugee health in a community setting.

CONTEXT: Helping Babies Breathe (HBB) is a well-established neonatal resuscitation program designed to reduce newborn mortality in low-resource settings. OBJECTIVES: In this literature review, we aim to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming. DATA SOURCES: Databases used in the systematic search included Medline, POPLINE, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, African Index Medicus, Cochrane, and Index Medicus. STUDY SELECTION: All articles related to HBB, in any language, were included. Article quality was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation framework. DATA EXTRACTION: Data were extracted if related to HBB, including its implementation, acquisition and retention of HBB knowledge and skills, changes in provider behavior and clinical care, or the impact on newborn outcomes. RESULTS: Ninety-four articles met inclusion criteria. Barriers to HBB implementation include staff turnover and limited time or focus on training and practice. Researchers of several studies found HBB cost-effective. Posttraining decline in knowledge and skills can be prevented with low-dose high-frequency refresher trainings, on-the-job practice, or similar interventions. Impact of HBB training on provider clinical practices varies. Although not universal, researchers in multiple studies have shown a significant association of decreased perinatal mortality with HBB implementation. LIMITATIONS: In addition to not conducting a gray literature search, articles relating only to Essential Care for Every Baby or Essential Care for Small Babies were not included in this review. CONCLUSIONS: Key challenges and requirements for success associated with each stage of HBB programming were identified. Despite challenges in obtaining neonatal mortality data, the program is widely believed to improve neonatal outcomes in resource-limited settings.

Background Responding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric’s (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP). Methods MEBCI used a training of trainer’s approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP’s Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools. Findings: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = − 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = − 0.33, p value Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p r = − 0.08, p Conclusion MEBCI’s integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally. Funding Children’s Investment Fund Foundation (CIFF).

Background: Clinical trainees face challenges throughout short-term experiences in global health (STEGH) that are not routinely addressed. Objectives: Describe common professional and ethical dilemmas faced by clinical trainees and identify gaps and solutions for pre, during, and post-STEGH training and mentoring. Methods: We conducted a mixed-methods study among trainees and mentors involved in global health. The study utilized focus groups with trainees (November–December 2015) and online surveys of trainees, in-country and stateside faculty mentors (October 2016–April 2017). Results: 85% (17/20) of students reported feeling prepared for their STEGH; however, 59% (23/39) of faculty felt students were unprepared. A majority of both students (90%) and faculty (77%) stated students would likely experience an ethical dilemma during STEGH. Major themes relating to meaningful global health work were elucidated: personal and inter-professional skills; interpersonal networks and collaboration; and awareness of power dynamics and bias. Conclusions: The most common challenges faced by trainees during STEGH related to leadership, bias, ethics and interprofessional collaboration. Redirecting trainee energies from a focus on ‘doing’ and deliv­erables to attitudes (e.g., humility, professionalism) that cultivate personal and professional growth will help create lifelong global health learners and leaders.

Background: Early management of respiratory distress is critical to reducing mortality in infants and children in resource-limited settings. Bubble continuous positive airway pressure (bCPAP) can offer effective and affordable non-invasive respiratory support. Objective: To determine the best physical components of bubble CPAP circuits for respiratory support of children in low-resource settings. Methods: Using PubMed, CINAHL and LILACS, studies of any design in any language published before June 2017 which examined the physical components of bCPAP circuits were identified and reviewed. Results: After screening, the review included 45 articles: 17 clinical trials, 11 literature reviews, 10 technical assessments of bCPAP components, three reports of real-world implementation in low-resource settings, three cost analyses and one case report. There is no ideal bCPAP circuit for all settings and patients, but some choices are generally better than others in designing a circuit for low-resource settings. Oxygen concentrators are usually the best source of oxygen. As yet, there is no affordable and accurate oxygen blender. Nasal prongs are the simplest patient interface to use with the fewest complications but are not the cheapest option. Expiratory limbs should be at least 1 cm in diameter. Home-made pressure generators are effective, safe and affordable. Conclusion: This narrative review found many studies which evaluated the real clinical outcomes with bCPAP in the target population as well as technical comparison of bCPAP components. However, many studies were not blinded or randomised and there was significant heterogeneity in design and outcome measures. Abbreviations: bCPAP, bubble continuous positive airway pressure; CPAP, continuous positive airway pressure; FiO2, fractional oxygen concentration; HFNC, high-flow nasal cannula; HIC, high-income countries; LMIC, low- and middle-income countries; NP, nasopharyngeal; O2, oxygen; PEEP, positive end-expiratory pressure; PICO, Population, Intervention, Comparison and Outcome.

Human trafficking is associated with a profound burden of physical and psychological trauma. Survivors of trafficking interact with the health care system during and after their experiences of trafficking. Socioeconomic isolation, stigma, shame, guilt, fear of judgment, fear of retribution by traffickers, fear of law enforcement authorities, and other factors known to inhibit disclosure can exert a formative influence on survivors’ health care experiences, health care access, and health services engagement. Using a mixed qualitative-quantitative social science research method, known as by-person factor analysis (or Q-methodology), the current analysis systematically examines the scope of trafficking survivors’ health care experiences and perceptions of medical care, health care access behaviors, and degree of engagement with health services. Among 33 survivors of human trafficking surveyed, 21 met inclusion criteria for this analysis. Three distinct profiles of survivor health care experiences and health services engagement— Avoidant, Distrustful, and Constrained—are identified from the aggregate of survivors’ perceptions of medical care. Although there are salient differences across the three survivor profiles, a feeling of disenfranchisement is a common thread and directly related to health care access behaviors and health services engagement. Understanding that the feeling of disenfranchisement functions as a filter through which trafficking survivors perceive and experience medical care can help health care professionals take appropriate countermeasures. Implications for improving health care access and engagement include the implementation of trauma-responsive, culturally sensitive, and survivor-centered care practices.

Health systems are frequently among the casualties of conflict. Within these settings, increased knowledge is needed on how to rebuild and strengthen health infrastructure resilience, such as primary health care (PHC) systems, in context-specific ways that promote health equity. Therefore, this study aimed to explore perspectives of experts with experience working on frontlines of social crises to contribute to understandings of pathways toward equitable PHC in conflict-affected settings. Semistructured qualitative interviews with 18 expert participants were completed. Through engaging elements of grounded theory situational analysis, three themes emerged iteratively, including (a) Building Blocks, (b) Intermediating Factors, and (c) a Roadmap. These emergent themes contribute to conceptual frameworks explaining key contextually specific priorities, challenges, and facilitating factors for developing resilient health infrastructures under social crises. Findings inform policy and practical guidelines that address complexities of conflict conditions and underscore the importance of PHC development toward promoting health as a human right.

Background: The need for palliative care services is rapidly increasing due to the rising number of patients with non-communicable diseases. The objective of this study was to assess the current availability and barriers to palliative care and healthcare worker knowledge and perceptions on palliative pain control in western Kenya. Methods: An evidence-based 40-question assessment tool was conducted between October 2015 and February 2016 in Siaya County, western Kenya. All level 4 and 5 facilities (e.g., regional and district hospitals) were assessed, as well as a selection of lower-level facilities chosen via convenience sampling, stratified by facility level (e.g., dispensaries, health centers, and health clinics). Results: A key informant at each of 22 facilities was surveyed and included 1 medical officer (5%), 12 clinical officers (55%), and 9 nurses (41%). Key themes included training and education, awareness of palliative care and hospice, services provided, and pain control. All 22 providers had heard of palliative care and 4 (18%) had received formal training. Fourteen (64%) providers knew that morphine was on the World Health Organization (WHO) essential medication list, 8 (36%) had previously prescribed opioids, and 5 (23%) had prescribed them for palliation. Provider concerns for opioid use included its addictive properties (59%), appropriate dosing (9%), cost (5%), side effects (9%), and availability (5%). Conclusions: Palliative care and hospice services were identified by providers as important components in the management of chronic illnesses in western Kenya. Further provider education as well as increased access to pain medications including opioids is necessary to improve the care of patients in western Kenya.

Background Globalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one’s scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified. Methods The authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years. Results A total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time. Conclusions Given that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.

Objective To validate a novel objective structured clinical examination (OSCE) tool for assessing neonatal care skills among delivery attendants trained as part of the Essential Care for Every Baby (ECEB) program and to assess ECEB training effectiveness. Methods Between August 1 and September 30, 2015, a cross-sectional study enrolled ECEB-trained healthcare providers who attended deliveries from the Brong Ahafo and Eastern regions of Ghana. Participants completed a previously developed 21-item OSCE tool that assessed neonatal-care competency. Participant performance was scored independently by regional trainers and national master trainers. The inter-rater scoring reliability was assessed using the Cohen kappa coefficient and performance was compared across participant characteristics. Results The study enrolled 57 trained delivery attendants from 12 district hospitals. Inter-rater agreement was perfect (kappa 1.00) or almost perfect (kappa 0.81–0.99) for nine OSCE items, substantial (kappa 0.61–0.80) or moderate (kappa 0.41–0.60) for 11 items, and fair (kappa 0.21–0.40) for one item. Differences in OSCE-item performance were recorded based on participants’ regions, facility type, age, and education level ( P Conclusions In a resource-limited setting, the OSCE tool demonstrated substantial reliability and ECEB-trained healthcare practitioners exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Objective To better understand the beliefs of men and women in western Kenya regarding the appropriate role of men in maternal health and to identify barriers to greater involvement. Methods Between June 1 and July 31, 2014, a cross-sectional qualitative study enrolled lay men, lay women, and community health workers from Kisumu and Nyamira counties in western Kenya. Semi-structured focus group discussions were conducted and qualitative approaches were utilized to analyze the transcripts and identify common themes. Results In total, 134 individuals participated in 18 focus group discussions. Participants discussed the role of men and a general consensus was recorded that it was a man’s duty to protect women during pregnancy. When discussing obstacles to male involvement, female participants highlighted gender dynamics and male participants raised financial limitations. Conclusion There was considerable discrepancy between how men described their roles and how they actually behaved, although educated men appeared to describe themselves as performing more supportive behaviors compared with male participants with less education. It is suggested that interventions aimed at increasing male involvement should incorporate the existing culturally sanctioned roles men perform as a foundation upon which to build, rather than attempting to construct roles that oppose prevailing norms.

African-born immigrants comprise one of the fastest growing populations in the U.S., nearly doubling its population size in recent years. However, it is also one of the most underrepresented groups in health-care research, especially research focused on gynecologic and breast malignancies. While the opportunity exists for access to an advanced health-care system, as immigrants migrate to the U.S., they encounter the same health-care inequalities that are faced by the native-born population based on ethnicity and social class, potentiated by limitations of health literacy and lack of familiarity with U.S. health systems. Given the continued influx of African-born immigrants in the U.S., we sought to understand the representation of this population in cervical and breast cancer research, recognizing the population's high risk for these diseases at baseline while residing in their native countries. We determined that there is limited research in these diseases that disproportionately affect them; yet, there are identifiable and potentially modifiable factors that contribute to this paucity of evidence. This clinical commentary seeks to underscore the clear lack of research available involving African-born immigrants with respect to gynecologic and breast malignancies in the existing literature, demonstrate the need for more robust research in this population, and provide fundamental insights into barriers and solutions critical to the continued health of this growing population.

Objective: An important but neglected consequence of the AIDS pandemic that continues across sub-Saharan Africa is the phenomenon of child-headed households (CHH). This study aims to describe the challenges to health and well-being for young people living in child-headed households.Methods: A mixed-methods research approach linked common themes using qualitative and quantitative instruments to provide a broad picture of the location and challenges of CHH in Kabira, Kyotera and Kamuganja in the Rakai District of southern Uganda. Local knowledge was used to locate CHH.Results: 163 children living in 40 CHH were traced: 42·5% of the household heads were double orphans caring for younger siblings, and 43% were also caring for chronically ill or disabled grandparents who were economically unproductive and largely dependent on the eldest child for survival. It was found that those heading households were more likely not to attend school than children living at home with a parent. Their immediate needs ranged from food and shelter to health-care and education. Fear was a major theme: 38% of those interviewed reported fear of ‘violence’. Children as young as 13 were responsible for navigating through complex decision-making processes from everyday basic necessities to decisions on the health care of younger siblings and grandparents.Conclusion: Children and young people living in CHH are a largely invisible and highly vulnerable population. Clear, officially accepted definitions of CHH are a first step in recognising this vulnerable group for whom safeguards will be necessary as social work develops in lower- and middle-income countries (LMICs). The precise numbers of CHH are unknown and further examination of this undocumented group is needed.

Recent political and demographic factors have exposed the vulnerability of the youth in the Middle East and North Africa (MENA) region. This study aimed to elucidate the current needs, activities, stakeholders and solutions related to at-risk youth and young adults in the MENA region. A systematic literature review was conducted of the peer-reviewed and grey literature. This was complemented by an in-region landscape analysis involving key-informant interviews and focus group discussions. After extensive screening of 1160 unique articles, 275 articles were considered relevant to this study. Of these 275, 145 (52.7%) were related to health (64.8% of these related to mental health), 101 (36.7%) to livelihood, 87 (31.6%) to violence prevention and 68 (24.7%) to education. Important themes and challenges identified in the literature and discussions included the MENA region's growing youth bulge; youth unemployment; critical gender gaps; and the impact of conflict on livelihoods, education and health, especially mental health.الشباب في أزمة (الشباب في سياق الأزمات) في الشرق الأوسط وشمال أفريقيا: مراجعة منهجية للأدبيات وتحليل مركَّز للمشهد.مايا فهلنج، زينة الجرّاح، ماجي تيرنان، سعيد البزرة، مايكل فاترويين، عبد المحسن الحكير، بريت نلسون.إن العوامل السياسية والسكانية الأخرة كشفت سرعة تأثر الشباب في إقليم الرق الأوسط وشال أفريقيا. و قد هدفت هذه الدراسة إلى إلقاء الضوء عى الاحتياجات الحالية والأنشطة والأطراف المعنية والحلول المتعلقة بالشباب وصغار البالغن المعرضين للخطر في إقليم الرق الأوسط وشال أفريقيا. فأجري استعراض منهجي للأدبيات التي تمت مراجعتها من قبل زماء (الأدبيات المُحكَّمة) وللأدبيات غر الرسمية. وقد استكمِل ذلك بتحليل للمشهد في الإقليم اشتمل عى إجراء مقابات مع المصادر الرئيسية للمعلومات وعى مناقشات جماعية مركزة، وبعد فحص شامل ل 1160 مقالة متميزة تم اعتبار 275 مقالة ذاتَ صلة بهذه الدراسة؛ 145 منها (52.7%) حول الصحة (ارتبطت منها 64.8 % بالصحة النفسية)، بينا ارتبطت 100 مقالة (36.7%) بسبل كسب الرزق، وتناولت 87 مقالة الوقاية من العنف وناقشت 68 مقالة (24.7%) التعليم. وكان من جملة المواضيع والتحديات الهامة التي تم التعرف عليها في الأدبيات والمناقشات تزايدُ أعداد الشباب في إقليم الرق الأوسط وشال أفريقيا، والبطالة في صفوف الشباب، والفجوات الخطرة القائمة بن الجنسن، وأثر الصراعات عى سبل كسب العيش وعى التعليم والصحة؛ لا سيما الصحة النفسية.Jeunesse en crise au Moyen-Orient et en Afrique du Nord : examen systématique de la littérature et analyse contextuelle ciblée.Des facteurs politiques et démographiques récents ont révélé la vulnérabilité des jeunes dans la Région du Moyen-Orient et de l’Afrique du Nord. La présente étude visait à connaître les besoins, les activités, les parties prenantes et les solutions liés aux jeunes et aux jeunes adultes à risque actuellement dans la Région du Moyen-Orient et de l’Afrique du Nord. Un examen systématique de la littérature revue par des pairs et de la littérature grise a été mené. Cette démarche a été complétée par une analyse contextuelle intrarégionale impliquant des entretiens avec des informateurs clés et des groupes de discussion thématiques. Après un examen approfondi de 1160 articles uniques, 275 articles ont été considérés comme pertinents pour l'étude. Sur ces 275 articles, 145 (52,7 %) concernaient la santé (64,8 % de ces derniers abordant la santé mentale), 101 (36,7 %) les moyens de subsistance, 87 (31,6 %) la prévention de la violence et 68 (24,7 %) l'éducation. Les difficultés et thèmes importants identifiés dans la littérature et les discussions au niveau de la Région du Moyen-Orient et de l’Afrique du Nord sont les suivants : l'augmentation rapide du nombre de jeunes, le chômage chez les jeunes, les écarts critiques entre les hommes et les femmes, et l’impact des conflits sur les moyens de subsistance, l’éducation et la santé, en particulier la santé mentale.

Background Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. Methods Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. Results Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. Conclusion The ESM-UBT device appears safe for use in women with uncontrolled PPH. Trial registration Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit.

The corrected order of the authors is as reflected in this erratum. Sebastian Suarez and Ayla Senay are co-second authors.

More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears.Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya.One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation.These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Objective To understand provider perceptions and experiences following training in the use of a condom-catheter uterine balloon tamponade (UBT) as second-line treatment for uncontrolled postpartum hemorrhage (PPH) in health facilities in Kenya. Methods As part of a qualitative study, interviews of facility-based providers who had managed PPH following comprehensive PPH training were conducted between February and April 2014. Facilities were purposively sampled to represent a range of experience with UBT, facility size, and geography. Interviews continued until thematic saturation was achieved. Interview transcripts were analyzed for themes. Results Overall, 68 providers from 29 facilities were interviewed, of whom 31 reported experience with UBT placement (25 midwives, 2 clinical officers, 4 medical officers). Qualitative analysis revealed several major themes. Providers used UBT appropriately within the PPH algorithm, although the timing and clinical severity of patients varied. UBT was most commonly used when bleeding was unresponsive to uterotonics, hysterectomy was unavailable, and referral times long. Providers reported that bleeding was arrested following UBT use in all except one patient, who had a suspected coagulopathy. Most providers described UBT as technically easy to use, although three described initial balloon displacement. Conclusion UBT has been readily accepted by providers at all levels of training and is being incorporated into the existing PPH management algorithm in Kenya.

a b s t r a c t Objectives: Newborn deaths comprise an alarming proportion of under-five mortality globally. In this ret- rospective cohort study, we investigated the effectiveness of focused newborn resuscitation training and delivery of a positive-pressure device in a rural midwife population in a low-resource setting. The present research attempts to better understand the extent to which knowledge and self-efficacy contribute to resuscitation attempts by birth attendants in practice. Methods: A one-year retrospective cohort analysis was undertaken in Aceh, Indonesia of two groups of community-based midwives, one having received formal training and a positive-pressure resuscita- tive device and the other receiving usual educational resources and management. A path analysis was undertaken to evaluate relative determinants of actual resuscitation attempts. Results: 348 community-based midwives participated in the evaluation and had attended 3116 births during the preceding year. Path analysis indicated that formal training in resuscitation and delivery of a positive-pressure device were significantly related to both increased knowledge (ˇ = 0.55, p = 0.001) and increased self-efficacy (ˇ = 0.52, p = 0.001) in performing neonatal resuscitations with a positive-pressure device. However, training impacted actual resuscitation attempts only indirectly through a relationship with self-efficacy and with knowledge. Combined across groups, self-efficacy was significantly associated with positive pressure ventilation attempts (ˇ = 0.26, p < 0.01) whereas knowledge was not (ˇ = −0.05, p = 0.39). Conclusion: Although, to date, evaluations of newborn resuscitation programs have primarily focused on training and has reported process indicators, these results indicate that in order to improve intrapartum-related hypoxic events ("birth asphyxia"), increased emphasis should be placed on par- ticipant self-efficacy and mastery of newborn resuscitation.

Background Isolated island populations face unique health challenges. In the Bahamas, the islands of Mayaguana, Inagua, Crooked Island, Acklins, and Long Cay—referred to as the MICAL Constituency—are among the most isolated. Objectives Our objective was to better understand regional emergency care needs and capabilities, and determine how emergency care can be optimized among island populations. Methods During the summer of 2013, the project team conducted semi-structured key-informant interviews and small-group discussions among all health care teams in the MICAL region, as well as a community-based household survey on the island of Mayaguana. The interviews and small-group discussions consisted of open-response questions related to health care services, equipment, supplies, medications, and human resources. The community-based survey examined the prevalence of chronic noncommunicable diseases (CNCDs) and associated risk factors affecting the inhabitants of the region. Results The average number of annual emergency referrals from each of the MICAL islands was approximately 25–30, and reasons for referrals off-island included chest pain, abdominal pain, trauma, and dysfunctional uterine bleeding. Traditional prehospital care is not established in the MICAL Constituency. Providers reported feelings of isolation from the distant health system in Nassau. Whereas most clinics have a well-stocked pharmacy of oral medications, diagnostic capabilities are limited. The household survey showed a high prevalence of CNCDs and associated risk factors. Conclusion Ongoing in-service emergency care training among MICAL providers is needed. Additional equipment could significantly improve emergency care capabilities, specifically, equipment to manage chest pain, fractures, and other trauma. Community-based preventive services and education could improve the overall health of the island populations.

OBJECTIVE To evaluate the impact of a post-Helping Babies Breathe bundle of interventions on the retention of provider-level knowledge and skills. METHOD The present prospective pre-post study following a 1-day Helping Babies Breathe training of professional midwives, physicians, and nurses was conducted in Cajamarca Province, Peru between January 1 and July 31, 2017. The interventions to improve retention included structured worksite practice before every shift, weekly in-service simulated scenarios, and monthly supervised peer-to-peer abbreviated refresher trainings. Knowledge and skills were assessed before, immediately after, and 6 months after training using two validated multiple-choice knowledge test and objective structured clinical examinations (OSCEs; OSCE A and OSCE B). Data were analyzed for changes in knowledge and skills over time and to identify predictors of performance. RESULTS There were 60 learners included. No significant differences were observed between assessments immediately after training and at 6-month follow-up for knowledge scores or time-to-effective-ventilation. Pass rates for OSCE B increased from 83% immediately after training to 95% at follow-up (P=0.007). The only factor associated with a reduced time to effective ventilation at 6-month follow-up was working in a hospital (P

Lack of access to emergency and essential surgery is widespread in low- and middle-income countries. Scarce anesthesia services contribute to this unmet need. The aim of this study was to evaluate the safety and feasibility of the Every Second Matters for Emergency and Essential Surgery-Ketamine (ESM-Ketamine) package for emergency and essential procedures when no anesthetist was available.From November 2013 to September 2017, the ESM-Ketamine package was used for patients requiring emergency or life-improving surgeries in fifteen selected facilities across Kenya when no anesthetist was available. A mixed-methods approach was used to assess safety and feasibility of the ESM-Ketamine package, including demand, acceptability, and practicality. The primary outcome was ketamine-related adverse events. Key-informant interviews captured perceptions of providers, hospital administrators, and surgeons/proceduralists.Non-anesthetist mid-level providers used ESM-Ketamine for 1216 surgical procedures across the fifteen study facilities. The median ketamine dose was 2.1 mg/kg. Brief (30 s) oxygen desaturations occurred in 39 patients (3%), and prolonged (30 s) oxygen desaturations occurred in seven patients (0.6%). There were 157 (13%) reported cases of hallucinations and agitation which were treated with diazepam. All patients recovered uneventfully, and no ketamine-related deaths were reported. Twenty-seven key-informant interviews showed strong support for the program with four main themes: financial considerations, provision of services, staff impact, and scaling considerations.The ESM-Ketamine package appears safe and feasible and is capable of expanding access to emergency and essential surgeries in rural Kenya when no anesthetist is available.