PHOTO BY ILSE ORSEL ON UNSPLASH

RESEARCH

A monthly literature search of open access, scientific articles related to global surgery

may 2021

INDEX COLLECTIONS

INTERACTIVE PDF SERIES

The One Surgery Index (OSI) is a collective project aiming to unite the wide body of academic

research relating to surgery in low and middle income countries. Although research dedicated to

this field is steadily increasing, it is often spread thinly across multiple sources and accessibility

settings. This results in great difficulty identifying important scientific work and advancing

progressive improvements within the sphere of global surgical practice. Furthermore, awareness

of these latest publications does not often filter to those that would benefit from it the most – the

healthcare staff working daily to improve surgical care across the world, in limited, resource poor

settings.

The One Surgery Index has therefore been designed to make relevant knowledge more accessible

to areas of the world where the research may have the greatest impact. By indexing and archiving

scientific research – country by country, region by region and surgical speciality by speciality, the

Index hopes to create an up-to-date library of global surgical research that can be easily found by

any participating stakeholder throughout the world. By doing so, the index hopes to promote

academic work in low and middle income countries and inspire further collaboration.

The One Surgery Index only uses publicly available information, including the title, journal,

authorship and abstract from published articles available on the internet. This is done with

respect to all copyright laws under the terms of fair use, similar to the fair usage of other internet

based libraries such as PubMed and Google Scholar. Full text articles are not stored in this index

in any format. Any articles with open access are forwarded to the respective content owner’s

publication pages. We recommend engaging with, and supporting both the authors and the

journals that so diligently contribute to our understanding of global surgical issues. All workswithin this publication are attributed to the content creators. If any copyright owner believes

the One Surgery Index to be in breach of copyright laws and requests a removal of any specific

indexed article, please contact us through the relevant channels at https://research.one.surgery.

This literature search is lovingly performed by the One.Surgery team (https://one.surgery/about-1-surgery/), using a pre-defined search algorithm - identifying and indexing new and relevant

global surgery articles. Only open access articles are included within this document. Once suitable

articles are identified, they are compiled into this PDF document, listing the article details with an

interactive online link to the full text and citation details. Naturally, some legible articles may have

been inadvertently missed during the search process and not be present within this collection. In

such circumstances, One.Surgery will strive to identify and index articles within the online OSI

platform: https://research.one.surgery

Our front covers are CC0 Creative Commons licensed images, representing street art throughout

the world. This collective literature search is free to download and share, in the hope ofenlightening and inspiring global surgical research collaboration.

ABOUT THE ONE.SURGERY INDEX

ABOUT THE COLLECTION

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CONTENTS

1. INFECTION PREVENTION AND CONTROL AT LIRA UNIVERSITY HOSPITAL, UGANDA: MORE NEEDSTO BE DONETropical Medicine And Infectious Disease – Marc Sam Opollo ,Tom Charles Otim ,Walter Kizito,Pruthu Thekkur ,Ajay M.v. Kumar ,Freddy Eric Kitutu ,Rogers Kisame,Maria Zolfo2. THE EVALUATION OF A SURGICAL TASK-SHARING PROGRAM IN SOUTH SUDANUbc Theses And Dissertations – Mina Salehi3. ECONOMIC IMPACT OF SURGERY ON HOUSEHOLDS AND INDIVIDUALS IN LOW INCOMECOUNTRIES: A SYSTEMATIC REVIEWInternational Journal Of Surgery – Esther Platt, Matthew Doe, Na Eun Kim, BrightChirengendure , Patrick Musonda, Simba Kaja, Caris Grimes4. PREDICTORS OF IRON CONSUMPTION FOR AT LEAST 90 DAYS DURING PREGNANCY: FINDINGSFROM NATIONAL DEMOGRAPHIC HEALTH SURVEY, PAKISTAN (2017–2018)Bmc Pregnancy And Childbirth – Sumera Aziz Ali, Savera Aziz Ali, Shama Razzaq, NayabKhowaja, Sarah Gutkind, Fazal Ur Raheman & Nadir Suhail5. RHEUMATIC HEART DISEASE: THE ROLE OF GLOBAL CARDIAC SURGERY.Journal Of Cardiac Surgery – Dominique Vervoort , Manuel J Antunes, A Thomas Pezzella6. DOES ADVANCED TRAUMA LIFE SUPPORT TRAINING WORK? 10-YEAR FOLLOW UP OFADVANCED TRAUMA LIFE SUPPORT INDIA PROGRAMJournal Of The American College Of Surgeons – Amulya Rattan, Amit Gupta , Subodh Kumar ,Sushma Sagar , Suresh Sangi , Neerja Bannerjee , Radhesh Nambiar , Vinod Jain , Parli Ravi ,Mahesh C. Misra ,7. GLOBAL BIRTH DEFECTS APP: AN INNOVATIVE TOOL FOR DESCRIBING AND CODINGCONGENITAL ANOMALIES AT BIRTH IN LOW RESOURCE SETTINGSUlster University – Helen Dolk, Aminkeng Zawuo Leke, Phil Whitfield, Rebecca Moore, KatyKarnell, Ingeborg Barišić, Linda Barlow‐Mosha, Lorenzo D. Botto, Ester Garne, PilarGuatibonza, Shana Godfred‐Cato, Christine M. Halleux, Lewis B. Holmes, Cynthia A. Moore,Ieda Orioli, Neena Raina, Diana Valencia8. MEDICAL AND NURSING STUDENTS’ PERCEPTION AND EXPERIENCE OF VIRTUAL CLASSROOMSDURING THE COVID-19 PANDEMIC IN NEPALInterdisciplinary Journal Of Virtual Learning In Medical Sciences – Pramila Poudel, GarimaTripathi , Ramesh Ghimire9. RECOMMENDATIONS FOR STREAMLINING PRECISION MEDICINE IN BREAST CANCER CARE INLATIN AMERICA.Cancer Reports – Alvarado-Cabrero I, Doimi F, Ortega V, De Oliveira Lima Jt, Torres R,Torregrosa L10. ANAESTHESIA FACILITY EVALUATION: A WHATSAPP SURVEY OF HOSPITALS IN BURUNDISouthern African Journal Of Anaesthesia And Analgesia – Gc Sund, Ms Lipnick, Tj Law, EaWollner, Ge Rwibuka11. EPIDEMIOLOGY OF SURGICAL AMPUTATIONS IN TAMALE TEACHING HOSPITAL, GHANAJournal Of Medical And Biomedical Sciences – Tolgou Yempabe, Waliu Jawula Salisu, Alexis D.B. Buunaaim, Hawawu Hussein, Charles N. Mock12. CHANGES IN BODY MASS INDEX, OBESITY, AND OVERWEIGHT IN SOUTHERN AFRICADEVELOPMENT COUNTRIES, 1990 TO 2019: FINDINGS FROM THE GLOBAL BURDEN OF DISEASE,INJURIES, AND RISK FACTORS STUDYObesity Science And Practice – Philimon N. Gona , Ruth W. Kimokoti , Clara M. Gona , SuhaBallout ,Sowmya R. Rao , Chabila C. Mapoma, Justin Lo , Ali H. Mokdad13. THE UNMET NEED FOR TREATMENT OF CHILDREN WITH MUSCULOSKELETAL IMPAIRMENT INMALAWIResearch Square – Leonard Banza Ngoie, Eva Dybvik, Geir Hallan , Jan-Erik Gjertsen , NyengoMkandawire , Carlos Varela, Sven Young

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14. IMPACT OF THE COVID-19 PANDEMIC ON ONCOLOGY CLINICAL RESEARCH IN LATIN AMERICA(LACOG 0420)Jco Global Oncology – Aline B. Lara Gongora ,Gustavo Werutsky ,Denis L. Jardim , AngelicaNogueira-Rodrigues , Carlos H. Barrios , Clarissa Mathias,Fernando Maluf ,RachelRiechelmann,Maurício Fraga, Henry Gomes , William N. William ,Camilla A. F. Yamada,Gilberto De Castro Jr , Daniela D. Rosa, Andreia C. De Melo , Raul Sala,Eva Bustamante,Denisse Bretel, Oscar Arrieta , Andrés F. Cardona , Diogo A. Bastos15. THE ROLE OF NONCOMMUNICABLE DISEASES IN THE PURSUIT OF GLOBAL HEALTH SECURITYHealth Security – Deliana Kostova, Patricia Richter, Gretchen Van Vliet, Michael Mahar, AndRonald L. Moolenaar16. OPPORTUNITIES FOR IMPROVEMENT IN THE ADMINISTRATION OF NEOADJUVANTCHEMOTHERAPY FOR T4 BREAST CANCER: A COMPARISON OF THE UNITED STATES AND NIGERIAThe Oncologist – Anya Romanoff ,Olalekan Olasehinde ,Debra A. Goldman ,Olusegun I. Alatise ,Jeremy Constable ,Ngozi Monu , Gregory C. Knapp ,Oluwole Odujoko ,Emmanuella Onabanjo,Adewale O. Adisa ,Adeolu O. Arowolo ,Adeleye D. Omisore ,Olusola C. Famurewa ,Benjamin O.Anderson ,Mary L. Gemignani , T. Peter Kingham17. COMPARISON OF CHALLENGES AND PROBLEMS ENCOUNTERED IN THE PRACTICE OFEXCLUSIVE BREAST FEEDING BY PRIMIPAROUS AND MULTIPAROUS WOMEN IN RURAL AREAS OFSINDH, PAKISTAN: A CROSS-SECTIONAL STUDYCureus – Sana Zafar, Khizer Shamim, Syeda Mehwish, Mohsin Arshad, Rahil Barkat18. INVASIVE BREAST CANCER TREATMENT IN TANZANIA: LANDSCAPE ASSESSMENT TO PREPAREFOR IMPLEMENTATION OF STANDARDIZED TREATMENT GUIDELINESBmc Cancer – Rupali Sood, Nestory Masalu, Roisin M. Connolly, Christina A. Chao, LucasFaustine, Cosmas Mbulwa, Benjamin O. Anderson , Anne F. Rositch19. SURGICAL CLIP LIGATION OF ANTERIOR COMMUNICATING ARTERY ANEURYSM IN ARESOURCE-LIMITED SETTINGCureus – Christopher Markosian, Igor Kurilets Jr., Luke D. Tomycz20. MORAL DISTRESS AND RESILIENCE ASSOCIATED WITH CANCER CARE PRIORITY SETTING IN ARESOURCE LIMITED CONTEXTThe Oncologist – Rebecca J. Deboer , Espérance Mutoniwase , Cam Nguyen , Anita Ho , GraceUmutesi , Eugene Nkusi , Fidele Sebahungu , Katherine Van Loon , Lawrence N. Shulman ,Cyprien Shyirambere21. FROM THE BREAST TO THE UPPER JAW: A RARE CASE OF METASTATIC BREAST CANCERSouth Sudan Medical Journal – Funmilola O. Wuraola , Bamidele A. Famurewa , OlalekanOlasehinde , Oluwole O. Odujoko , Olufunlola M. Adesina , Stephen B. Aregbesola22. ARTIFICIAL INTELLIGENCE: A RAPID CASE FOR ADVANCEMENT IN THE PERSONALIZATION OFGYNAECOLOGY/OBSTETRIC AND MENTAL HEALTH CAREWomen’s Health – Gayathri Delanerolle, Xuzhi Yang, Suchith Shetty, Vanessa Raymont, AshishShetty, Peter Phiri, Dharani K Hapangama, Nicola Tempest, Kingshuk Majumder, Jian Qing Shi23. BARRIERS AND FACILITATORS TO ONLINE MEDICAL AND NURSING EDUCATION DURING THECOVID-19 PANDEMIC: PERSPECTIVES FROM INTERNATIONAL STUDENTS FROM LOW- AND MIDDLE-INCOME COUNTRIES AND THEIR TEACHING STAFFHuman Resources For Health – Wen Li, Robyn Gillies, Mingyu He, Changhao Wu, Shenjun Liu,Zheng Gong , Hong Sun24. BURDEN OF CERVICAL CANCER IN THE EASTERN MEDITERRANEAN REGION DURING THE YEARS2000 AND 2017: RETROSPECTIVE DATA ANALYSIS OF THE GLOBAL BURDEN OF DISEASE STUDYJmir Public Health Surveillance – Fereshteh Safaeian, Shidrokh Ghaemimood , Ziad El-Khatib,Sahba Enayati , Roksana Mirkazemi , Bruce Reeder25. THE ROLE OF MITROFANOFF APPENDICOVESICOSTOMY IN THE MANAGEMENT OF A PELVICFRACTURE DISTRACTION DEFECT IN A 24- YEAR-OLD MAN AFTER MULTIPLE FAILEDRECONSTRUCTION ATTEMPTSEast And Central African Journal Of Surgery – Mumba Chalwe, Seke M.e. Kazuma26. SURGICAL MANAGEMENT AND OUTCOMES OF LATE-PRESENTING ACUTE LIMB ISCHAEMIA AT 2REFERRAL HOSPITALS IN ADDIS ABABA, ETHIOPIA: A 1-YEAR PROSPECTIVE STUDYEast And Central African Journal Of Surgery – Nebyou Seyoum, Berhanu D. Mekonnen,Berhanu N. Alemu

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27. RESPIRATORY MORBIDITY AND MORTALITY OF TRAUMATIC CERVICAL SPINAL CORD INJURY ATA LEVEL I TRAUMA CENTER IN INDIASpinal Cord Series And Cases – Deep Sengupta, Ashish Bindra, Niraj Kumar, Keshav Goyal,Pankaj Kumar Singh, Arvind Chaturvedi, Rajesh Malhotra & Ashwani Kumar Mishra28. CERVICAL CANCER DIAGNOSIS AND TREATMENT DELAYS IN THE DEVELOPING WORLD:EVIDENCE FROM A HOSPITAL-BASED STUDY IN ZAMBIAGynecologic Oncology Reports – Jane Mwamba Mumba, Lackson Kasonka, Okola Basil Owiti,Mwansa Ketty Lubeya , Lufunda Lukama, Susan C Msadabwe, Chester Kalinda29. INCREASING ANTIMICROBIAL RESISTANCE IN SURGICAL WARDS AT MULAGO NATIONALREFERRAL HOSPITAL, UGANDA, FROM 2014 TO 2018—CAUSE FOR CONCERN?Tropical Medicine And Infectious Disease – Gerald Mboowa ,Dickson Aruhomukama ,IvanSserwadda ,Freddy Eric Kitutu ,Hayk Davtyan ,Philip Owiti ,Edward Mberu Kamau,Wendemagegn Enbiale ,Anthony Reid ,Douglas Bulafu ,Jeffrey Kisukye ,Margaret Lubwama,Henry Kajumbula30. OXYGEN DELIVERY SYSTEMS FOR ADULTS IN SUB-SAHARAN AFRICA: A SCOPING REVIEWJournal Of Global Health – Neelima Navuluri, Maria L Srour, Peter S Kussin, David M Murdoch,Neil R Macintyre, Loretta G Que, Nathan M Thielman, Eric D Mccollum31. GLOBAL COMMUNITY PERCEPTION OF ‘SURGICAL CARE’ AS A PUBLIC HEALTH ISSUE: A CROSSSECTIONAL SURVEYBmc Public Health Volume – Nurhayati Lubis, Meena Nathan Cherian, Chinmayee Venkatraman, Fiemu E. Nwariaku32. ANALYSING A GLOBAL HEALTH EDUCATION FRAMEWORK FOR PUBLIC HEALTH EDUCATIONPROGRAMS IN INDIAThe University Of Sydney – Sawleshwarkar, Shailendra Nagorao33. MANAGEMENT OF PROLONGED FIRST STAGE OF LABOUR IN A LOW-RESOURCE SETTING:LESSONS LEARNT FROM RURAL MALAWIBmc Pregnancy And Childbirth – Wouter Bakker, Elisabeth Van Dorp, Misheck Kazembe, AlfredNkotola, Jos Van Roosmalen & Thomas Van Den Akker34. HEALTH RESEARCH CAPACITY BUILDING OF HEALTH WORKERS IN FRAGILE AND CONFLICT-AFFECTED SETTINGS: A SCOPING REVIEW OF CHALLENGES, STRENGTHS, ANDRECOMMENDATIONSHealth Research Policy And Systems – Rania Mansour, Hady Naal, Tarek Kishawi, Nassim ElAchi, Layal Hneiny , Shadi Saleh35. COMMUNICATION INTERVENTION USING DIGITAL TECHNOLOGY TO FACILITATE INFORMEDCHOICES AT CHILDBIRTH IN THE CONTEXT OF THE COVID-19 PANDEMIC: PROTOCOL FOR ARANDOMIZED CONTROLLED TRIALJmir Research Protocols – Carmen Simone Grilo Diniz , Ana Carolina Arruda Franzon , BeatrizFioretti-Foschi , Denise Yoshie Niy , Livia Sanches Pedrilio , Edson Amaro Jr , João Ricardo Sato36. TIMELINESS OF DIAGNOSIS OF BREAST AND CERVICAL CANCERS AND ASSOCIATED FACTORSIN LOW-INCOME AND MIDDLE-INCOME COUNTRIES: A SCOPING REVIEW PROTOCOLBmj Open. – Chukwudi A Nnaji, Paul Kuodi, Fiona M Walter, Jennifer Moodley37. SHORT-TERM GENERAL, GYNECOLOGIC, ORTHOPEDIC, AND PEDIATRIC SURGICAL MISSIONTRIPS IN NICARAGUA: A COST-EFFECTIVENESS ANALYSISJournal Of Global Health – Keyanna P Taylor , Anna Ortiz , Jason Paltzer38. THE ROLE OF HEALTH SERVICE DELIVERY NETWORKS IN ACHIEVING UNIVERSAL HEALTHCOVERAGE IN AFRICASouth Eastern European Journal Of Public Health – Knovicks Simfukwe , Yusuff AdebayoAdebisi ,Amos Abimbola Oladunni ,Salma Elmukashfi Eltahir Mohammed, Don Eliseo Lucero-Prisno Iii39. SEQUENTIAL IMPROVEMENT IN PAEDIATRIC MEDULLOBLASTOMA OUTCOMES IN A LOW-AND-MIDDLE-INCOME COUNTRY SETTING OVER THREE DECADESSouth African Journal Of Oncology – Johann Riedemann, Anthony Figaji, Alan Davidson, ClareStannard, Komala Pillay, Tracy Kilborn, Jeannette Parkes

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40. VIEWS FROM MULTIDISCIPLINARY ONCOLOGY CLINICIANS ON STRENGTHENING CANCER CAREDELIVERY SYSTEMS IN TANZANIAThe Oncologist – Sarah K. Nyagabona , Rohan Luhar , Jerry Ndumbalo , Nanzoke Mvungi ,Mamsau Ngoma , Stephen Meena , Sadiq Siu , Mwamvita Said , Julius Mwaiselage , EdithTarimo , Geoffrey Buckle , Msiba Selekwa , Beatrice Mushi , Elia J. Mmbaga , Katherine VanLoon , Rebecca J. Deboer41. DIGITAL HEALTH STRATEGIES FOR CERVICAL CANCER CONTROL IN LOW- AND MIDDLE-INCOMECOUNTRIES: SYSTEMATIC REVIEW OF CURRENT IMPLEMENTATIONS AND GAPS IN RESEARCHJournal Of Medical Internet Research – Andrea H Rossman ,Hadley W Reid ,Michelle M Pieters ,Cecelia Mizelle , Megan Von Isenburg , Nimmi Ramanujam , Megan J Huchko, LavanyaVasudevan42. EMPANELMENT OF HEALTH CARE FACILITIES UNDER AYUSHMAN BHARAT PRADHAN MANTRIJAN AROGYA YOJANA (AB PM-JAY) IN INDIAPlos One – Jaison Joseph ,Hari Sankar D.,Devaki Nambiar43. ECONOMIC EVALUATIONS OF BREAST CANCER CARE IN LOW- AND MIDDLE-INCOMECOUNTRIES: A SCOPING REVIEWThe Oncologist – Parsa Erfani, Kayleigh Bhangdia, Catherine Stauber, Jean Claude Mugunga,Lydia E. Pace, Temidayo Fadelu

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1. INFECTION PREVENTION AND CONTROL AT LIRAUNIVERSITY HOSPITAL, UGANDA: MORE NEEDS TO BE DONETropical Medicine And Infectious Disease

Authors: Marc Sam Opollo ,Tom Charles Otim ,Walter Kizito ,Pruthu Thekkur ,Ajay M.V.Kumar ,Freddy Eric Kitutu ,Rogers Kisame,Maria ZolfoRegion / country: Eastern Africa – UgandaSpeciality: Health policy

Globally, 5%–15% of hospitalized patients acquire infections (often caused by antimicrobial-resistant microbes) due to inadequate infection prevention and control (IPC) measures. Weused the World Health Organization’s (WHO) ‘Infection Prevention and Control AssessmentFramework’ (IPCAF) tool to assess the IPC compliance at Lira University hospital (LUH), ateaching hospital in Uganda. We also characterized challenges in completing the tool. This wasa hospital-based, cross-sectional study conducted in November 2020. The IPC focal person atLUH completed the WHO IPCAF tool. Responses were validated, scored, and interpreted perWHO guidelines. The overall IPC compliance score at LUH was 225/800 (28.5%), implying abasic IPC compliance level. There was no IPC committee, no IPC team, and no budgets.Training was rarely or never conducted. There was no surveillance system and nomonitoring/audit of IPC activities. Bed capacity, water, electricity, and disposal of hospitalwaste were adequate. Disposables and personal protective equipment were not available inappropriate quantities. Major challenges in completing the IPCAF tool were related to thedetailed questions requiring repeated consultation with other hospital stakeholders and thelong time it took to complete the tool. IPC compliance at LUH was not optimal. The gapsidentified need to be addressed urgently.

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2. THE EVALUATION OF A SURGICAL TASK-SHARINGPROGRAM IN SOUTH SUDANUbc Theses And Dissertations

Authors: Mina SalehiRegion / country: Central Africa, Eastern Africa – South SudanSpeciality: General surgery, Health policy, Surgical Education

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-SaharanAfrica (SSA) is the region with the scarcest access to surgical care. The surgical workforce iscrucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforcedensity. Task-sharing being a cost-effective training method, in 2019, the University of BritishColumbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skillsprogram and launched it in South Sudan. This study aims to evaluate this pilot program.Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- andpost-training outputs (number and types of surgeries, complication, re-operation, and mortality)and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), andlogbook data), and online survey for trainers. Semi-structured interviews were performed withtrainees at the program completion. Results: Since July 2019, trainees performed 385operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%),wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed,out of which 136 (79%) showed that the trainee could independently perform the procedure.During the training, the operating room and surgical ward mortality remained similar to thepre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%.The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgicalknowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- andMiddle-Income Countries (LMICs), and patient care has improved. Also, the programempowered trainees, developed career path, and local acceptance and retention. The moduleswere relevant to community needs. Conclusions: This study casts light on the feasibility oftraining surgeons through a virtual platform in under-resourced regions. The COVID-19 globalpandemic highlighted the need to make LMICs independent from fly-in trainers and traditionalapprenticeship. Knowledge translation of this training platform’s evaluation will hopefullyinform Ministries of Health and their partners to develop their National Surgical, Obstetric andAnesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of trainingand geography, it paves the way for virtual surgical education everywhere in the world.

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3. ECONOMIC IMPACT OF SURGERY ON HOUSEHOLDS ANDINDIVIDUALS IN LOW INCOME COUNTRIES: A SYSTEMATICREVIEWInternational Journal Of Surgery

Authors: Esther Platt, Matthew Doe, Na Eun Kim, Bright Chirengendure , Patrick Musonda,Simba Kaja, Caris GrimesRegion / country: GlobalSpeciality: Health policy, Other

BackgroundSurgical disease in Low Income Countries (LIC) is common, and overall provision of surgicalcare is poor. A key component of surgical health systems as part of universal health coverage(UHC) is financial risk protection (FRP) – the need to protect individuals from financial hardshipdue to accessing healthcare. We performed a systematic review to amalgamate currentunderstanding of the economic impact of surgery on the individual and household. Our studywas registered on Research registry (www.researchregistry.com).MethodsWe searched Pubmed and Medline for articles addressing economic aspects of surgicaldisease/care in low income countries. Data analysis was descriptive in light of a wide range ofmethodologies and reporting measures. Quality assessment and risk of bias analysis wasperformed using study design specific Joanna-Briggs Institute checklists. This study has beenreported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews)Guidelines.Results31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4qualitative studies and 5 economic analysis studies of varying quality. Direct medical, directnon-medical and indirect costs were variably reported but were substantial, resulting incatastrophic expenditure. Costs had far reaching economic impacts on individuals andhouseholds, who used entire savings, took out loans, reduced essential expenditure andremoved children from school to meet costs.ConclusionSeeking healthcare for surgical disease is economically devastating for individuals andhouseholds in LICs. Policies directed at strengthening surgical health systems must seek waysto reduce financial hardship on individuals and households from both direct and indirect costsand these should be monitored and measured using defined instruments from the patientperspective

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4. PREDICTORS OF IRON CONSUMPTION FOR AT LEAST90 DAYS DURING PREGNANCY: FINDINGS FROM NATIONALDEMOGRAPHIC HEALTH SURVEY, PAKISTAN (2017–2018)Bmc Pregnancy And Childbirth

Authors: Sumera Aziz Ali, Savera Aziz Ali, Shama Razzaq, Nayab Khowaja, Sarah Gutkind,Fazal Ur Raheman & Nadir SuhailRegion / country: Southern Asia – PakistanSpeciality: Obstetrics and Gynaecology

BackgroundIron supplementation is considered an imperative strategy for anemia prevention and controlduring pregnancy in Pakistan. Although there is some evidence on the predictors of irondeficiency anemia among Pakistani women, there is a very limited understanding of factorsassociated with iron consumption among Pakistani pregnant women. Thus, this study aimed toinvestigate the predictors of iron consumption for at least ≥90 days during pregnancy inPakistan.MethodsWe analyzed dataset from the nationally representative Pakistan Demographic Health Survey2017–2018. The primary outcome of the current study was the consumption of ironsupplementation for ≥90 days during the pregnancy of the last birth. Women who had lastchildbirth 5 years before the survey and who responded to the question of iron intake wereincluded in the final analysis (n = 6370). We analyzed the data that accounted for complexsampling design by including clusters, strata, and sampling weights.ResultsAround 30% of the women reported consumed iron tablets for ≥90 days during their lastpregnancy. In the multivariable logistic regression analysis, we found that factors such aswomen’s age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42–1.62)], wealthindex (rich/richest) (aPR = 1.25; [95% CI: 1.18–1.33]), primary education (aPR = 1.33; [95% CI:1.24–1.43), secondary education (aPR = 1.34; [95% CI: 1.26–1.43), higher education(aPR = 2.13; [95% CI: 1.97–2.30), women’s say in choosing husband (aPR = 1.68; [95% CI:1.57–1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43–2.89]), history of the lastCaesarian-section (aPR = 1.29; [95% CI: 1.23–1.36]) were significantly associated with ironconsumption for ≥90 days.ConclusionThese findings demonstrate complex predictors of iron consumption during pregnancy inPakistan. There is a need to increase the number of ANC visits and the government should takenecessary steps to improve access to iron supplements by targeting disadvantaged andvulnerable women who are younger, less educated, poor, and living in rural areas.

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5. RHEUMATIC HEART DISEASE: THE ROLE OF GLOBALCARDIAC SURGERY.Journal Of Cardiac Surgery

Authors: Dominique Vervoort , Manuel J Antunes, A Thomas PezzellaRegion / country: GlobalSpeciality: Cardiothoracic surgery

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicatedin high-income countries due to timely detection and treatment of acute rheumatic fever, RHDremains highly prevalent in low- and middle-income countries (LMICs) and among indigenousand disenfranchised populations in high-income countries. As a result, over 30 million people inthe world have RHD, of which approximately 300,000 die each year despite this being apreventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, andSoutheast Asia, access to cardiac surgical care for RHD remains limited, impacting countries’population health and resulting economic growth. Humanitarian missions play a role in thiscontext but can only make a difference in the long term if they succeed in training andestablishing autonomous local surgical teams. This is particularly difficult because thesepopulations are typically young and largely noncompliant to therapy, especially anticoagulationrequired by mechanical valve prostheses, while bioprostheses have unacceptably highdegeneration rates, and valve repair requires considerable experience. Devoted and sustainedleadership and local government and public health cooperation and support with the clinicalmedical and surgical sectors are absolutely essential. In this review, we describe historicaldevelopments in the global response to RHD with a focus on regional, international, andpolitical commitments to address the global burden of RHD. We discuss the surgical andclinical considerations to properly manage surgical RHD patients and describe the logisticalneeds to strengthen cardiac centers caring for RHD patients worldwide.

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6. DOES ADVANCED TRAUMA LIFE SUPPORT TRAININGWORK? 10-YEAR FOLLOW UP OF ADVANCED TRAUMA LIFESUPPORT INDIA PROGRAMJournal Of The American College Of Surgeons

Authors: Amulya Rattan, Amit Gupta , Subodh Kumar , Sushma Sagar , Suresh Sangi , NeerjaBannerjee , Radhesh Nambiar , Vinod Jain , Parli Ravi , Mahesh C. Misra ,Region / country: Southern Asia – IndiaSpeciality: Health policy, Trauma surgery

BackgroundStudies evaluating the efficacy of ATLS in Low & Middle-income countries (LMICs) are limited.We followed up ATLS providers certified by ATLS India program over a decade (2008-2018),aiming at measuring the benefits, if any, in knowledge, skills & attitude (KSA) from ATLS, andattrition over time.MethodsSurvey instrument was developed taking a cue from published literature on ATLS andimprovised using the Delphi method. Randomly selected ATLS providers were sent the surveyinstrument via email, as a Google form along with a statement of purpose. Results arepresented descriptively.Results1030 (41.2%) doctors responded. Improvement in knowledge (n=1013; 98.3%), psychomotorskills (n=986; 95.7%), organizational skills (n=998; 96.9%), overall trauma management(n=1013; 98.7%), self-confidence (n= 939; 91%) and ATLS promulgation at workplace inpersonal capacity (904; 87.8%) were reported. More than 60% opined benefits lasting beyondtwo years; more than 40% opined cognitive (492; 47.8%), psychomotor (433; 42%), andorganizational benefits (499; 48.4%) lasting beyond three years. The Faculty-ATLS subgroupreported significantly more improvement in confidence, tendency to teach ATLS at theworkplace, and retention of organizational skills than the providers’ subgroup. Lack of trainedmanpower (660; 64.1%) & attitude issues (n-495; 48.1%) were the major impediments atworkplace. One third (n=373; 36.2%) recalled & enumerated life/ limb saving incidentsapplying ATLS principles.ConclusionCognitive, psychomotor, organizational, and affective impact of ATLS is overwhelminglypositive in the Indian scenario. Till establishing formal trauma systems, ATLS remains the besthope for critically injured patients in LMICs.

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7. GLOBAL BIRTH DEFECTS APP: AN INNOVATIVE TOOL FORDESCRIBING AND CODING CONGENITAL ANOMALIES ATBIRTH IN LOW RESOURCE SETTINGSUlster University

Authors: Helen Dolk, Aminkeng Zawuo Leke, Phil Whitfield, Rebecca Moore, Katy Karnell,Ingeborg Barišić, Linda Barlow‐Mosha, Lorenzo D. Botto, Ester Garne, Pilar Guatibonza, ShanaGodfred‐Cato, Christine M. Halleux, Lewis B. Holmes, Cynthia A. Moore, Ieda Orioli, NeenaRaina, Diana ValenciaRegion / country: GlobalSpeciality: Health policy, Obstetrics and Gynaecology

Background: Surveillance programs in low‐ and middle‐income countries (LMICs) havedifficulty in obtaining accurate information about congenital anomalies.Methods: As part of the ZikaPLAN project, an International Committee developed an app forthe description and coding of congenital anomalies that are externally visible at birth, for use inlow resource settings. The “basic” version of the app was designed for a basic clinical settingand to overcome language and terminology barriers by providing diagrams and photos, sourcedmainly from international Birth Defects Atlases. The “surveillance” version additionally allowsrecording of limited pseudonymized data relevant to diagnosis, which can be uploaded to asecure server, and downloaded by the surveillance program data center.Results: The app contains 98 (88 major and 10 minor) externally visible anomalies and 12syndromes (including congenital Zika syndrome), with definitions and InternationalClassification of Disease v10 ‐based code. It also contains newborn examination videos andlinks to further resources. The user taps a region of the body, then selects among a range ofimages to choose the congenital anomaly that best resembles what they observe, with guidanceregarding similar congenital anomalies. The “basic” version of the app has been reviewed byexperts and made available on the Apple and Google Play stores. Since its launch in November2019, it has been downloaded in 39 countries. The “surveillance” version is currently beingfield‐tested.Conclusion: The global birth defects app is a mHealth tool that can help in developingcongenital anomaly surveillance in low resource settings to support prevention and care.

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8. MEDICAL AND NURSING STUDENTS’ PERCEPTION ANDEXPERIENCE OF VIRTUAL CLASSROOMS DURING THECOVID-19 PANDEMIC IN NEPALInterdisciplinary Journal Of Virtual Learning In Medical Sciences

Authors: Pramila Poudel, Garima Tripathi , Ramesh GhimireRegion / country: Southern Asia – NepalSpeciality: Surgical Education

Background: On March 9, 2020, the government of Nepal declared suspension of all academicactivities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pacewith the academic calendar, medical universities resumed their teaching and learning activitiesthrough virtual means on account of nonfeasibility of holding physical classes. The presentstudy sought to identify the perception and experiences of undergraduate medical and nursingstudents regarding the virtual classrooms.Methods: We adopted a sequential explanatory mixed method design whereby data werecollected in two phases. Quantitative data were gathered from a survey (n=737) and qualitativedata from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed usingdescriptive and inferential statistics, whereas qualitative data was examined using a narrativethematic analytic approach.Results: Mean age of participants was 22±2.01 with (81%) female participation. Thequantitative findings revealed that the “synchrony” domain had the highest mean score(4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the fourdomains. The domains were significantly correlated to each other (P=0.01) and (P=0.05).Results from focus group discussion indicated that interactions were lower in the virtual classesand there was a great variation between the learners’ perception and their experiences ofvirtual classrooms. Students preferred blended classes to be implemented in future sessions.Conclusion: In spite of various challenges, the students perceived the transition from traditionalto virtual classrooms in a positive and enthusiastic way. An effective virtual learning experiencerequires a modified instructional approach on the part of educators and a consistent attitudefrom learners.

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9. RECOMMENDATIONS FOR STREAMLINING PRECISIONMEDICINE IN BREAST CANCER CARE IN LATIN AMERICA.Cancer Reports

Authors: Alvarado-Cabrero I, Doimi F, Ortega V, de Oliveira Lima JT, Torres R, Torregrosa LRegion / country: Central America, South AmericaSpeciality: General surgery, Surgical oncology

BackgroundThe incidence of breast cancer (BC) in LMICs has increased by more than 20% within the lastdecade. In areas such as Latin America (LA), addressing BC at national levels evoke discussionssurrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine(PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for betterpatient outcomes. Thus, its application may aid in overcoming these barriers.Recent findingsA panel of LA experts in fields related to BC and PM were provided with a series of relevantquestions to address prior to a multi-day conference. Within this conference, each narrative wasedited by the entire group, through numerous rounds of discussion until a consensus wasachieved. The panel proposes specific, realistic recommendations for implementing CDx in BCin LA and other LMIC regions. In these recommendations, the authors strived to address allbarriers to the widespread use and access mentioned previously within this manuscript.ConclusionThis manuscript provides a review of the current state of CDx for BC in LA. Of most importance,the panel proposes practical and actionable recommendations for the implementation of CDxthroughout the Region in order to identify the right patient at the right time for the righttreatment.

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10. ANAESTHESIA FACILITY EVALUATION: A WHATSAPPSURVEY OF HOSPITALS IN BURUNDISouthern African Journal Of Anaesthesia And Analgesia

Authors: GC Sund, MS Lipnick, TJ Law, EA Wollner, GE RwibukaRegion / country: Central Africa – BurundiSpeciality: Anaesthesia

Background: Data regarding the capacity to provide safe anaesthesia is lacking in many low-income countries. With the increasing popularity of WhatsApp for both personal andprofessional communication in Africa, we sought to test the feasibility of using this platform toadminister a brief survey of anaesthesia equipment availability in Burundi. The aims of thestudy were to survey a subset of anaesthesia equipment availability in Burundi and to assessthe suitability of using a WhatsApp chat group to administer such a survey.Methods: The survey was distributed via WhatsApp by ATSARPS (Agora des TechniciensSupérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé), an association ofanaesthesia providers in Burundi. The questions focused on the presence of five pieces ofanaesthesia equipment recommended by the World Health Organization – World Federation ofSocieties of Anesthesiologists (WHO–WFSA) International Standards for a Safe Practice ofAnesthesia, namely a Lifebox pulse oximeter, anaesthesia machine, capnograph, ECG anddefibrillator. Questions were sent as free text, and responses were received as a reply or as apersonal message to the president of ATSARPS who sent the survey.Results: Responses received represented data from 55 (85%) of the 65 hospitals that offeranaesthesia care across Burundi. Eightynine per cent of hospitals had a Lifebox pulse oximeter,91% had an anaesthesia machine, 16% had capnography, 24% had an ECG and 14% had adefibrillator. Among hospitals which responded to our survey, only 60% reported perfominggeneral endotracheal anaesthesia on a monthly basis.Conclusion: Data collection in low- and middle-income countries (LMICs) can be challenging;therefore, simple, low-cost methods of data collection need to be developed. We havedemonstrated the feasibility of using a WhatsApp chat group among a national society ofanaesthesia providers in Burundi to perform an initial abbreviated audit of anaesthesiafacilities. We have also identified significant deficits in anaesthesia equipment in Burundi.

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11. EPIDEMIOLOGY OF SURGICAL AMPUTATIONS IN TAMALETEACHING HOSPITAL, GHANAJournal Of Medical And Biomedical Sciences

Authors: Tolgou Yempabe, Waliu Jawula Salisu, Alexis D. B. Buunaaim, Hawawu Hussein,Charles N. MockRegion / country: Western Africa – GhanaSpeciality: General surgery, Trauma and orthopaedic surgery, Vascular surgery

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. Thiswas a retrospective descriptive study. We analyzed case files of 112 patients who underwentsurgical amputationsbetween 2011 and 2017. Demographics, site of amputation, indication for amputation, andoutcomes wereretrieved from case files. Descriptive statistics were used to report the means and frequencies.Associationsbetween variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean ageof the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limbamputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalentindication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days(range 5 to 120). Surgical site infection (17.9%) was the main complication. In our studysetting, there is thus far limited capability for proper management of diabetes mellitus, whichneeds to be improved. There is also an urgent need for multidisciplinary foot care teams thatwill help patients receive comprehensive care to reduce complications from diabetes and othervasculopathies

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12. CHANGES IN BODY MASS INDEX, OBESITY, ANDOVERWEIGHT IN SOUTHERN AFRICA DEVELOPMENTCOUNTRIES, 1990 TO 2019: FINDINGS FROM THE GLOBALBURDEN OF DISEASE, INJURIES, AND RISK FACTORS STUDYObesity Science And Practice

Authors: Philimon N. Gona , Ruth W. Kimokoti , Clara M. Gona , Suha Ballout ,Sowmya R. Rao ,Chabila C. Mapoma, Justin Lo , Ali H. MokdadRegion / country: Southern AfricaSpeciality: General surgery, Health policy

BackgroundHigh body mass index (BMI) is associated with stroke, ischemic heart disease (IHD), and type 2diabetes mellitus (T2DM). An epidemiological analysis of the prevalence of high BMI, stroke,IHD, and T2DM was conducted for 16 Southern Africa Development Community (SADC) usingGlobal Burden of Diseases, Injuries, and Risk Factors (GBD) Study data.MethodsGBD obtained data from vital registration, verbal autopsy, and ICD codes. Prevalence of highBMI (≥25 kg/m2), stroke, IHD, and T2DM attributed to high BMI were calculated. Cause ofDeath Ensemble Model and Spatiotemporal Gaussian regression was used to estimate mortalitydue to stroke, IHD, and T2DM attributable to high BMI.ResultsObesity in adult females increased 1.54‐fold from 12.0% (uncertainty interval [UI]: 11.5–12.4) to18.5% (17.9–19.0), whereas in adult males, obesity nearly doubled from 4.5 (4.3–4.8) to 8.8(8.5–9.2). In children, obesity more than doubled in both sexes, and overweight increased by27.4% in girls and by 37.4% in boys. Mean BMI increased by 0.7 from 22.4 (21.6–23.1) to 23.1(22.3–24.0) in adult males, and by 1.0 from 23.8 (22.9–24.7) to 24.8 (23.8–25.8) in adultfemales. South Africa 44.7 (42.5–46.8), Swaziland 33.9 (31.7–36.0) and Lesotho 31.6 (29.8–33.5)had the highest prevalence of obesity in 2019. The corresponding prevalence in males for thethree countries were 19.1 (17.5–20.7), 19.3 (17.7–20.8), and 9.2 (8.4–10.1), respectively. TheDRC and Madagascar had the least prevalence of adult obesity, from 5.6 (4.8–6.4) and 7.0(6.1–7.9), respectively in females in 2019, and in males from 4.9 (4.3–5.4) in the DRC to 3.9(3.4–4.4) in Madagascar.ConclusionsThe prevalence of high BMI is high in SADC. Obesity more than doubled in adults and nearlydoubled in children. The 2019 mean BMI for adult females in seven countries exceeded 25kg/m2. SADC countries are unlikely to meet UN2030 SDG targets. Prevalence of high BMIshould be studied locally to help reduce morbidity.

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13. THE UNMET NEED FOR TREATMENT OF CHILDREN WITHMUSCULOSKELETAL IMPAIRMENT IN MALAWIResearch Square

Authors: Leonard Banza Ngoie, Eva Dybvik, Geir Hallan , Jan-Erik Gjertsen , NyengoMkandawire , Carlos Varela, Sven YoungRegion / country: Southern Africa – MalawiSpeciality: Paediatric surgery, Trauma and orthopaedic surgery

Background More than a billion people globally are living with disability and the prevalence islikely to increase rapidly in the coming years in low- and middle-income countries (LMICs). Thevast majority of those living with disability are children residing in LMICs. There is very littlereliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and evenless is available for MalawiMethods Clusters were selected across the whole country through probability proportional tosize sampling with an urban/rural and demographic split that matched the national distributionof the population. Clusters were distributed around all 27-mainland districts of Malawi.Population of Malawi was 18.3 million from 2018 estimates, based on age categories weestimated that about 8.9 million were 16 years and younger. MSI diagnosis from ourrandomized sample was extrapolated to the population of Malawi, confidence limits wascalculated using normal approximation.Results Of 3,792 children aged 16 or less who were enumerated, 3,648 (96.2%) were examinedand 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7-7.3).Extrapolated to the Malawian population this means as many as 576,000 (95% CI505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were dueto congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% wereacquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated atotal number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O),42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000(47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and20,000 (6,000-33,000) children in need of orthopaedic surgery. Low parents’ educational levelwas one factor associated with an increased risk of MSIConclusion This survey has uncovered a large burden of MSI among children aged 16 andunder in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended,revealing a need to scale up both P&O services, physical & occupational therapy, and surgicalservices in the country

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14. IMPACT OF THE COVID-19 PANDEMIC ON ONCOLOGYCLINICAL RESEARCH IN LATIN AMERICA (LACOG 0420)Jco Global Oncology

Authors: Aline B. Lara Gongora ,Gustavo Werutsky ,Denis L. Jardim , Angelica Nogueira-Rodrigues , Carlos H. Barrios , Clarissa Mathias,Fernando Maluf ,Rachel Riechelmann,MaurícioFraga, Henry Gomes , William N. William ,Camilla A. F. Yamada, Gilberto de Castro Jr , DanielaD. Rosa, Andreia C. de Melo , Raul Sala,Eva Bustamante, Denisse Bretel, Oscar Arrieta , AndrésF. Cardona , Diogo A. BastosRegion / country: Central America, South AmericaSpeciality: Other, Surgical oncology

PURPOSECOVID-19 has affected cancer care worldwide. Clinical trials are an important alternative forthe treatment of oncologic patients, especially in Latin America, where trials can be the onlyopportunity for some of them to access novel and, sometimes, standard treatments.METHODSThis was a cross-sectional study, in which a 22-question survey regarding the impact of theCOVID-19 pandemic on oncology clinical trials was sent to 350 representatives of researchprograms in selected Latin American institutions, members of the Latin American CooperativeOncology Group.RESULTSThere were 90 research centers participating in the survey, with 70 of them from Brazil. Themajority were partly private or fully private (n = 77; 85.6%) and had confirmed COVID-19 casesat the institution (n = 57; 63.3%). Accruals were suspended at least for some studies in 80% (n= 72) of the responses, mostly because of sponsors’ decision. Clinical trials’ routine wasaffected by medical visits cancelation, reduction of patients’ attendance, reduction of otherspecialties’ availability, and/or alterations on follow-up processes. Formal COVID-19 mitigationpolicies were adopted in 96.7% of the centers, including remote monitoring and remote siteinitiation visits, telemedicine visits, reduction of research team workdays or home office,special consent procedures, shipment of oral drugs directly to patients’ home, and increase inoutpatient diagnostic studies. Importantly, some of these changes were suggested to be part offuture oncology clinical trials’ routine, particularly the ones regarding remote methods, such astelemedicine.CONCLUSIONTo our knowledge, this was the first survey to evaluate the impact of COVID-19 on LatinAmerican oncology clinical trials. The results are consistent with surveys from other worldregions. These findings may endorse improvements in clinical trials’ processes andmanagement in the postpandemic period.

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15. THE ROLE OF NONCOMMUNICABLE DISEASES IN THEPURSUIT OF GLOBAL HEALTH SECURITYHealth Security

Authors: Deliana Kostova, Patricia Richter, Gretchen Van Vliet, Michael Mahar, and Ronald L.MoolenaarRegion / country: GlobalSpeciality: Health policy, Other

Noncommunicable diseases and their risk factors are important for all aspects of outbreakpreparedness and response, affecting a range of factors including host susceptibility, pathogenvirulence, and health system capacity. This conceptual analysis has 2 objectives. First, we usethe Haddon matrix paradigm to formulate a framework for assessing the relevance ofnoncommunicable diseases to health security efforts throughout all phases of the disaster lifecycle: before, during, and after an event. Second, we build upon this framework to identify 6technical action areas in global health security programs that are opportune integration pointsfor global health security and noncommunicable disease objectives: surveillance, workforcedevelopment, laboratory systems, immunization, risk communication, and sustainable financing.We discuss approaches to integration with the goal of maximizing the reach of global healthsecurity where infectious disease threats and chronic disease burdens overlap.

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16. OPPORTUNITIES FOR IMPROVEMENT IN THEADMINISTRATION OF NEOADJUVANT CHEMOTHERAPY FOR T4BREAST CANCER: A COMPARISON OF THE UNITED STATESAND NIGERIAThe Oncologist

Authors: Anya Romanoff ,Olalekan Olasehinde ,Debra A. Goldman ,Olusegun I. Alatise , JeremyConstable ,Ngozi Monu , Gregory C. Knapp ,Oluwole Odujoko ,Emmanuella Onabanjo ,AdewaleO. Adisa ,Adeolu O. Arowolo ,Adeleye D. Omisore ,Olusola C. Famurewa ,Benjamin O. Anderson,Mary L. Gemignani , T. Peter KinghamRegion / country: Northern America, Western Africa – Nigeria, United States of AmericaSpeciality: General surgery, Surgical oncology

BACKGROUNDNeoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa)treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct futureinterventions.MATERIALS AND METHODSCross‐sectional retrospective analysis included all non‐metastatic T4 BCa patients treated from2010‐2016 at Memorial Sloan Kettering Cancer Center (New York, U.S.) and Obafemi AwolowoUniversity Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR)and survival were compared and factors contributing to disparities evaluated.RESULTS308 patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S.patients received NAC and surgery compared with 93 (62%) Nigerian patients. 56/93 (60%)Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and highersocioeconomic status were associated with treatment receipt.Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria).Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative vs.39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5%(4/76) of Nigerian patients. Five‐year survival was significantly shorter in Nigeria vs. the U.S.(61% vs. 72%). However, among the subset of patients who received multimodality therapy,including NAC and surgery with curative intent, 5‐year survival (67% vs. 72%) and 5‐yearrecurrence‐free survival (48% vs. 61%) did not significantly differ between countries.CONCLUSIONAddressing health system, socioeconomic, and psychosocial barriers is necessary foradministration of complete NAC to improve BCa outcomes in Nigeria.

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17. COMPARISON OF CHALLENGES AND PROBLEMSENCOUNTERED IN THE PRACTICE OF EXCLUSIVE BREASTFEEDING BY PRIMIPAROUS AND MULTIPAROUS WOMEN INRURAL AREAS OF SINDH, PAKISTAN: A CROSS-SECTIONALSTUDYCureus

Authors: Sana Zafar, Khizer Shamim, Syeda Mehwish, Mohsin Arshad, Rahil BarkatRegion / country: Southern Asia – PakistanSpeciality: Health policy, Obstetrics and Gynaecology

Introduction: The UNICEF (United Nations International Children Education Fund) and WHO(World Health Organization) recommend exclusive breastfeeding (EBF) for the first six monthsof life. EBF is considered to be an important practice for enhancing infant health and wellbeing.Breastfeeding offers a wide range of psychological and physical health benefits in the long-termand short-term for young children, infants, and mothers. This study aims to compare exclusivebreastfeeding practice among primiparous and multiparous mothers including reasons fordiscontinuing exclusive breastfeeding and problems faced during breastfeeding.Methodology: This cross-sectional study was conducted in rural areas of Sindh, registered withthe Maternal Newborn Health Registry (MNHR). The study used a systematic samplingtechnique for the enrollment of study participants. A survey questionnaire was used to collectdata from mothers about the practices of EBF. A total of 397 mothers were interviewed andanalyzed.Results: Among Primiparous mothers, 14.1% of mothers initiated breastfeeding within one hourof birth, while 22.4% of multiparous mothers, initiated breastfeeding within one hour of birth.The difference between the two is statistically insignificant (p-value=0.234). A high percentageof multiparous mothers exclusively breastfed their infants for six months (63.5%) as comparedto primiparous mothers (51.5%). The most common reason for introducing pre-lacteal feedbefore six months among primiparous mothers is the lack of adequate milk production to fulfillbaby needs; this was the case for 35.4% of mothers. On the other hand, the baby remaininghungry post breastfeeding was the major reason among multiparous mothers (44.0%) forintroducing pre-lacteal feed before six months.Conclusion: This study helped in the identification of issues faced by primiparous andmultiparous mothers during exclusive breastfeeding. Interventions for promoting EBF need tobe tailored as per the need and challenges of the population.

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18. INVASIVE BREAST CANCER TREATMENT IN TANZANIA:LANDSCAPE ASSESSMENT TO PREPARE FORIMPLEMENTATION OF STANDARDIZED TREATMENTGUIDELINESBmc Cancer

Authors: Rupali Sood, Nestory Masalu, Roisin M. Connolly, Christina A. Chao, Lucas Faustine,Cosmas Mbulwa, Benjamin O. Anderson , Anne F. RositchRegion / country: Eastern Africa – TanzaniaSpeciality: General surgery, Surgical oncology

BackgroundIncidence of breast cancer continues to rise in low- and middle-income countries, with datafrom the East African country of Tanzania predicting an 82% increase in breast cancer from2017 to 2030. We aimed to characterize treatment pathways, receipt of therapies, and identifyhigh-value interventions to increase concordance with international guidelines and avertunnecessary breast cancer deaths.MethodsPrimary data were extracted from medical charts of patients presenting to Bugando MedicalCenter, Tanzania, with breast concerns and suspected to have breast cancer. Clinicopathologicfeatures were summarized with descriptive statistics. A Poisson model was utilized to estimateprevalence ratios for variables predicted to affect receipt of life-saving adjuvant therapies andcompletion of therapies. International and Tanzanian guidelines were compared to current carepatterns in the domains of lymph node evaluation, metastases evaluation, histopathologicaldiagnosis, and receptor testing to yield concordance scores and suggest future areas of focus.ResultsWe identified 164 patients treated for suspected breast cancer from April 2015–January 2019.Women were predominantly post-menopausal (43%) and without documented insurance (70%).Those with a confirmed histopathology diagnosis (69%) were 3 times more likely to receiveadjuvant therapy (PrR [95% CI]: 3.0 [1.7–5.4]) and those documented to have insurance were1.8 times more likely to complete adjuvant therapy (1.8 [1.0–3.2]). Out of 164 patients, 4%(n = 7) received concordant care based on the four evaluated management domains. The firstmost common reason for non-concordance was lack of hormone receptor testing as 91%(n = 144) of cases did not undergo this testing. The next reason was lack of lymph nodeevaluation (44% without axillary staging) followed by absence of abdominopelvic imaging inthose with symptoms (35%) and lack of histopathological confirmation (31%).ConclusionsPatient-specific clinical data from Tanzania show limitations of current breast cancermanagement including axillary staging, receipt of formal diagnosis, lack of predictivebiomarker testing, and low rates of adjuvant therapy completion. These findings highlight theneed to adapt and adopt interventions to increase concordance with guidelines includingimproving capacity for pathology, developing complete staging pathways, and ensuringcompletion of prescribed adjuvant therapies.

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19. SURGICAL CLIP LIGATION OF ANTERIORCOMMUNICATING ARTERY ANEURYSM IN A RESOURCE-LIMITED SETTINGCureus

Authors: Christopher Markosian, Igor Kurilets Jr., Luke D. TomyczRegion / country: Eastern Europe – UkraineSpeciality: Vascular surgery

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures toensure total occlusion and avoid ischemic complications is standard in countries such as theUnited States. However, alternatives need to be considered in resource-limited settings. Theclipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited settingis presented and special nuances that optimize safety are described. Careful surgical technique,meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm andadjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achievefavorable results.

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20. MORAL DISTRESS AND RESILIENCE ASSOCIATED WITHCANCER CARE PRIORITY SETTING IN A RESOURCE LIMITEDCONTEXTThe Oncologist

Authors: Rebecca J. DeBoer , Espérance Mutoniwase , Cam Nguyen , Anita Ho , Grace Umutesi, Eugene Nkusi , Fidele Sebahungu , Katherine Van Loon , Lawrence N. Shulman , CyprienShyirambereRegion / country: GlobalSpeciality: Health policy, Surgical oncology

BackgroundMoral distress and burnout are highly prevalent among oncology clinicians. Research is neededto better understand how resource constraints and systemic inequalities contribute to moraldistress in order to develop effective mitigation strategies. Oncology providers in low- andmiddle-income countries (LMICs) are well positioned to provide insight into the moralexperience of cancer care priority setting and expertise to guide solutions.MethodsSemi-structured interviews were conducted with a purposive sample of 22 oncology physicians,nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews wererecorded, transcribed verbatim, and analyzed using the framework method.ResultsParticipants identified sources of moral distress at three levels of engagement with resourceprioritization: witnessing program-level resource constraints drive cancer disparities,implementing priority setting decisions into care of individual patients, and communicatingwith patients directly about resource prioritization implications. They recommended individualand organizational level interventions to foster resilience, such as communication skills trainingand mental health support for clinicians, interdisciplinary team-building, fair procedures forpriority setting, and collective advocacy for resource expansion and equity.ConclusionThis study adds to the current literature an in-depth examination of the impact of resourceconstraints and inequities on clinicians in a low resource setting. Effective interventions areurgently needed to address moral distress, reduce clinician burnout, and promote well-beingamong a critical but strained oncology workforce. Collective advocacy is concomitantly neededto address the structural forces that constrain resources unevenly and perpetuate disparities incancer care and outcomes.

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21. FROM THE BREAST TO THE UPPER JAW: A RARE CASE OFMETASTATIC BREAST CANCERSouth Sudan Medical Journal

Authors: Funmilola O. Wuraola , Bamidele A. Famurewa , Olalekan Olasehinde , Oluwole O.Odujoko , Olufunlola M. Adesina , Stephen B. AregbesolaRegion / country: Western Africa – NigeriaSpeciality: General surgery, Surgical oncology

Breast cancer is the commonest malignancy in women globally. Metastases of advanced breastcarcinoma to bones, lungs and liver are well known but spread to maxillary bone presenting asmaxillary sinus and palatal swelling is rare. We present a case of advanced breast carcinoma ina female Nigerian with clinical, radiological and histopathological features of lung and rightmaxillary bone metastases. To the best of our knowledge, this is the first reported case ofmetastatic breast cancer to the lungs and maxilla in Nigeria. The debilitating sequelae ofadvanced untreated breast carcinoma in a resource limited setting with suboptimalcomprehensive cancer care are highlighted.

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22. ARTIFICIAL INTELLIGENCE: A RAPID CASE FORADVANCEMENT IN THE PERSONALIZATION OFGYNAECOLOGY/OBSTETRIC AND MENTAL HEALTH CAREWomen’s Health

Authors: Gayathri Delanerolle, Xuzhi Yang, Suchith Shetty, Vanessa Raymont, Ashish Shetty,Peter Phiri, Dharani K Hapangama, Nicola Tempest, Kingshuk Majumder, Jian Qing ShiRegion / country: GlobalSpeciality: Obstetrics and Gynaecology, Other

To evaluate and holistically treat the mental health sequelae and potential psychiatriccomorbidities associated with obstetric and gynaecological conditions, it is important tooptimize patient care, ensure efficient use of limited resources and improve health-economicmodels. Artificial intelligence applications could assist in achieving the above. The WorldHealth Organization and global healthcare systems have already recognized the use of artificialintelligence technologies to address ‘system gaps’ and automate some of the more cumbersometasks to optimize clinical services and reduce health inequalities. Currently, both mental healthand obstetric and gynaecological services independently use artificial intelligence applications.Thus, suitable solutions are shared between mental health and obstetric and gynaecologicalclinical practices, independent of one another. Although, to address complexities with somepatients who may have often interchanging sequelae with mental health and obstetric andgynaecological illnesses, ‘holistically’ developed artificial intelligence applications could beuseful. Therefore, we present a rapid review to understand the currently available artificialintelligence applications and research into multi-morbid conditions, including clinical trial-based validations. Most artificial intelligence applications are intrinsically data-driven tools, andtheir validation in healthcare can be challenging as they require large-scale clinical trials.Furthermore, most artificial intelligence applications use rate-limiting mock data sets, whichrestrict their applicability to a clinical population. Some researchers may fail to recognize therandomness in the data generating processes in clinical care from a statistical perspective witha potentially minimal representation of a population, limiting their applicability within a real-world setting. However, novel, innovative trial designs could pave the way to generate betterdata sets that are generalizable to the entire global population. A collaboration betweenartificial intelligence and statistical models could be developed and deployed with algorithmicand domain interpretability to achieve this. In addition, acquiring big data sets is vital to ensurethese artificial intelligence applications provide the highest accuracy within a real-worldsetting, especially when used as part of a clinical diagnosis or treatment.

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23. BARRIERS AND FACILITATORS TO ONLINE MEDICAL ANDNURSING EDUCATION DURING THE COVID-19 PANDEMIC:PERSPECTIVES FROM INTERNATIONAL STUDENTS FROMLOW- AND MIDDLE-INCOME COUNTRIES AND THEIRTEACHING STAFFHuman Resources For Health

Authors: Wen Li, Robyn Gillies, Mingyu He, Changhao Wu, Shenjun Liu, Zheng Gong , HongSunRegion / country: GlobalSpeciality: Health policy, Surgical Education

BackgroundThe COVID-19 pandemic posed a huge challenge to the education systems worldwide, forcingmany countries to provisionally close educational institutions and deliver courses fully online.The aim of this study was to explore the quality of the online education in China forinternational medical and nursing students from low- and middle-income countries (LMICs) aswell as the factors that influenced their satisfaction with online education during the COVID-19pandemic.MethodsQuestionnaires were developed and administered to 316 international medical and nursingstudents and 120 teachers at a university in China. The Chi-square test was used to detect theinfluence of participants’ personal characteristics on their satisfaction with online education.The Kruskal–Wallis rank-sum test was employed to identify the negative and positive factorsinfluencing the online education satisfaction. A binary logistic regression model was performedfor multiple-factor analysis to determine the association of the different categories of influentialfactors—crisis-, learner-, instructor-, and course-related categories, with the online educationsatisfaction.ResultsOverall, 230 students (response rate 72.8%) and 95 teachers (response rate 79.2%) completedthe survey. It was found that 36.5% of students and 61.1% of teachers were satisfied with theonline education. Teachers’ professional title, students’ year of study, continent of origin andlocation of current residence significantly influenced the online education satisfaction. Themost influential barrier for students was the severity of the COVID-19 situation and for teachersit was the sense of distance. The most influential facilitating factor for students was a well-accomplished course assignment and for teachers it was the successful administration of theonline courses.ConclusionsSeveral key factors have been identified that affected the attitudes of international healthscience students from LMICs and their teachers towards online education in China during theCOVID-19 pandemic. To improve the online education outcome, medical schools are advised topromote the facilitating factors and cope with the barriers, by providing support for studentsand teaching faculties to deal with the anxiety caused by the pandemic, caring for the state ofmind of in-China students away from home, maintaining the engagement of out-China studentsstudying from afar and enhancing collaborations with overseas institutions to create practiceopportunities at students’ local places.

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24. BURDEN OF CERVICAL CANCER IN THE EASTERNMEDITERRANEAN REGION DURING THE YEARS 2000 AND2017: RETROSPECTIVE DATA ANALYSIS OF THE GLOBALBURDEN OF DISEASE STUDYJmir Public Health Surveillance

Authors: Fereshteh Safaeian, Shidrokh Ghaemimood , Ziad El-Khatib,Sahba Enayati , RoksanaMirkazemi , Bruce ReederRegion / country: Middle East, Northern Africa, Southern AsiaSpeciality: Obstetrics and Gynaecology, Surgical oncology

Background:Cervical cancer is a growing health concern, especially in resource-limited settings.Objective:The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally betweenthe years 2000 and 2017 by using a pooled data analysis approach.Methods:We used an ecological approach at the country level. This included extracting data frompublicly available databases and linking them together in the following 3 steps: (1) extraction ofdata from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2)categorization of EMR countries according to the World Bank gross domestic product percapita, and (3) linking age-specific population data from the Population Statistics Division of theUnited Nations (20-29 years, 30-49 years, and >50 years) and GBD’s data with gross nationalincome per capita and globally extracted data, including cervical cancer mortality and DALYnumbers and rates per country. The cervical cancer mortality rate was provided by the GBDstudy using the following formula: number of cervical cancer deaths × 100,000/femalepopulation in the respective age group.Results:The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326)to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this diseasedecreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). Accordingto age-specific data, the age group ≥50 years showed the highest mortality rate in both EMRcountries and globally, and the age group of 20-29 years showed the lowest mortality rate bothglobally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR werelower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rateper 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000;respectively). However, the relative difference in the number of DALYs due to cervical cancerbetween the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively).Conclusions:We found an increase in the burden of cervical cancer in the EMR as per the data on theabsolute number of deaths and DALYs. Further, we found that the health care system has anincreased number of cases to deal with, despite the decrease in the absolute number of deathsand DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and earlyscreening is performed. Therefore, we recommend identifying effective vaccination programsand interventions to reduce the burden of this disease.

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25. THE ROLE OF MITROFANOFF APPENDICOVESICOSTOMY INTHE MANAGEMENT OF A PELVIC FRACTURE DISTRACTIONDEFECT IN A 24- YEAR-OLD MAN AFTER MULTIPLE FAILEDRECONSTRUCTION ATTEMPTSEast And Central African Journal Of Surgery

Authors: Mumba Chalwe, Seke M.E. KazumaRegion / country: Eastern Africa – ZambiaSpeciality: General surgery, Trauma and orthopaedic surgery, Trauma surgery, Urologysurgery

Failed Pelvic Fracture Distraction Defect repairs present a considerable challenge formanagement. Re-do urethroplasties for failed repairs are associated with higher recurrence andmorbidity rates. The case presented describes a male patient with a pelvic fracture urethraldistraction defect (PFUDD) who had undergone multiple failed repairs. The Mitrofanoffappendicovesicostomy was successfully carried out and the patient remains continent to date.The Mitrofanoff appendicovesicostomy is not commonly employed in the management of adulturethral stricture disease. We present our experience with managing a pelvic fracture urethraldisruption defect (PFUDD) after multiple failed urethroplasties using a continent catheterisableurinary diversion technique

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26. SURGICAL MANAGEMENT AND OUTCOMES OF LATE-PRESENTING ACUTE LIMB ISCHAEMIA AT 2 REFERRALHOSPITALS IN ADDIS ABABA, ETHIOPIA: A 1-YEARPROSPECTIVE STUDYEast And Central African Journal Of Surgery

Authors: Nebyou Seyoum, Berhanu D. Mekonnen, Berhanu N. AlemuRegion / country: Eastern Africa – EthiopiaSpeciality: Emergency surgery, Vascular surgery

Objective: The study was performed to show the overall perspective of surgical management foracute limb ischemia specific to Ethiopian population.Methods: A prospective planned cohort study was conducted to analyze the socio-demography,clinical presentation, causes of limb ischemia, and outcomes of surgical intervention, andvariables associated with complications of acute limb ischemia.Results:A total of 102 patients were operated upon. The male to female ratio was 2:1; the meanage of presentation was 54±17 years. Patients presented after an average of 9±4.8 days ofsymptom onset. The type of procedures performed were, thrombectomy 51(47.2%), primaryamputation 24(22.2%), bypass or interposition vascular grafts 10(9.2%), embolectomy10(9.2%), primary vascular repair 7(6.4%), and femoro-femoral graft 6(5.5%). Local andsystemic complications occurred in 35.3% and 17.6% respectively. Amputation after re-vascularization surgery was seen in 32.4%. A 30-day total amputation & mortality rate was52.9% and 9.8% respectively. Clinical variables found to have a statistical significantassociation (P<0.05) with complications were age ≥ 60 years, late presentation (≥ 9days),patients with hypertensive disease and previous myocardial infarction.Conclusions: Optimizing co-morbidities, timely detection and treating immediately on arrivalcould potentially play a key role in improving surgical outcomes of acute limb ischemia.

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27. RESPIRATORY MORBIDITY AND MORTALITY OFTRAUMATIC CERVICAL SPINAL CORD INJURY AT A LEVEL ITRAUMA CENTER IN INDIASpinal Cord Series And Cases

Authors: Deep Sengupta, Ashish Bindra, Niraj Kumar, Keshav Goyal, Pankaj Kumar Singh,Arvind Chaturvedi, Rajesh Malhotra & Ashwani Kumar MishraRegion / country: Southern Asia – IndiaSpeciality: Emergency surgery, Neurosurgery, Trauma and orthopaedic surgery, Traumasurgery

Study designDescriptive retrospective.ObjectivesTo evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) daysand length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality inpatients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country(LMIC).SettingJai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences(AIIMS), New Delhi, India.MethodsA total of 135 patients admitted with CSCI in the NICU between January 2017 to December2018 were screened. Information regarding age, gender, American Spinal Injury Association(ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, andoutcome in terms of mortality or discharge from the hospital were obtained from the medicalrecords.ResultsA total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) yearsand male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was amedian of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortalitywas 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, andduration of ICU and hospital stay. All patients were discharged to home only after they becameventilator-free.ConclusionsThe ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs.Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is aneed for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

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28. CERVICAL CANCER DIAGNOSIS AND TREATMENT DELAYSIN THE DEVELOPING WORLD: EVIDENCE FROM A HOSPITAL-BASED STUDY IN ZAMBIAGynecologic Oncology Reports

Authors: Jane Mwamba Mumba, Lackson Kasonka, Okola Basil Owiti, Mwansa Ketty Lubeya ,Lufunda Lukama, Susan C Msadabwe, Chester KalindaRegion / country: Central Africa, Eastern Africa – ZambiaSpeciality: Obstetrics and Gynaecology, Surgical oncology

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in theeffort to improve clinical outcomes of the disease. However, in some developing countries likeZambia, there is paucity of data that assesses factors influencing diagnostic and treatmentturnaround time (TAT) and other metrics vital for quality cancer care. We conducted aretrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancercases presenting to the facility between January 2014 and December 2018. Descriptivestatistics were used to summarize demographic characteristics while a generalized linear modelof the negative binomial was used to assess determinants of overall TAT. Our study included2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n=634,31%) were aged between 41–50 years. The International Federation of Gynaecology andObstetrics (FIGO) Cancer stage II (n =941, 48%) was the most prevalent while stage IV (n=103,5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI:1.21–1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days(IQR: 24–152) and the overall TAT (oTAT) was 110 days (IQR: 62–204). The age of the patient,HIV status, stage of cancer and histological subtype did not influence oTAT while marital statusinfluenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomesamong cervical cancer patients. There is a need to improve cancer care in Zambia throughimproved health expenditure especially in public health facilities.

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29. INCREASING ANTIMICROBIAL RESISTANCE IN SURGICALWARDS AT MULAGO NATIONAL REFERRAL HOSPITAL,UGANDA, FROM 2014 TO 2018—CAUSE FOR CONCERN?Tropical Medicine And Infectious Disease

Authors: Gerald Mboowa ,Dickson Aruhomukama ,Ivan Sserwadda ,Freddy Eric Kitutu ,HaykDavtyan ,Philip Owiti ,Edward Mberu Kamau ,Wendemagegn Enbiale ,Anthony Reid ,DouglasBulafu ,Jeffrey Kisukye ,Margaret Lubwama ,Henry KajumbulaRegion / country: Eastern Africa – UgandaSpeciality: General surgery, Health policy, Other

Antimicrobial Resistance (AMR) and Healthcare Associated Infections (HAIs) are major globalpublic health challenges in our time. This study provides a broader and updated overview ofAMR trends in surgical wards of Mulago National Referral Hospital (MNRH) between 2014 and2018. Laboratory data on the antimicrobial susceptibility profiles of bacterial isolates from 428patient samples were available. The most common samples were as follows: tracheal aspirates(36.5%), pus swabs (28.0%), and blood (20.6%). Klebsiella (21.7%), Acinetobacter (17.5%), andStaphylococcus species (12.4%) were the most common isolates. The resistance patterns fordifferent antimicrobials were: penicillins (40–100%), cephalosporins (30–100%), β-lactamaseinhibitor combinations (70–100%), carbapenems (10–100%), polymyxin E (0–7%),aminoglycosides (50–100%), sulphonamides (80–100%), fluoroquinolones (40–70%), macrolides(40–100%), lincosamides (10–45%), phenicols (40–70%), nitrofurans (0–25%), and glycopeptide(0–20%). This study demonstrated a sustained increase in resistance among the most commonlyused antibiotics in Uganda over the five-year study period. It implies ongoing hospital-basedmonitoring and surveillance of AMR patterns are needed to inform antibiotic prescribing, andto contribute to national and global AMR profiles. It also suggests continued emphasis oninfection prevention and control practices (IPC), including antibiotic stewardship. Ultimately,laboratory capacity for timely bacteriological culture and sensitivity testing will provide arational choice of antibiotics for HAI.

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30. OXYGEN DELIVERY SYSTEMS FOR ADULTS IN SUB-SAHARAN AFRICA: A SCOPING REVIEWJournal Of Global Health

Authors: Neelima Navuluri, Maria L Srour, Peter S Kussin, David M Murdoch, Neil RMacIntyre, Loretta G Que, Nathan M Thielman, Eric D McCollumRegion / country: Central Africa, Eastern Africa, Southern Africa, Western AfricaSpeciality: Critical care, Health policy, Other

BackgroundRespiratory diseases are the leading cause of death and disability worldwide. Oxygen is anessential medicine used to treat hypoxemia from respiratory diseases. However, the availabilityand utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described.We aim to identify and describe existing data around oxygen availability and provision foradults in sub-Saharan Africa, determine knowledge or research gaps, and makerecommendations for future research and capacity building.MethodsWe systematically searched four databases for articles on April 22, 2020, for variations ofkeywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteriawere studies that included adults and addressed hypoxemia assessment or outcome, oxygendelivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapyand outcomes.Results35 studies representing 22 countries met inclusion criteria. Availability of oxygen deliverysystems ranged from 42%-94% between facilities, with wide variability in the consistency ofavailability. There was also wide reported prevalence of hypoxemia, with most studies focusingon specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, andtitrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the mostcost-effective delivery system in areas where power is readily available.ConclusionsThere is a substantial need for building capacity for oxygen delivery throughout sub-SaharanAfrica. Addressing this critical issue will require innovation and a multi-faceted approach ofdeveloping infrastructure, better equipping facilities, and health care worker training

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31. GLOBAL COMMUNITY PERCEPTION OF ‘SURGICAL CARE’AS A PUBLIC HEALTH ISSUE: A CROSS SECTIONAL SURVEYBmc Public Health Volume

Authors: Nurhayati Lubis, Meena Nathan Cherian, Chinmayee Venkatraman , Fiemu E.NwariakuRegion / country: GlobalSpeciality: Health policy

BackgroundIn the last decade surgical care has been propelled into the public health domain with theestablishment of a World Health Organisation (WHO) designated programme and keypublications. The passing of the historic World Health Assembly Resolution (WHA)acknowledged surgical care as a vital component towards achieving Universal Health Coverage(UHC). We conducted the first worldwide survey to explore the perception of surgical care as apublic health issue.MethodThe anonymous, cross sectional survey targeted worldwide participants across a range ofprofessional backgrounds, including non-medical using virtual snowball sampling method (inEnglish) using Google Forms (Google Inc., Mountain View, CA, USA) from 20th February 2019to 25th June 2019. The survey questions were designed to gauge awareness on SustainableDevelopment Goals (SDGs), UHC, WHO programmes and key publications on surgical care aswell as perception of surgical care as a priority topic in public health.ResultsThe survey was completed by 1954 respondents from 118 countries. Respondents were leastaware of surgical care as a teaching topic in public health courses (27%; n = 526) and as aWHO programme (20%; n = 384). 82% of respondents were aware of UHC (n = 1599) and ofthis 72% (n = 1152) agreed that surgical care fits within UHC. While 77% (n = 1495) ofrespondents were aware of SDGs, only 19% (n = 370) agreed that surgery was a priority tomeet SDGs. 48% (n = 941) rated surgical care as a cost-effective component of Primary HealthCare. 88% (n = 1712) respondents had not read the WHA Resolution on ‘Strengtheningemergency and essential surgical care and anaesthesia as a component of UHC’.ConclusionThere is still a widespread gap in awareness on the importance of surgical care as a publichealth issue amongst our respondents. Surgical care was not seen as a priority to reach theSDGs, less visible as a WHO programme and not perceived as an important topic for publichealth courses.

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32. ANALYSING A GLOBAL HEALTH EDUCATION FRAMEWORKFOR PUBLIC HEALTH EDUCATION PROGRAMS IN INDIAThe University Of Sydney

Authors: Sawleshwarkar, Shailendra NagoraoRegion / country: Southern Asia – IndiaSpeciality: Health policy, Surgical Education

Academic global health is of increasing interest to educators and students in public health butcompetency domains as well as education pathways that deliver this training, are still beingidentified and refined. This thesis was undertaken using an education program developmentparadigm and aimed to analyse the factors shaping global health education in India byexamining multistakeholder perspectives. The research framework consisted of fourcomponents: curriculum and content, students, faculty and key experts, and employers. Studiescaptured the perspectives of students through a survey and focus group discussions, facultyand other key experts through semi-structured interviews, and employers through jobadvertisement analysis. We identified eleven global health competency domains focussed onthree aspects: foundational competencies, core public health skills and soft skills. Global healthand public health were seen as interconnected, with global health having transnational contextand public health having a more national focus. Global health was seen as a nascent concept inIndia and although integration of global health education into the public health curriculum wassupported, there were concerns given that public health is still too new a discipline in India.Global health competencies were seen as a ‘step up’ from the public health competencies.Based on the results, a two-level approach to global health education is proposed for Indianpublic health institutions. The first approach, targeted at recent graduates, focuses on a‘foundational global health education’ within public health programs such as an MPH. Thesecond approach is an ‘Executive Global Health Certificate Program’, aimed at experiencedpublic health professionals planning to enter the global health workforce. This thesis hasoutlined a framework for Indian and other LMIC institutions looking to expand the scope ofpublic health education and intend to develop global health education programs.

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33. MANAGEMENT OF PROLONGED FIRST STAGE OF LABOURIN A LOW-RESOURCE SETTING: LESSONS LEARNT FROMRURAL MALAWIBmc Pregnancy And Childbirth

Authors: Wouter Bakker, Elisabeth van Dorp, Misheck Kazembe, Alfred Nkotola, Jos vanRoosmalen & Thomas van den AkkerRegion / country: Southern Africa – MalawiSpeciality: Health policy, Obstetrics and Gynaecology

BackgroundCaesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence ofadequate labour monitoring and by appropriate use of evidence-based interventions forprolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim todescribe the incidence of prolonged first stage of labour and the use of amniotomy andaugmentation with oxytocin in a low-resource setting in Malawi.MethodsRetrospective analysis of medical records and partographs of all women who gave birth in 2015and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolongedfirst stage of labour based on partograph tracings, caesarean section indications and utilizationof amniotomy and oxytocin augmentation.ResultsOut of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line inthe first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolongedfirst stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%)membranes were still intact at the start of caesarean section. Excluding the 60 women withprior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section foraugmentation of labour.ConclusionThe diagnosis prolonged first stage of labour was often made without being evident from labourtracings and two basic obstetric interventions to prevent caesarean section, amniotomy andlabour augmentation with oxytocin, were underused.

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34. HEALTH RESEARCH CAPACITY BUILDING OF HEALTHWORKERS IN FRAGILE AND CONFLICT-AFFECTED SETTINGS: ASCOPING REVIEW OF CHALLENGES, STRENGTHS, ANDRECOMMENDATIONSHealth Research Policy And Systems

Authors: Rania Mansour, Hady Naal, Tarek Kishawi, Nassim El Achi, Layal Hneiny , ShadiSalehRegion / country: GlobalSpeciality: Health policy

BackgroundFragile and conflict-affected settings (FCAS) have a strong need to improve the capacity of localhealth workers to conduct health research in order to improve health policy and healthoutcomes. Health research capacity building (HRCB) programmes are ideal to equip healthworkers with the needed skills and knowledge to design and lead health-related researchinitiatives. The study aimed to review the characteristics of HRCB studies in FCASs in order toidentify their strengths and weaknesses, and to recommend future directions for the field.MethodsWe conducted a scoping review and searched four databases for peer-reviewed articles thatreported an HRCB initiative targeting health workers in a FCAS and published after 2010.Commentaries and editorials, cross-sectional studies, presentations, and interventions that didnot have a capacity building component were excluded. Data on bibliographies of the studiesand HRCB interventions and their outcomes were extracted. A descriptive approach was usedto report the data, and a thematic approach was used to analyse the qualitative data.ResultsOut of 8822 articles, a total of 20 were included based on the eligibility criteria. Most of theinitiatives centred around topics of health research methodology (70%), targeted an individual-level capacity building angle (95%), and were delivered in university or hospital settings (75%).Ten themes were identified and grouped into three categories. Significant challenges revolvedaround the lack of local research culture, shortages in logistic capability, interpersonaldifficulties, and limited assessment and evaluation of HRCB programmes. Strengths of HRCBinterventions included being locally driven, incorporating interactive pedagogies, andpromoting multidisciplinary and holistic training. Common recommendations covered by thestudies included opportunities to improve the content, logistics, and overarching structuralcomponents of HRCB initiatives.ConclusionOur findings have important implications on health research policy and related capacitybuilding efforts. Importantly, FCASs should prioritize (1) funding HRCB efforts, (2)strengthening equitable international, regional, and national partnerships, (3) delivering locallyled HRCB programmes, (4) ensuring long-term evaluations and implementing programmes atmultiple levels of the healthcare system, and (5) adopting engaging and interactive approaches.

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35. COMMUNICATION INTERVENTION USING DIGITALTECHNOLOGY TO FACILITATE INFORMED CHOICES ATCHILDBIRTH IN THE CONTEXT OF THE COVID-19 PANDEMIC:PROTOCOL FOR A RANDOMIZED CONTROLLED TRIALJmir Research Protocols

Authors: Carmen Simone Grilo Diniz , Ana Carolina Arruda Franzon , Beatriz Fioretti-Foschi ,Denise Yoshie Niy , Livia Sanches Pedrilio , Edson Amaro Jr , João Ricardo SatoRegion / country: South America – BrazilSpeciality: Health policy, Other

Background:In Brazil and other low- and middle-income countries, excess interventions in childbirth areassociated with an increase in preterm and early-term births, contributing to stagnantmorbidity and mortality of mothers and neonates. The fact that women often report a negativeexperience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, orabuse, may explain the high acceptability of elective cesarean sections. The recognition ofinformation needs and of the right to informed choice during childbirth can help change thisreality. The internet has been the main source of health information, but its quality is highlyvariable.Objective:This study aimed to develop and evaluate an information and communication strategy through asmartphone app with respect to childbirth, to facilitate informed choices for access to safer andevidence-based care in the context of the COVID-19 pandemic.Methods:A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind,parallel design, will be conducted with a smartphone app designed for behavior and opinionresearch in Brazil, with women of reproductive age previously registered on the app. Aftercompleting an entry questionnaire to verify the eligibility criteria and obtaining ethical consent,approximately 20,000 participants will be randomly allocated to the intervention and controlgroups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engagein a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth andthe safety of the care processes. The information is based on the guidelines of the Ministry ofHealth and the World Health Organization for a positive childbirth experience and has beenupdated to include the new challenges and disruptions in maternity care within the context ofthe COVID-19 pandemic. The control group will receive information regarding disposable andreusable diapers as a placebo intervention. The groups will be compared in their responses ingenerating the birth plan and the entry and exit questionnaires, regarding responses less ormore aligned with the guidelines for a positive childbirth experience. A qualitative componentto map information needs is included.Results:The digital trial started recruiting participants in late October 2020, and data collection hasbeen projected to be complete by December 2020.Conclusions:This study will evaluate an innovative intervention that has the potential to promote bettercommunication between women and providers, such that they can make better choices using anapproach suitable for use during the COVID-19 pandemic

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36. TIMELINESS OF DIAGNOSIS OF BREAST AND CERVICALCANCERS AND ASSOCIATED FACTORS IN LOW-INCOME ANDMIDDLE-INCOME COUNTRIES: A SCOPING REVIEW PROTOCOLBmj Open.

Authors: Chukwudi A Nnaji, Paul Kuodi, Fiona M Walter, Jennifer MoodleyRegion / country: GlobalSpeciality: General surgery, Obstetrics and Gynaecology, Surgical oncology

IntroductionBreast and cervical cancer are leading causes of morbidity and mortality in women globally,with disproportionately high burdens in low-income and middle-income countries (LMICs).While the incidence of both cancers increases across LMICs, many cases continue to goundiagnosed or diagnosed late. The aim of this review is to comprehensively map the currentevidence on the time to breast or cervical cancer diagnosis and its associated factors in LMICs.Methods and analysisThis scoping review (ScR) will be informed by Arksey and O’Malley’s enhanced ScRmethodology framework. It will be reported in accordance with the Preferred Reporting Itemsfor Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will conduct acomprehensive search of the following electronic databases: MEDLINE (via PubMed), CochraneLibrary, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).Two reviewers will independently screen all abstracts and full texts using predefined inclusioncriteria. All publications describing the time to diagnosis and its associated factors in thecontexts of breast or cervical cancer will be considered for inclusion. Evidence will benarratively synthesised and analysed using a predefined conceptual framework.Ethics and disseminationAs this is a ScR of publicly available data, with no primary data collection, it will not requireethical approval. Findings will be disseminated widely through a peer-reviewed publication andforums such as conferences and community engagement sessions. This review will provide auser-friendly evidence summary for understanding the enormity of diagnostic delays andassociated factors for breast and cervical cancers in LMICs, while helping to inform policyactions and implementation of interventions for addressing such delays.

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37. SHORT-TERM GENERAL, GYNECOLOGIC, ORTHOPEDIC,AND PEDIATRIC SURGICAL MISSION TRIPS IN NICARAGUA: ACOST-EFFECTIVENESS ANALYSISJournal Of Global Health

Authors: Keyanna P Taylor , Anna Ortiz , Jason PaltzerRegion / country: Central America – NicaraguaSpeciality: General surgery, Obstetrics and Gynaecology, Paediatric surgery, Trauma andorthopaedic surgery

Background Short-term surgical missions facilitated by non-governmental organizations (NGOs)may be a possible platform for cost-effective international global surgical efforts. The objectiveof this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective.Methods Using a provider perspective, the costs of implementing the surgical trips werecollected via Esperança’s previous trip reports. The reports and patient data were analyzed todetermine disability-adjusted life years averted from each surgical procedure provided inNicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialtywere calculated to determine the average cost of averting one disability adjusted life year.Results Esperança’s surgical missions’ program in Nicaragua from 2016 to 2020 was found tobe cost-effective, with pediatric and gynecology surgical specialties being highly cost-effectiveand general and orthopedic surgical specialties being moderately cost-effective. These resultswere echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialtywhich was found to not be cost-effective when testing an increased discount rate.Conclusions The cost-effectiveness of short-term surgical missions provided by NGOs can becost-effective, but limitations include inconsistent data from a societal perspective and lack ofan appropriate counterfactual. Future studies should examine the capacity for NGOs to collectadequate data and conduct rigorous economic evaluations

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38. THE ROLE OF HEALTH SERVICE DELIVERY NETWORKS INACHIEVING UNIVERSAL HEALTH COVERAGE IN AFRICASouth Eastern European Journal Of Public Health

Authors: Knovicks Simfukwe , Yusuff Adebayo Adebisi ,Amos Abimbola Oladunni ,SalmaElmukashfi Eltahir Mohammed, Don Eliseo Lucero-Prisno IIIRegion / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, WesternAfricaSpeciality: Health policy

Most countries in Africa are faced with health system problems that vary from one to the next.Countries with a low Human Development Index (HDI) seem to be more prone to challenges inhealth service delivery. To mark its 70th anniversary on World Health Day, the World HealthOrganization (WHO) selected the theme “Universal Health Coverage (UHC): Everyone,Everywhere” and the slogan “Health for All. ”UHC refers to ensuring that all people haveaccess to needed health services (including prevention, promotion, treatment, rehabilitation,and palliation) of sufficient quality to be effective while also ensuring that the use of theseservices does not expose the user to financial hardship. UHC is a WHO’s priority objective.Most governments have made it their major goal.This paper provides a perspective on the challenges of achieving UHC in Sub-Saharan Africa(SSA). It also endeavors to spotlight the successful models of Health Service Delivery Networks(HSDNs) that make significant strides in making progress towards achieving UHC. HSDNspropose models that facilitate the attainment of affordability and accessibility while maintainingquality in delivering health services. Additionally, it brings up to speed the challengesassociated with setting up HSDNs in health systems in SSA. It then makes propositions of whatmeasures and strategic approaches should be implemented to strengthen HSDNs in SSA. Thispaper further argues that UHC is not only technically feasible but it is also attainable ifcountries embrace HSDNs in SSA.

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39. SEQUENTIAL IMPROVEMENT IN PAEDIATRICMEDULLOBLASTOMA OUTCOMES IN A LOW-AND-MIDDLE-INCOME COUNTRY SETTING OVER THREE DECADESSouth African Journal Of Oncology

Authors: Johann Riedemann, Anthony Figaji, Alan Davidson, Clare Stannard, Komala Pillay,Tracy Kilborn, Jeannette ParkesRegion / country: GlobalSpeciality: Neurosurgery, Paediatric surgery, Surgical oncology

Background: Medulloblastoma (MB) is the commonest malignant brain tumour of childhood.Accurate clinical data on paediatric MB in the low-and-middle-income countries (LMIC) settingare lacking. Sequential improvements in outcomes seen in high-income countries are yet to bereflected in LMICs.Aim: The aim of this study was quantification of paediatric MB outcomes in the LMIC settingover three decades of advances in multidisciplinary intervention.Setting: Cape Town, South Africa.Methods: This was a retrospective study of 136 children with MB diagnosed between 1985 and2015. The modified Chang criteria were used for risk stratification. The primary objective ofthis study was overall survival (OS), quantified by analysis of epidemiological, clinical andpathological data.Results: OS improved significantly during the most recent decade (2005–2015) when comparedwith the preceding two decades (1985–1995 and 1995–2005). Despite reduced-dosecraniospinal irradiation (CSI) for standard risk cases, OS was significantly greater than duringthe preceding two decades. High-risk disease was identified in 71.4% of cases and wasassociated with significantly inferior OS compared with standard-risk cases. Improved OS waspositively correlated with the therapeutic era, three-dimensional (3D) conformal radiotherapytechnique, older age at diagnosis, classic and desmoplastic histology, extent of resection andabsence of leptomeningeal spread on imaging.Conclusion: Advances in multidisciplinary management of MB in our combined service areassociated with improved survival. Access to improved imaging modalities, advances in surgicaltechniques, increased number of patients receiving risk-adapted combination chemotherapy orradiotherapy, as well as CSI using a linear accelerator with 3D planning, are considered ascontributing factors.

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40. VIEWS FROM MULTIDISCIPLINARY ONCOLOGYCLINICIANS ON STRENGTHENING CANCER CARE DELIVERYSYSTEMS IN TANZANIAThe Oncologist

Authors: Sarah K. Nyagabona , Rohan Luhar , Jerry Ndumbalo , Nanzoke Mvungi , MamsauNgoma , Stephen Meena , Sadiq Siu , Mwamvita Said , Julius Mwaiselage , Edith Tarimo ,Geoffrey Buckle , Msiba Selekwa , Beatrice Mushi , Elia J. Mmbaga , Katherine Van Loon ,Rebecca J. DeBoerRegion / country: Eastern Africa – TanzaniaSpeciality: Surgical oncology

BackgroundIn response to the increasing burden of cancer in Tanzania, the Ministry of Health CommunityDevelopment, Gender, Elderly and Children launched National Cancer Treatment Guidelines(TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care inthe country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informedimplementation strategy to promote guideline-concordant care. As part of the situation analysisfor implementation strategy development, we conducted focus group discussions to evaluateclinical systems and contextual factors that influence guideline-based practice prior tolaunching of TNCTG.MethodsIn June 2019, three focus group discussions were conducted with a total of 21 oncologyclinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogueabout facilitators and barriers to delivery of guideline concordant care. Discussions were audiorecorded, transcribed, translated, and analyzed using thematic framework analysis.ResultsParticipants identified factors both within the inner context of ORCI clinical systems andoutside of ORCI. Themes within the clinical systems included: capacity and infrastructure,information technology, communication, efficiency and quality of services provided. Contextualfactors external to ORCI included: inter-institutional coordination, oncology capacity inperipheral hospitals, public awareness and beliefs, and financial barriers. Participants providedpragmatic suggestions for strengthening cancer care delivery in Tanzania.ConclusionOur results highlight several barriers and facilitators within and outside of the clinical systemsat ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broaderguideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.

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41. DIGITAL HEALTH STRATEGIES FOR CERVICAL CANCERCONTROL IN LOW- AND MIDDLE-INCOME COUNTRIES:SYSTEMATIC REVIEW OF CURRENT IMPLEMENTATIONS ANDGAPS IN RESEARCHJournal Of Medical Internet Research

Authors: Andrea H Rossman ,Hadley W Reid ,Michelle M Pieters , Cecelia Mizelle , Megan vonIsenburg , Nimmi Ramanujam , Megan J Huchko, Lavanya VasudevanRegion / country: GlobalSpeciality: Obstetrics and Gynaecology, Other, Surgical oncology

Background:Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries(LMICs). In recent years, many digital health strategies have been implemented in LMICs toameliorate patient-, provider-, and health system–level challenges in cervical cancer control.However, there are limited efforts to systematically review the effectiveness and currentlandscape of digital health strategies for cervical cancer control in LMICs.Objective:We aim to conduct a systematic review of digital health strategies for cervical cancer control inLMICs to assess their effectiveness, describe the range of strategies used, and summarizechallenges in their implementation.Methods:A systematic search was conducted to identify publications describing digital health strategiesfor cervical cancer control in LMICs from 5 academic databases and Google Scholar. Thereview excluded digital strategies associated with improving vaccination coverage againsthuman papillomavirus. Titles and abstracts were screened, and full texts were reviewed foreligibility. A structured data extraction template was used to summarize the information fromthe included studies. The risk of bias and data reporting guidelines for mobile health wereassessed for each study. A meta-analysis of effectiveness was planned along with a narrativereview of digital health strategies, implementation challenges, and opportunities for futureresearch.Results:In the 27 included studies, interventions for cervical cancer control focused on secondaryprevention (ie, screening and treatment of precancerous lesions) and digital health strategies tofacilitate patient education, digital cervicography, health worker training, and data quality.Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in otherLMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and amoderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk ofbias. A meta-analysis of effectiveness was not conducted because of insufficient studies withrobust study designs and matched outcomes or interventions.Conclusions:Current evidence on the effectiveness of digital health strategies for cervical cancer control islimited and, in most cases, is associated with a high risk of bias. Further studies arerecommended to expand the investigation of digital health strategies for cervical cancer usingrobust study designs, explore other LMIC settings with a high burden of cervical cancer (eg,South America), and test a greater diversity of digital strategies.

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42. EMPANELMENT OF HEALTH CARE FACILITIES UNDERAYUSHMAN BHARAT PRADHAN MANTRI JAN AROGYA YOJANA(AB PM-JAY) IN INDIAPlos One

Authors: Jaison Joseph ,Hari Sankar D.,Devaki NambiarRegion / country: Southern Asia – IndiaSpeciality: Health policy

IntroductionIndia’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health assurancescheme providing health cover of 500,000 INR (about USD 6,800) per family per year. Itprovides financial support for secondary and tertiary care hospitalization expenses to about 500million of India’s poorest households through various insurance models with care delivered bypublic and private empanelled providers. This study undertook to describe the providerempanelment of PM-JAY, a key element of its functioning and determinant of its impact.MethodsWe carried out secondary analysis of cross-sectional administrative program data publiclyavailable in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wisedistribution, type and sector of empanelled hospitals and services offered through PM-JAYscheme across all the states and UTs.ResultsWe found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020,more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities wereprivate for profit, and 733 (4%) were private not for profit entities. State wise distribution ofhospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%),Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We alsoobserved that 40% of facilities were offering between two and five specialties while 14% ofempanelled hospitals provided 21–24 specialties.ConclusionA majority of the hospital empanelled under the scheme are in states with previous experienceof implementing publicly funded health insurance schemes, with the exception of UttarPradesh. Reasons underlying these patterns of empanelment as well as the impact ofempanelment on service access, utilisation, population health and financial risk protectionwarrant further study. While the inclusion and regulation of the private sector is a goal thatmay be served by empanelment, the role of public sector remains critical, particularly inunderserved areas of India.

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43. ECONOMIC EVALUATIONS OF BREAST CANCER CARE INLOW- AND MIDDLE-INCOME COUNTRIES: A SCOPING REVIEWThe Oncologist

Authors: Parsa Erfani, Kayleigh Bhangdia, Catherine Stauber, Jean Claude Mugunga, Lydia E.Pace, Temidayo FadeluRegion / country: GlobalSpeciality: General surgery, Surgical oncology

BackgroundUnderstanding the cost of delivering breast cancer (BC) care in low- and middle-incomecountries (LMICs) is critical to guide effective care delivery strategies. This scoping reviewsummarizes the scope of literature on the costs of BC care in LMICs and characterizes themethodological approaches of these economic evaluations.Materials and MethodsA systematic literature search was performed in five databases and gray literature up to March2020. Studies were screened to identify original articles that included a cost outcome for BCdiagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility.Data related to study characteristics and methodology were extracted. Study quality wasassessed using the Drummond et al. checklist.ResultsNinety-one articles across 38 countries were included. The majority (73%) of studies werepublished between 2013 and 2020. Low-income countries (2%) and countries in Sub-SaharanAfrica (9%) were grossly underrepresented. The majority of studies (60%) used a health caresystem perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies thatestimated the cost of multiple steps in the BC care pathway, the majority (73%) were of highquality, but studies varied in their inclusion of nonmedical direct and indirect costs.ConclusionThere has been substantial growth in the number of BC economic evaluations in LMICs in thepast decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use ofexisting frameworks for economic evaluations may help achieve comparable, transparentcosting analyses.

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