Xu, Mary Jue

Background: Access to high-quality airway equipment is critical for effective otolaryngological and emergency care. In sub-Saharan Africa (SSA), challenges in the procurement infrastructure may hinder equipment availability, impacting patient outcomes. Given the paucity of literature investigating equipment procurement in SSA, this study aims to map out the multilevel barriers to procurement of airway equipment in SSA to inform opportunities for improvement. Methods: A qualitative study design was employed using semi-structured interviews and open-ended survey responses. Participants included otolaryngologists in SSA, manufacturing company representatives and international policymakers, selected through purposive sampling to ensure representation of various roles in the procurement process. Six interviews, one focus group and six survey responses with regional healthcare providers (n = 13), manufacturing representatives (n = 3) and international policymakers (n = 2) explored supply chain dynamics, regulatory challenges, manufacturing capabilities, financial constraints and policy frameworks. Data were analysed using thematic analysis to identify recurrent themes and interrelationships. Results: Systemic barriers exist in the procurement process, including fragmented supply chains, inconsistent regulatory enforcement, limited local manufacturing capacity and insufficient funding mechanisms. Otolaryngologists emphasised frequent delays in equipment availability, while manufacturers reported logistical challenges and regulatory hurdles. Policymakers noted gaps in infrastructure and regional coordination. Emerging themes suggest opportunities for streamlining procurement processes, fostering local production and enhancing collaboration to improve supply chain efficiency. Conclusion: This study underscores the multifaceted challenges in airway equipment procurement in SSA and highlights the need for integrated approaches involving stakeholders across the supply chain. Contribution: Findings provide actionable insights to inform policy development and capacity-building initiatives with the goal of enhancing access to life-saving airway equipment and improving healthcare outcomes.

1510 Background: The National Comprehensive Cancer Network (NCCN) Harmonized Guidelines for Sub-Saharan Africa (SSA) have emerged as leading cancer treatment guidelines in SSA. The NCCN-SSA guidelines, derived by adapting NCCN guidelines for the SSA context, offer standardized recommendations to guide cancer care and shape policy in SSA. This study examines the evidence cited in support of the NCCN-SSA guidelines, with a focus on population characteristics and generalizability to SSA. Methods: Two reviewers independently examined the NCCN-SSA guidelines for the eight most common cancers in SSA to identify all studies cited in support of treatment/management recommendations. Study selection discrepancies were resolved by discussion. Full-text articles were reviewed and data on age, sex, race, and recruitment geography were abstracted. Descriptive analyses were performed using R statistical software. Results: Overall, 4,589 citations were reviewed, and 2,938 (64.0%) studies with individual-level data were included, representing >10.4 million study participants. Of the 2,061 studies reporting geographic information (70%), 50 (2.4%) recruited in SSA; of these, 39 (83.0%) recruited from South Africa. Three studies (0.2%) recruited exclusively in SSA. Most studies (95.3%) recruited exclusively from high or upper-middle income countries. Only 29.2% of studies with race data included >10% Black study participants. Conclusions: Most studies cited in the NCCN-SSA guidelines were conducted in high-income countries outside SSA. A small minority of all study participants were Black. Our findings underscore potential limitations in the generalizability of the NCCN-SSA guidelines to SSA and highlight a pressing need to generate and incorporate context-specific data to guide care and inform policy. WHO region of recruitment, race, and country-level income of studies included in NCCN-SSA guidelines. Cancer type # (%) studies reporting geography # (%) studies by recruitment region*: Americas # (%) studies by recruitment region*: Europe # (%) studies by recruitment region*: Sub-Sah. Africa % participants, White % participants, Black % participants, Other race # (%) studies representing only HMIC (per World Bank) Overall 2061(70%) 1177 (57%) 921 (45%) 50 (2%) 79% 9% 11% 1964(95%) B-cell 325(57%) 173 (53%) 178 (55%) 5(2%) 82% 7% 10% 307(94%) Breast 206(44%) 123 (60%) 124 (60%) 12 (6%) 80% 9% 11% 179(87%) Cervical 163(90%) 100 (61 %) 44(27%) 3(2%) 64% 14% 22% 158(97%) Colorectal 584(82%) 278 (48%) 292 (50%) 11 (2%) 80% 10% 10% 571 (98%) Hepato-cellular 183(74%) 80(44%) 68(37%) 0(0%) 69% 9% 22% 169(92 %) Kaposi sarcoma 51(80%) 25 (49%) 19(37%) 5(10%) 38% 51% 10% 44(86%) Ovarian 115(56%) 76 (66%) 35 (30%) 0(0%) 83% 4% 13% 115(100%) Prostate 434(88 %) 322 (74 %) 161 (37%) 14 (3%) 79% 9% 12% 421(97%) HMIC = high and upper-middle income countries. *Percent of studies includes as the denominator only the number of studies with reported geographies.

ImportanceUnderstanding the global barriers to otolaryngology–head and neck surgery (OHNS) care is crucial in addressing disparities in access to care, particularly in low-income and middle-income countries (LMICs).ObjectiveTo characterize barriers to comprehensive otolaryngology care across World Bank income groups.Design, Setting, and ParticipantsUsing an online cross-sectional survey that was administered by the Global OHNS Initiative via international and national professional societies, personal contacts, and social media, this study captured the perceptions of otolaryngologists regarding barriers to OHNS care at the levels of the country, health sector, clinician, and patient. Participants included otolaryngologists from the 194 World Health Organization member states and Taiwan. Eligibility criteria included a medical degree and specialized training in managing conditions of the ear, nose, and throat. The nonresponse rate was not recorded. The data collection period spanned from October 2022 to June 2023.ExposuresExposures included World Bank income group classification.Main Outcomes and MeasuresThe primary outcomes were Likert scale responses regarding frequency of barriers to OHNS care. The a priori hypothesis was that LMICs would report more frequent barriers to OHNS care.ResultsThe study involved 146 otolaryngologists (47 female individuals [32%]), with 69 (47%) from high-income countries and 77 (53%) from LMICs. Male individuals represented 45 high-income country respondents (65%) and 54 LMIC respondents (70%). Barriers were reported across income groups at all levels of the health system, with a higher frequency in LMICs. Several barriers were reported to be more substantial in LMICs, such as the national volume and distribution of otolaryngologists, financial compensation for clinicians, and patient stigma, and others were common across income settings, such as the availability of operating rooms and inflexible working hours. Common concerns included national and health sector barriers: OHNS workforce, referral networks, government support; clinician barriers: excessive clinician workloads, understaffing, poor administration support; patient barriers: distance to health care facilities, financial burdens such as medical costs and foregone wages, stigma, and health literacy.Conclusions and RelevanceThe results of this cross-sectional study suggest that there are barriers to otolaryngology care globally that affected all levels of the health care system. This work may inform prioritization of otolaryngology within research and policy, and it emphasizes the need for effective strategies to expand access to otolaryngology care, particularly in lower-income settings.

ABSTRACTImportanceHighlighting the global disparities in otolaryngology training and, ultimately, service delivery, emphasizing the need for equitable access to training resources and programs.ObjectiveTo describe the relationship between the quality, content, and location of otolaryngology–head and neck surgery training and education and the resulting impact on the delivery of otolaryngology care globally.DesignAn online cross‐sectional survey to otolaryngologists, gathering information on their training and education experiences, and factors influencing their choice of training location and practice.SettingThe online survey was available in multiple languages, distributed via national and international professional otolaryngology societies, snowballing and social media.ParticipantsThe respondents were practicing otolaryngologists representing all seven World Health Organization regions.ExposuresWorld Bank income groups classification.Main Outcomes and MeasuresOur expected outcome was that subspecialty training and access to educational resources were significantly readily available to respondents from high‐income countries, leading to more confidence in performing complex procedures post training.ResultsA total of 91 participants were included in the analysis, with 47 (52%) practicing in high‐income countries and 44 (48%) in low‐ and middle‐income countries. Sixty‐one participants (67%) were male. Subspecialty training and access to educational resources were significantly less available in low‐ and middle‐income countries, leading to lower confidence among low‐ and middle‐income countries physicians in performing complex procedures. High‐income country respondents reported better access to diverse training resources and felt more prepared for a broader range of procedures.Conclusion and RelevanceSignificant disparities exist in OHNS training resources and subspecialty training opportunities between high‐ and low‐middle‐income countries. There is a critical need to integrate complementary training and educational modalities into local systems. Addressing the shortage of educational resources and promoting open‐access initiatives in low‐middle‐income countries are essential steps toward enhancing surgical education and improving global otolaryngology healthcare outcomes.

ABSTRACT Objective Availability of surgical equipment and access to essential clinical services remains an important barrier to surgical care delivery, particularly in low‐ and middle‐income countries (LMICs). This study aims to characterize the relative availability of essential equipment for otolaryngology‐head and neck surgery (OHNS) care across World Bank income groups. Methods We conducted a cross‐sectional survey on otolaryngologists' perceptions on the availability of surgical equipment and ancillary services in their respective practice settings per a 5‐point Likert scale ranging from never to always available. The study was disseminated online via professional societies, personal contacts, and social media. Eligible participants included otolaryngologists from 194 WHO‐recognized countries, which were grouped by World Bank income group classification and WHO region. Results The study involved 146 otolaryngologists, 69 (47%) from high‐income countries (HICs), and 77 (53%) from LMICs. LMIC respondents were predominantly from the African and South‐East Asian regions, which comprised 48% and 7.8% of all LMIC respondents, respectively. Results revealed significant differences in the availability of otologic, rhinologic, and endoscopic airway equipment between HICs and LMICs. Differences existed among commonly used equipment such as tympanomastoidectomy equipment and rigid bronchoscopy, to subspecialized equipment such as functional endoscopic sinus surgery equipment and cochlear implants ( p < 0.05 each). Conclusions The study highlighted key disparities in the availability of essential equipment for baseline OHNS care, especially for pediatric airway and otologic conditions. These results can be used to guide investment and advocacy efforts to improve specialty‐specific surgical infrastructure relative to the global burden of OHNS diseases in low‐resource settings. Level of Evidence 3

Sub-Saharan Africa (SSA), home to over 1 billion people, has only one paediatric otolaryngology fellowship program and nine fellowship-trained paediatric Otolaryngology Head and Neck Surgery (OHNS) specialists covering seven countries. Seven of these specialists estimated an average of 40+ patients per month are in need of critical surgical airway management in their respective countries and that 2–25 deaths per year (mainly paediatric) occur in their country from lack of access to foreign body removal equipment. Investing in paediatric airway infrastructure and capacity would largely benefit the health system in SSA, where the current lack of equipment alone leads to unmeasured morbidity and mortality. As a region of the world with the largest paediatric populations, sub-Saharan Africa’s need is all the more pressing given the disproportionately low number of medical specialists, institutions and resources. Collaborative approaches in procurement and maintenance of high-quality, cost-effective equipment are crucially desirable factors in both low- and middle-income countries (LMICs) and high-income countries (HICs). We, as the Global OHNS Initiative, urge for multi-stakeholder engagement and collaboration to forge lasting change.

Abstract Importance: There is a notable lack of low-cost OHNS simulation models that are relevant for early medical trainees and students. By conducting this study, we will understand the current landscape of low-cost otolaryngology-head and neck surgery simulation for early medical trainees and students. Objectives: Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature. Evidence Review: This scoping review followed the five stages of Arksey and O’Malley’s Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as “low-cost,” “cost-effective,” or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents. Findings: Of the 1706 studies screened, 17 met the inclusion criteria. Most studies were conducted in HICs. Most models were low fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation. Conclusion and Relevance: Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.