Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis

Abstract: Background: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. Method: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. Results: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. Conclusion: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees’ views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations

Protocol for Nearly Full-Length Sequencing of HIV-1 RNA from Plasma

Nearly full-length genome sequencing of HIV-1 using peripheral blood mononuclear cells (PBMC) DNA as a template for PCR is now a relatively routine laboratory procedure. However, this has not been the case when using virion RNA as the template and this has made full genome analysis of circulating viruses difficult. Therefore, a well-developed procedure for sequencing of full-length HIV-1 RNA directly from plasma was needed. Plasma from U.S. donors representing a range of viral loads (VL) was used to develop the assay. RNA was extracted from plasma and reverse-transcribed. Two or three overlapping regions were PCR amplified to cover the entire viral genome and sequenced for verification. The success of the procedure was sensitive to VL but was routinely successful for VL greater than 105 and the rate declined in proportion to the VL. While the two-amplicon strategy had an advantage of increasing the possibility of amplifying a single species of HIV-1, the three-amplicon strategy was more successful in amplifying samples with low viral loads. This protocol provides a useful tool for molecular analysis to understand the HIV epidemic and pathogenesis, as well as diagnosis, therapy and future vaccine strategies

Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

BACKGROUND: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. METHOD: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. RESULTS: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. CONCLUSION: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees' views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations

Factors associated with completion of bowel cancer screening and the potential effects of simplifying the screening test algorithm

BACKGROUND: The primary colorectal cancer screening test in England is a guaiac faecal occult blood test (gFOBt). The NHS Bowel Cancer Screening Programme (BCSP) interprets tests on six samples on up to three test kits to determine a definitive positive or negative result. However, the test algorithm fails to achieve a definitive result for a significant number of participants because they do not comply with the programme requirements. This study identifies factors associated with failed compliance and modifications to the screening algorithm that will improve the clinical effectiveness of the screening programme. METHODS: The BCSP Southern Hub data for screening episodes started in 2006–2012 were analysed for participants aged 60–69 years. The variables included age, sex, level of deprivation, gFOBt results and clinical outcome. RESULTS: The data set included 1 409 335 screening episodes; 95.08% of participants had a definitively normal result on kit 1 (no positive spots). Among participants asked to complete a second or third gFOBt, 5.10% and 4.65%, respectively, failed to return a valid kit. Among participants referred for follow up, 13.80% did not comply. Older age was associated with compliance at repeat testing, but non-compliance at follow up. Increasing levels of deprivation were associated with non-compliance at repeat testing and follow up. Modelling a reduction in the threshold for immediate referral led to a small increase in completion of the screening pathway. CONCLUSIONS: Reducing the number of positive spots required on the first gFOBt kit for referral for follow-up and targeted measures to improve compliance with follow-up may improve completion of the screening pathway