Testing Fairtrade’s Labour Rights Commitments in South Asian Tea Plantations

This article looks at the effectiveness of Fairtrade’s labour rights commitments through the lens of convention theory. It zooms in on workers involved in the cultivation, harvest and processing of tea as Fairtrade’s single most important plantation product. Based on data generated in 2016 through a mixed methods study on the role of Fairtrade certification for tea plantation workers in India and Sri Lanka, we find a wide gulf between living wages and plantation workers’ actual earnings as well as a separation of Fairtrade’s role from trade unions. This ‘test’ of certification standards as a compromise between ‘civic’ conventions concerned with equality and productivity-oriented ‘industry’ conventions suggests that, in actual certification practice, industrial conventions reign

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Do International Health Partnerships contribute to reverse innovation? a mixed methods study of THET-supported partnerships in the UK

Background International health partnerships (IHPs) are changing, with an increased emphasis on mutual accountability and joint agenda setting for both the high- and the low- or middle-income country (LMIC) partners. There is now an important focus on the bi-directionality of learning however for the UK partners, this typically focuses on learning at the individual level, through personal and professional development. We sought to evaluate whether this learning also takes the shape of ‘Reverse Innovation’ –when an idea conceived in a low-income country is subsequently adopted in a higher-income country. Methods This mixed methods study used an initial scoping survey of all the UK-leads of the Tropical Health Education Trust (THET)-supported International Health Partnerships (n = 114) to ascertain the extent to which the IHPs are or have been vehicles for Reverse Innovation. The survey formed the sampling frame for further deep-dive interviews to focus on volunteers’ experiences and attitudes to learning from LMICs. Interviews of IHP leads (n = 12) were audio-recorded and transcribed verbatim. Survey data was analysed descriptively. Interview transcripts were coded thematically, using an inductive approach. Results Survey response rate was 27% (n = 34). The majority (70%) strongly agreed that supporting LMIC partners best described the mission of the partnership but only 13% of respondents strongly agreed that learning about new innovations and models was a primary mission of their partnership. Although more than half of respondents reported having observed innovative practice in the LMIC, only one IHP respondent indicated that this has led to Reverse Innovation. Interviews with a sample of survey respondents revealed themes primarily around how learning is conceptualised, but also a central power imbalance between the UK and LMIC partners. Paternalistic notions of knowledge could be traced to partnership power dynamics and latent attitudes to LMICs. Conclusions Given the global flow of innovation, if High-income countries (HICs) are to benefit from LMIC practices, it is paramount to keep an open mind about where such learning can come from. Making the potential for learning more explicit and facilitating innovation dissemination upon return will ultimately underpin the success of adoption

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Co-producing a culturally sensitive storytelling intervention with Nepalese migrant workers

Background: Labour migration is an increasingly important contributing factor to Nepal's economy; remittance from migrants abroad contribute to quarter of Nepal's gross domestic product. However, this income comes at a great cost; nearly 1,000 Nepalese migrant workers (NMWs) die every year in Gulf States and Malaysia. This interdisciplinary study informs the co-production of a culturally adaptive storytelling intervention to support the mental health and wellbeing of NMWs. Methods: We focused on outgoing and returnee adult NMWs in the GCC countries. The study was conducted in Dhading district, Nepal and involved three different but interconnected phases; 1. a systematic review and a mixed methods study exploring health and wellbeing issues of NMWs (both studies already published, available online); 2. exploration, and analysis of Nepalese literature relevant to contemporary migration (n = 49); and 3. co-development of storytelling intervention working together with a co-production group (n = 12). Results: Findings from phase one and two showed that NMWs suffer from various health and wellbeing issues (mental health, physical health including workplace hazard, abuse, and exploitation). Themes identified from the Nepalese literature centred around hopelessness, helplessness, and separation. Based on these findings, a culturally sensitive storytelling intervention was co-produced to support the mental health and wellbeing of NMWs in GCC countries. The intervention video includes an animated story centred around the struggles of an archetypal male migrant worker and their use of coping strategies for dealing with adversities. Conclusions: Our study suggests that co-production of storytelling intervention provides shared spaces for migrant workers to engage, imagine and participate as communities. The process also helps to redistribute power and redress top-down modes of working that may undermine and devalue the stories of marginalised groups. Key messages: • Co-production of storytelling intervention provides shared spaces to engage, imagine and participate as communities. • Co-production helps to redistribute power and redress top-down modes of working that may undermine and devalue the stories of marginalised groups