Mitigating the cultural, social and organisational barriers for meeting the needs of patients with major limb loss (MLL) in Northern Uganda

随着世界经历其近代史上最动荡的时期之一，重大肢体丧失所产生的与“冲突后残疾”相关的健康、社会和经济后果已成为一个重大的公共卫生问题。我们在两个冲突后社会--乌干达北部的亚阿霍里地区和斯里兰卡北部/东部省份--的初步观察和社区参与活动表明，这是一个被低估的复杂和多方面的问题，其特点是：a：缺乏能够满足受影响人口复杂需求的适当服务b：受影响人口由于交通不便而无法获得现有服务，C：在冲突发生时(或冲突后立即)利用不可持续的资金来源发展特别服务，但没有充分考虑到当地人民的需要。d：对受害者的日常经历产生不利影响并阻止他们重新融入社会的社会文化因素和信仰体系。因此，影响和参与这一领域未来的决策需要多学科团队采取综合办法。这项提议旨在将“人道主义和冲突应对研究所”--一个专门研究全球卫生的机构和“战争场所”--一个在冲突后环境中开展文化方案的专门组织--聚集在一起，专注于两个冲突后社会--乌干达和斯里兰卡--与大规模毁灭性武器相关的多方面残疾问题。该项目将把HCRI和Ipow与Gulu医学学院(GMF)联系起来，GMF是专门为满足乌干达北部的医疗需求而建立的，“Gulu转诊矫形工作坊(Growth)”是乌干达北部Gulu区唯一提供假肢服务的中心，以及“英国方法基金会”(MF)--一家在战后斯里兰卡开创假肢服务先河的慈善机构，使用来自英国的回收部件和创新的外展服务模式提供服务。曼彻斯特大学(UOM)的地理信息科学家、乌干达北部的外科医生/公共卫生官员和乌干达-英国健康联盟(UUHA)--负责在两国之间建立可持续伙伴关系的官方政府间机构--的参与将加强拟议的网络。该网络的研究成果将：a.评估艺术和社会剧场在挑战与MLLb相关的根深蒂固的文化观点和偏见方面的影响：突出冲突环境中特别服务发展造成的危害c：提供论坛、试点数据、政策选择和对中低收入国家交付系统的批判性评估，以符合成本效益的方式应对日益高涨的MLL浪潮d：使用外展服务交付模式(在战后斯里兰卡成功实施)制造和交付50个假肢，并评估其适宜性，这一伙伴关系还将创造一个质量有保证的环境，使英国的专业人员和学生能够进行短期/长期志愿服务和学生安置，这对两国都是有利的。UUHA和英格兰健康教育(HEE)作为项目合作伙伴的参与创造了一个机会之窗，通过影响培训、研究、政策制定和资金优先事项来支持该地区(和英国)的残疾人事业。我们认为，这些政策文件，特别是与低收入国家开展外展假肢服务的可行性/可取性有关的文件，将在亚洲、中东和非洲的许多其他冲突后社会的服务规划中得到更广泛的应用。

As the world goes through one of the most turbulent periods in its recent history, the health, social & economic consequences associated with 'post-conflict disability' arising through major limb loss (MLL) has gained importance as a significant public health issue. Our preliminary observations and community engagement activities in two post-conflict societies - the Sub-Acholi Region in Northern Uganda and Northern/Eastern provinces in Sri Lanka, have demonstrated this to be an under-appreciated complex and multi-faceted problem characterised by:a: Lack of suitable services capable of addressing the complex needs of the affected populationsb:Inability of the affected population to access the existing services due to poor transport links, poverty and ignorance.c: Ad-hoc service development using non-sustainable funding sources at the time (or the immediate aftermath) of the conflict with inadequate characterisation of the needs of the local population.d: Social-cultural factors and belief systems that adversely affect the day-to-day experiences of the victims and prevent their reintegration into the society.Influencing and engaging with future policy making in this field therefore requires an integrated approach involving multi-disciplinary teams. This proposal aims to bring together the 'Humanitarian and Conflict Response Institute (HCRI)' - an institution specialising in global health and 'In Place of War (IPOW)'- an organisation with expertise in conducting cultural programmes in post conflict settings, to focus on the multi-faceted problem of disability associated with MLL in two post-conflict societies - Uganda and Sri Lanka. The project will link HCRI and IPOW with Gulu Medical Faculty (GMF)-established specifically to address the health needs of Northern Uganda, the 'Gulu Referral Orthopaedic Workshop (GROW)' - the only centre providing prosthetic limb services in Gulu district in Northern Uganda, and 'Meththa Foundation UK' (MF)-a charity that pioneered prosthetic services in post-war Sri Lanka using recycled components from the UK and an innovative outreach model for service delivery. The involvement of Geographical Information Scientists (GIS) from University of Manchester (UOM), surgeons/public health officials from Northern Uganda and the Uganda-UK Health Alliance (UUHA) - the official intergovernmental body with a mandate to create sustainable partnerships between the two countries, will strengthen the proposed network. Research output from this network will: a. Evaluate the impact of arts and social theatre in challenging entrenched cultural views and bias associated with MLLb: Highlight the harm caused by ad-hoc service development in conflict environmentsc: Provide the forum, pilot data, policy options and critical appraisals of delivery systems in low-middle income countries to deal with the rising tide of MLL cost-effectivelyd: Fabricate and deliver 50 prosthetic limbs using an outreach service delivery model (successfully implemented in post-war Sri Lanka) and assess its suitability, acceptability and cost effectiveness in Northern Uganda.The partnership will also create a quality assured environment where UK based professionals and students will be able to undertake short/long term volunteering and student placements with mutual benefits to both countries. The involvement of UUHA and Health Education England (HEE) as project partners creates a window of opportunity to champion the cause of disabled people in the region (and the UK) by influencing training, research, policy making and funding priorities. We submit that the policy documents, particularly those in relation to the feasibility/desirability of outreach prosthetic services in LMICs, will have wider applications in service planning in many other post-conflict societies in Asia, the Middle east, and Africa