A survey of prehospital and acute hospital care in three low and middle income countries

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs.

METHODS

This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies.

CONCLUSIONS

The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.

A 3-Country Assessment of Traumatic Brain Injury Practices and Capacity

BACKGROUND

The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova.

METHODS

After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources.

RESULTS

All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries.

CONCLUSIONS

Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.

Survey of resources available to implement severe pediatric traumatic brain injury management guidelines in low and middle-income countries

PURPOSE

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionately high burden in low-middle income countries. Guideline implementation has been associated with mortality reduction in high-income countries (HIC), but it is not known if hospitals in low and middle-income countries possess the resources to implement the pre-hospital TBI guidelines and the guidelines for the management of severe pediatric traumatic brain injury.

METHOD

An anonymous online survey was undertaken by a range of health care professionals currently managing children with severe TBI in low to middle-income countries. A variety of international and national pediatric, intensive care, and neurological societies assisted in the survey distribution. Thirty-eight questions were included to evaluate patient care and the provider's perceptions of their resources available to implement the pre-hospital specific TBI and current pediatric severe TBI guidelines.

RESULTS

Two hundred and forty-seven hospitals were represented from 68 countries. Fifty percent of LMIC hospitals that responded had the resources to implement 13 of 15 guidelines for the pediatric component of pre-hospital management for TBI and all baseline care recommendations. First tier therapies including the intracranial pressure (ICP) and cerebral perfusion pathways (CPP), however, demonstrated low capacity for uptake with 21.5% and 38.5% of surveyed hospitals possessing sufficient resources to follow the recommended pathways.

CONCLUSION

Pediatric TBI ICP/CPP management guidelines require numerous resources not widely sourced in LMIC. The creation of international guidelines that outline recommendations of care for LMIC may benefit patient care and outcomes in these settings.